Fever (>38.3�C or >38�C sustained for 1 hr), with an ANC of <500 or an ANC expected to fall to <500 in the next 48 hr

Clinical change

Clinical change

Persistent or new fever after >96 hr

Defervescence

Repeat blood and urine cultures every 24 hr
Start empirical fungal treatment with a mold-active antifungal agent
Consider imaging of sinuses, chest, abdomen, and pelvis, looking for an infectious nidus
Biweekly galactomannan levels

Clinically unstable

Cover GP, GN, and anaerobes
Double-cover Pseudomonas
MRSA coverage

Follow cultures, adjust Abx accordingly.
Continue Abx until count recovery (ANC >200 and rising)

End

Defervescence

^* Antibiotic selection should account for local resistance patterns as well as prior infections with resistant organisms. Commonly used monotherapies include antipseudomonal β-lactams and fourth-generation cephalosporins or carbapenems.

Clinically stable

Broad spectrum GP and GN coverage, including pseudomonal coverage^* (minimum of 48 hr)
If HSCT, recent high-dose cyclophosphamide, AML induction or consolidation, ALL relapse induction, intensification, or GVHD, consider MRSA coverage for 48 hr

Defervescence

Persistent or new fever after >96 hr

Thorough physical examination, including oropharynx, skin, lines/port sites, and perianal area
Laboratory tests: CBC + diff, blood cultures, noncatheterized urine culture, electrolytes, and LFTs
Imaging: CXR or abdominal CT as dictated by symptoms

Clinically stable

Broad spectrum GP and GN coverage, including pseudomonal coverage^* (minimum of 48 hr)
If HSCT, recent high-dose cyclophosphamide, AML induction or consolidation, ALL relapse induction, intensification, or GVHD, consider MRSA coverage for 48 hr

Clinically unstable

Cover GP, GN, and anaerobes
Double-cover Pseudomonas
MRSA coverage