Table 54-3.

Modification of Standard Empiric Therapy in Patients with Neutropenia

Clinical Event	Possible Modifications of Standard Empiric Therapy
Breakthrough bacteremia	If gram-positive isolate (e.g., Staphylococcus aureus), add vancomycin until susceptibility pattern of isolate is known. If gram-negative isolate, add two new agents likely to have activity until susceptibility pattern of pathogen is known.
Cellulitis or catheter-associated infection	Add vancomycin.
Severe necrotizing mucositis or gingivitis	Add specific antianaerobic agent (e.g., metronidazole, meropenem, imipenem, or piperacillin-tazobactam) plus agent with activity against streptococci; consider acyclovir.
Ulcerative mucositis or gingivitis	Add acyclovir and anaerobic coverage.
Esophagitis	Add fluconazole or caspofungin; consider adding acyclovir.
Pneumonitis, diffuse or interstitial	Add trimethoprim-sulfamethoxazole and azithromycin or levofloxacin or moxifloxacin (plus broad-spectrum antibiotics if the patient is granulocytopenic).
Perianal tenderness	Include anaerobic agents such as metronidazole, imipenem, meropenem, or piperacillin-tazobactam.
Abdominal involvement	Add antianaerobic agent (e.g., metronidazole, meropenem, imipenem, or piperacillin-tazobactam).