During morning rounds on the hematology-oncology ward, a 45-year-old female patient is not… — USMLE Step 2 CK

During morning rounds on the hematology-oncology ward, a 45-year-old female patient is noted to have a temperature of $38.8^\circ C$ ( $101.8^\circ F$ ). She was admitted two weeks ago for induction chemotherapy to treat acute myeloid leukemia. The patient reports moderate fatigue but denies any localizing symptoms such as cough, dysuria, abdominal pain, or skin changes. Vital signs show a blood pressure of $115/75$ mm Hg, a heart rate of $105$ /min, and a respiratory rate of $16$ /min. Physical examination demonstrates an indwelling central venous catheter with clean, non-erythematous margins and no tenderness to palpation. Her lungs are clear to auscultation, and her abdomen is soft and non-tender. Laboratory analysis reveals a leukocyte count of $400/\mu L$ with an absolute neutrophil count of $50/\mu L$ . After drawing blood cultures from the catheter and a peripheral vein, which of the following is the most appropriate initial pharmacologic management?

Intravenous cefepimeAnswer
B
Intravenous piperacillin-tazobactam and vancomycin
C
Intravenous ceftriaxone
D
Oral ciprofloxacin and amoxicillin-clavulanate
E
Intravenous meropenem and micafungin

Answer

Intravenous cefepime

Febrile neutropenia is a medical emergency characterized by a temperature of

\geq 38.3^\circ C

(

101.0^\circ F

) and an absolute neutrophil count (ANC)

< 500/\mu L

. Because patients lack the white blood cells necessary to mount a standard inflammatory response, an infection can rapidly progress to fatal sepsis. Initial empiric therapy must include an intravenous bactericidal agent with reliable activity against Pseudomonas aeruginosa. Current guidelines recommend monotherapy with an antipseudomonal beta-lactam, such as cefepime, meropenem, or piperacillin-tazobactam, for high-risk patients (e.g., those with hematologic malignancies undergoing induction). The patient in this vignette is hemodynamically stable and has no specific indications requiring MRSA or antifungal coverage, making antipseudomonal monotherapy the most appropriate next step.

Step-by-Step Solution

Identify the primary clinical syndrome and severity.

The patient has febrile neutropenia (fever > 38.3 C and ANC < 500) and is classified as high-risk due to acute myeloid leukemia induction therapy.

Risk stratification determines whether the patient requires inpatient intravenous therapy (high-risk) or can be managed with outpatient oral therapy (low-risk).

Determine the necessary empiric antimicrobial spectrum.

Therapy must rapidly and reliably cover serious Gram-negative bacilli, specifically Pseudomonas aeruginosa, as well as common Gram-positive organisms.

Pseudomonas aeruginosa can cause rapidly fatal sepsis in profoundly neutropenic hosts if not covered immediately.

Assess if specific criteria for empiric Methicillin-resistant Staphylococcus aureus (MRSA) or fungal coverage are met.

The patient is hemodynamically stable, has a clean catheter site, no pneumonia, and this is her first day of fever. Therefore, neither MRSA nor fungal coverage is indicated yet.

Antibiotic stewardship principles dictate avoiding unnecessarily broad agents (like vancomycin) to prevent toxicity and the emergence of resistant organisms.

Select the appropriate pharmacologic agent based on the established parameters.

An intravenous antipseudomonal beta-lactam as monotherapy (such as cefepime, meropenem, or piperacillin-tazobactam) is the correct choice.

This provides the required bactericidal activity against Pseudomonas without violating stewardship principles.

Key Concept

Patients with high-risk febrile neutropenia require immediate empiric intravenous monotherapy with an antipseudomonal beta-lactam (e.g., cefepime, meropenem, piperacillin-tazobactam); vancomycin should not be routinely added without specific indications.

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