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A 40-year-old male patient who is receiving chem - highsky
#1

A 40-year-old male patient who is receiving chemotherapy with paclitaxel, ifosfamide and cisplatin for a squamous cell cancer of the tongue presents with nausea, vomiting and fever. He had low-grade fever, for the past 1 day, and it is not associated with any rigors or chills. He denies any cough, chest pain, abdominal pain, diarrhea or burning micturition. His vitals are, PR: 90/min; Temperature: 38.5C(101.3F) BP: 127/70mm Hg; RR: 18/min. Examination of all of his systems is unremarkable and there is no apparent source of infection. Labs show hematocrit of 28%, WBC count of 1,000/micro-L and platelet count of 70,000/micro-L. Chest X-ray does not show any abnormality. Urine analysis is negative for infection. His blood and urine are collected and are sent for culture. What is the most appropriate next step in this patient?


A. Admit the patient and start IV ceftazidime
B. Admit the patient and start tobramycin
C. Admit the patient and start vancomycin
D. Outpatient treatment with ciprofloxacin
E. Admit the patient and start IV amphotericin B
F. Admit the patient and start IV vancomycin plus ceftazidime
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#2
any one
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#3
is it fff?
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#4
u have to caver p. aeruginosa and other GM - /+
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#5
then it's F
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#6
is it a
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#7
YES ITS A
This patient has febrile neutropenia that is considered a medical emergency and empiric antibiotics should be started immediately. Fever in a neutropenic patient is defined as a single temperature reading of greater than 38.3C(100.9F) or a sustained T of greater than 38C(100.4F), over 1 hour. Neutropenia is defined as an absolute neutrophil count of less than 500/micro-L. Bacteria, fungi and viruses can all cause infection in neutropenic patients. Bacterial infections are the most common and are frequently caused by endogenous skin or colon flora. Gram-negative organisms especially Pseudomonas aeruginosa used to be the usual culprit, but now infections by gram-positive organisms are increasing in number. Empiric therapy for febrile neutropenia should be targeted against gram-negative bacilli especially P. aeruginosa. Either monotherapy or combination therapy can be employed. Monotherapy consists of ceftazidime, imipenem, cefepime or meropenem. Combination therapy is equally effective and consists of an aminoglycoside plus an anti-pseudomonal beta-lactam. Fungal infections occur quite commonly in patients with prolonged neutropenia. When fever in neutropenic persists despite empiric antibacterial therapy, antifungal agents like amphotericin B are added to the empiric regimen. Vancomycin is added to the empiric regimen when patient is hypotensive or he has severe mucositis, evidence of skin or line infection, history of colonization with resistant strains of S. aureus or pneumococcus or recent prophylaxis with fluoroquinolones.

Educational Objective:
Empiric antibiotic therapy with either ceftazidime or cefepime should be started in febrile neutropenic patients.
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