Diagnosis and Assessment Tests and Cultures
ÎLaboratory tests should include a complete blood count (CBC) with differential leukocytes and platelets, serum creatinine, blood urea nitrogen, electrolytes, hepatic transaminase enzymes, and total bilirubin (A-III).
ÎAt least 2 sets of blood cultures are recommended:
> One set collected simultaneously from each lumen of an existing central venous catheter (if present) and from a peripheral vein site.
> 2 sets from separate venipunctures if no central catheter is present (A-III). > Blood culture volumes should be limited to < 1% of total blood volume (usually approximately 70 mL/kg) in patients weighing < 40 kg (C-III).
ÎCulture specimens from other sites of suspected infection should be obtained as clinically indicated (A-III).
ÎA chest radiograph is indicated for patients with respiratory signs or symptoms (A-III).
Empiric Antibiotic Therapy
ÎHigh-risk patients require hospitalization for IV empirical antibiotic therapy: monotherapy with an anti-pseudomonal β-lactam agent such as cefepime, a carbapenem (meropenem or imipenem-cilastatin), or piperacillin-tazobactam (A-I).
Other antimicrobials (aminoglycosides, fluoroquinolones and/or vancomycin) may be added to the initial regimen for management of complications (ie, hypotension, pneumonia) or if antimicrobial resistance is suspected or proven (B-III).
ÎVancomycin (or other agents active against aerobic Gram-positive cocci) is
ÎModifications to initial empirical therapy may be considered for patients at risk for infection with MRSA, VRE, extended-spectrum beta-lactamase (ESBL)-producing Gram-negative bacteria and carbapenemase-producing organisms, including
carbapenemase (KPC) bacteria, particularly if the patient
is unstable or has positive blood cultures suspicious for resistant bacteria (B-III). Risk factors include previous infection or colonization with the organism or treatment in a hospital with high endemic rates.
> MRSA: Consider early addition of vancomycin, linezolid or daptomycin (B-III). > VRE: Consider early addition of linezolid or daptomycin (B-III). > ESBLs: Consider early use of a carbapenem (B-III). > KPCs: Consider early use of polymyxin/colistin or tigecycline (C-III).
recommended as a standard part of the initial antibiotic regimen for fever and neutropenia (A-I). (See Table 4 for indications.)
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