What is the initial action for a cancer patient with fever and recent chemotherapy?

Initial Management of Febrile Neutropenia in Cancer Patients

Prescribe empiric antibiotics immediately—this is the most critical initial action for a cancer patient with fever and recent chemotherapy, as infection can progress rapidly in neutropenic patients and urgent antibiotic administration (within 2 hours) significantly improves outcomes. 1

Immediate Actions (Within 2 Hours)

1. Initiate Empiric Antibiotics FIRST

• Start broad-spectrum IV antibiotics urgently before obtaining any diagnostic workup results 1
• The IDSA guidelines explicitly state that empirical antibiotic therapy must be initiated within 2 hours of presentation because infection may progress rapidly in neutropenic patients 1
• Substantially better outcomes are achieved with prompt initiation of antibiotics rather than waiting for laboratory confirmation 1

2. Obtain Diagnostic Studies Simultaneously (Not Before Antibiotics)

While antibiotics are being prepared and administered, obtain:

• STAT CBC with differential to document neutropenia (ANC <500 cells/mm³ or expected to fall below 500) 1
• At least 2 sets of blood cultures: one from each lumen of central venous catheter if present, plus peripheral venipuncture 1
• Chest radiograph if any respiratory signs or symptoms are present 1
• Urine cultures and other site-specific cultures as clinically indicated 1
• Serum creatinine, electrolytes, hepatic enzymes to guide antibiotic dosing 1

Antibiotic Selection

High-Risk Patients (This Patient Qualifies)

Recent chemotherapy within 2 weeks places this patient at high risk for profound neutropenia. Use IV monotherapy with an anti-pseudomonal β-lactam 1:

First-line options (choose one):

• Cefepime 2g IV every 8 hours 1, 2
• Meropenem or imipenem-cilastatin 1
• Piperacillin-tazobactam 1

Do NOT routinely add vancomycin unless specific indications exist 1:

• Hemodynamic instability
• Suspected catheter-related infection
• Skin/soft tissue infection
• Known MRSA colonization
• Gram-positive cocci in blood cultures 1

Critical Pitfalls to Avoid

1. Never delay antibiotics to obtain diagnostic studies first—the CBC, cultures, and imaging should be obtained concurrently with or after antibiotic initiation, not before 1

2. Do not wait for neutrophil count confirmation—fever in a patient with chemotherapy within 2 weeks is febrile neutropenia until proven otherwise 1

3. Avoid rectal examinations and rectal temperatures during neutropenia due to risk of bacterial translocation 1

4. Do not use oral antibiotics for initial management in this setting—this patient requires IV therapy given recent chemotherapy and presumed high-risk status 1

Risk Stratification Context

While the question asks about initial action, subsequent management depends on risk assessment 1:

High-risk features (require hospitalization and IV antibiotics):

• Anticipated prolonged neutropenia (>7 days)
• Profound neutropenia (ANC <100 cells/mm³)
• Hypotension, pneumonia, abdominal pain, or neurologic changes
• Recent chemotherapy (as in this case) 1

The correct answer is: Prescribe empiric antibiotics. All other options (CBC, chest X-ray, urine cultures) should be obtained but must not delay antibiotic administration, which is the life-saving intervention that must occur within 2 hours of presentation 1.