The administration of empiric therapy should begin immediately after cultures are taken. Therapy should not be withheld until after culture results are obtained.

As illustrated in Figure 99-1, specific criteria exist for the addition of vancomycin for coverage of resistant gram-positive organisms or agents for coverage of fungal infections. Additional agents are necessary in the setting of continued fever or declining clinical status in neutropenic patients. In general, all empiric therapy is continued until recovery of the ANC to levels above 500 x 10%L (500 x 109/L) cells in patients with negative cultures. If a specific etiology is identified, appropriate therapy should be continued until 7 days after neutropenia resolves. Specific regimens with recommended dosages are summarized in Table 99-8.

Nonpharmacologic Therapy

Prevention of infection is key. Hand-washing is critical in the prevention of disease transmission.26 It is also important to ensure that patients receive annual influenza vaccines and have had a pneumonia vaccine and neutropenic patients should avoid

individuals with active respiratory infections. Plants and animal secretions are also

sources of infection and should be avoided. Indwelling catheters are often a source of infection; however, the Infectious Disease Society of America acknowledges that catheters do not always need to be removed. Catheters should be removed in the following circumstances: established tunnel infection (subcutaneous tunnel or periport infection, septic emboli, hypotension associated with catheter use, or a nonpatent catheter); recurrent infection; no response to antibiotics within 2 or 3 days.19 Wound debridement should also be performed upon catheter removal. In the setting of peripheral blood stem cell or bone marrow transplant, the Centers for Disease Control (CDC) recommends the use of high-efficiency particulate air (HEPA) filtration systems in patient rooms and the NCCN suggests that HEPA filters are reasonable to be considered for other patients who experience prolonged neutropenia.26 HEPA filters are likely to be most useful in preventing mold infections. Though several small studies have attempted to evaluate the effectiveness of isolation of neutropenic patients as a mechanism for infection prevention, no clear data are available to support this prac-tice.31

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