ÎMost penicillin-allergic patients tolerate cephalosporins, but those with a history of an immediate-type hypersensitivity reaction (hives, bronchospasm) should be treated with a combination that avoids β-lactams and carbapenems, such as ciprofloxacin plus clindamycin, or aztreonam plus vancomycin (A-II).
ÎAfebrile neutropenic patients who have new signs or symptoms suggesting infection should be evaluated and treated as high-risk patients (B-III).
ÎLow-risk patients should receive initial oral or IV empirical antibiotic doses in a clinic or hospital setting.
> Ciprofloxacin plus amoxicillin/clavulanate in combination is recommended for oral empirical treatment (A-I). Other oral regimens, including levofloxacin or ciprofloxacin monotherapy, or ciprofloxacin plus clindamycin, are less well studied but are commonly used (B-III).
They may be transitioned to outpatient oral or IV treatment if they meet specific clinical criteria (A-I).
> Patients receiving fluoroquinolone prophylaxis should not receive oral empirical therapy with a fluoroquinolone (A-III).
> Hospital re-admission or continued stay in the hospital is required for persistent fever, or signs and symptoms of worsening infection (A-III).
Modifying Antibiotic Therapy
ÎModifications to the initial antibiotic regimen should be guided by clinical and microbiologic data (A-II).
ÎUnexplained persistent fever in an otherwise stable patient rarely requires an empirical change to the initial antibiotic regimen. If an infection is identified, antibiotics should be adjusted accordingly (A-I).
ÎDocumented clinical and/or microbiological infections should be treated with antibiotics appropriate for the site and susceptibilities of any isolated organisms (A-I).
ÎIf vancomycin or other Gram-positive coverage was started initially, it may be stopped after 2 days if there is no evidence for a Gram-positive infection (A-II).
ÎPatients who are hemodynamically unstable should have their antimicrobial regimen broadened to include coverage for resistant Gram-negative, Gram-positive, and anaerobic bacteria and fungi (A-III).
ÎLow-risk patients who have been started on IV or oral antibiotics in the hospital may have their treatment approach simplified if they are clinically stable (A-I).
> An IV-to-oral switch in antibiotic regimen may be made if patients are clinically stable and gastrointestinal absorption is felt to be adequate (A-I).
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