What is the treatment for an elderly patient with Acute Myeloid Leukemia (AML) who develops febrile neutropenia after chemotherapy?

Treatment of Febrile Neutropenia in Elderly AML Patient

Immediate intravenous (IV) antibiotics is the appropriate treatment for an elderly AML patient with febrile neutropenia after chemotherapy. 1, 2

Initial Assessment and Management

• Temperature 38.5°C with neutrophil count of 0.1 × 10^9/L constitutes febrile neutropenia, which is a medical emergency requiring prompt intervention
• Blood and urine cultures have been appropriately sent, but treatment should not be delayed while awaiting results
• This patient is considered high-risk due to:
  • Underlying hematologic malignancy (AML)
  • Severe neutropenia (neutrophil count 0.1 × 10^9/L)
  • Advanced age

Antibiotic Therapy

First-line Treatment:

• Begin with broad-spectrum anti-pseudomonal beta-lactam antibiotic monotherapy within 1 hour of presentation 2
• Options include:
  • Cefepime (FDA-approved for empiric treatment of febrile neutropenia) 3
  • Piperacillin-tazobactam
  • Meropenem

Additional Considerations:

• Add vancomycin if there are signs of catheter-related infection, known colonization with resistant gram-positive organisms, hemodynamic instability, or positive blood cultures for gram-positive bacteria 2
• If there is clinical evidence of intra-abdominal or pelvic infection, add metronidazole 2

Antifungal Therapy

• Not indicated initially, but should be considered if fever persists >96 hours (3-7 days) despite appropriate antibacterial therapy 2
• Options for empiric antifungal therapy include:
  • Caspofungin (loading dose 70 mg on day 1, then 50 mg daily) 4
  • Liposomal amphotericin B (3 mg/kg/day) 2

Duration of Therapy

• Continue antibiotics until:
  • Neutrophil count recovers to ≥0.5 × 10^9/L
  • Patient has been afebrile for at least 48 hours
  • Blood cultures are negative 2
• If fever persists at 48 hours but patient is clinically stable, continue initial antibacterial therapy
• If clinically unstable at 48 hours, broaden antibiotic coverage 1

Monitoring and Follow-up

• Perform daily clinical assessment for response to therapy
• Monitor complete blood counts to assess bone marrow recovery
• Consider repeat imaging if clinically indicated 2

Colony Stimulating Factors (CSFs)

• CSFs are not generally recommended for treatment of established fever and neutropenia 1
• However, prophylactic use should be considered for future chemotherapy cycles if the anticipated risk of fever and neutropenia is >20% 1

Pitfalls to Avoid

1. Delaying antibiotic therapy while waiting for culture results
2. Using oral antibiotics alone in high-risk patients (elderly with AML)
3. Adding antifungal therapy too early (before 96 hours) or too late (after 7 days of persistent fever)
4. Discontinuing antibiotics too early before neutrophil recovery
5. Relying on colony stimulating factors as primary treatment for established febrile neutropenia

The correct answer is B. IV antibiotics.