A 55-year-old woman is evaluated in the emergency department for a fever that started earl… — USMLE Step 2 CK

A $55$ -year-old woman is evaluated in the emergency department for a fever that started earlier today. She is currently undergoing systemic chemotherapy for diffuse large B-cell lymphoma; her most recent treatment cycle was $8$ days ago. The patient reports associated chills and generalized weakness. Temperature is $39.0^\circ\text{C}$ ( $102.2^\circ\text{F}$ ), blood pressure is $98/60\text{ mmHg}$ , heart rate is $112/\text{min}$ , and respiratory rate is $18/\text{min}$ . Physical examination reveals a chronically ill-appearing woman. Her indwelling central venous port site appears clean, with no erythema, induration, or purulent discharge. The lungs are clear to auscultation, and the remainder of the examination is unremarkable.

Laboratory studies show:
- Hemoglobin: $9.2\text{ g/dL}$
- Platelets: $85,000/\mu\text{L}$
- Leukocytes: $600/\mu\text{L}$
- Absolute neutrophil count: $150/\mu\text{L}$

Blood and urine cultures are obtained. Which of the following is the most appropriate next step in management?

Administer intravenous cefepimeAnswer
B
Administer intravenous vancomycin
C
Administer oral ciprofloxacin and amoxicillin-clavulanate
D
Administer subcutaneous filgrastim
E
Withhold antibiotics until culture results return

Answer

Administer intravenous cefepime

The correct answer is to administer intravenous cefepime. This patient presents with febrile neutropenia, defined as a single oral temperature of

\geq 38.3^\circ\text{C}

(

101.0^\circ\text{F}

) and an absolute neutrophil count (ANC) of

< 500/\mu\text{L}

. Febrile neutropenia is an oncologic emergency due to the high risk of rapid progression to overwhelming sepsis. Because patients lack adequate neutrophils to mount a focal inflammatory response, a fever is often the only sign of a severe underlying infection. Following the acquisition of blood cultures, high-risk patients must immediately receive empiric intravenous broad-spectrum antibiotics that cover Pseudomonas aeruginosa. Acceptable monotherapy options include an antipseudomonal cephalosporin (e.g., cefepime), a carbapenem (e.g., meropenem), or piperacillin-tazobactam.

Step-by-Step Solution

Identify the patient's primary clinical syndrome.

The patient has a fever of

39.0^\circ\text{C}

and an absolute neutrophil count of

150/\mu\text{L}

following recent chemotherapy.

Establishing the diagnosis of febrile neutropenia is critical as it is an oncologic emergency requiring immediate action.

Risk-stratify the patient to determine the appropriate treatment setting and route of administration.

The patient has borderline hypotension (

98/60\text{ mmHg}

) and tachycardia (

112/\text{min}

), placing her in a high-risk category.

High-risk patients require admission for intravenous empiric antibiotics, whereas strictly low-risk patients might be safely managed with oral regimens.

Select the appropriate initial empiric antibiotic therapy.

An antipseudomonal beta-lactam agent, such as intravenous cefepime, meropenem, or piperacillin-tazobactam, is chosen.

Immediate broad-spectrum coverage targeting Pseudomonas aeruginosa and other gram-negative rods is the standard of care to prevent fatal sepsis.

Key Concept

Immediate empiric treatment of high-risk febrile neutropenia requires intravenous broad-spectrum antibiotics with antipseudomonal activity, such as cefepime.

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