Figure 3. High Risk Patient with Fever After 4 Days of Empirical Antibiotics
High Risk Patient with Prolonged (> 4 Days) Fever
> Daily exam and history > Blood cultures – repeat on limited basis > Cultures for any suspected sites of infection
Unexplained fever
> Clinically stable > Rising ANC: Myeloid recovery imminent
Unexplained fever
> Clinically stable > Myeloid recovery NOT imminent
> Consider CT scan sinuses and lungs
Documented infection
> Clinically unstable > Worsening signs and symptoms of infection
Serum galactomannan testing
On fluconazole (anti- yeast prophylaxis)
Pre-emptive approach*: Start antifungal based upon results of: > CT scans chest/ sinuses
> Serial serum galactomannan tests
Observe; No
antimicrobial changes unless clinical, microbiologic or radiographic data
suggest new infection *Limited data to support recommendation
On anti-mold prophylaxis
Switch to: Empirical antifungal therapy with anti-mold coverage:
> Echinacandin > Voriconazole > Amphotericin B preparation
Empirical anti-fungal therapy*:
Consider switch to a
different class of mold active antifungal
> Examine and re-image (CT, MRI) for new or worsening sites of infection
> Culture/biopsy/drain sites of worsening infection: assess for bacterial, viral and fungal pathogens
> Review antibiotic coverage for adequacy of dosing and spectrum
> Consider adding empirical antifungal therapy
> Broaden antimicrobial coverage for hemodynamic instability
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