A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 13-year-old male is admitted to the hospital for treatment of acute lymphoblastic leukemia. During his hospital course, he develops a fever of 39.0 degrees Celsius. A CBC demonstrates a leukocyte count of <500 /mm^3. Which of the following is the most appropriate initial management of this patient?
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A
Granulocyte colony-stimulating factor (G-CSF)Incorrect. G-CSF can shorten neutropenia in some patients but is not the immediate management for febrile neutropenia; empiric antibiotics are the life-saving intervention.
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B
IV ceftazidimeCorrect. IV ceftazidime (or an equivalent antipseudomonal beta-lactam such as cefepime, piperacillin-tazobactam, or a carbapenem) is the recommended empiric monotherapy for high-risk febrile neutropenia.
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C
Oral doxycyclineIncorrect. Oral doxycycline lacks adequate antipseudomonal coverage and would be inappropriate for empiric therapy in a high-risk neutropenic patient.
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D
Oral ciprofloxacin and amoxicillin/clavulanic acidIncorrect. Oral fluoroquinolone + amoxicillin-clavulanate is a low-risk febrile neutropenia regimen (used in patients with expected neutropenia <7 days, no comorbidities, hemodynamically stable, and able to take oral meds); this patient with acute leukemia and ANC <500 is high-risk and warrants IV monotherapy.
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E
IV vancomycin monotherapyIncorrect. Vancomycin alone lacks gram-negative and antipseudomonal coverage; it may be added to a beta-lactam in specific scenarios (catheter infection, MRSA risk, hemodynamic instability) but is not appropriate as empiric monotherapy for febrile neutropenia.
↑ Tap an answer to reveal the reasoning
Answer: B. A leukemia patient with neutropenic fever (temperature ≥38.0°C and absolute neutrophil count <500/mm3) is at high risk for life-threatening Gram-negative bacteremia and requires emergent empiric broad-spectrum IV antibiotics with antipseudomonal coverage. The standard of care is monotherapy with an antipseudomonal beta-lactam: cefepime, ceftazidime, piperacillin-tazobactam, or a carbapenem (meropenem, imipenem).
The rationale: Gram-negative bacteremia, particularly Pseudomonas aeruginosa, can rapidly progress to septic shock and death in neutropenic patients. Mortality benefit is greatest when antibiotics are administered within an hour of recognizing fever. Cultures (blood, urine, any indwelling line) and a chest x-ray should be obtained but treatment should not be delayed for results.
Additional agents are added based on clinical scenario: vancomycin for suspected catheter-related infection, skin/soft-tissue source, hemodynamic instability, or known MRSA colonization; an antifungal for persistent fever after 4-7 days of broad-spectrum antibiotics. G-CSF is not first-line empiric therapy but may shorten neutropenia duration in selected cases.
**Why each option:**
**A.** G-CSF can shorten neutropenia in some patients but is not the immediate management for febrile neutropenia; empiric antibiotics are the life-saving intervention.
**B.** Correct. IV ceftazidime (or an equivalent antipseudomonal beta-lactam such as cefepime, piperacillin-tazobactam, or a carbapenem) is the recommended empiric monotherapy for high-risk febrile neutropenia.
**C.** Oral doxycycline lacks adequate antipseudomonal coverage and would be inappropriate for empiric therapy in a high-risk neutropenic patient.
**D.** Oral fluoroquinolone + amoxicillin-clavulanate is a low-risk febrile neutropenia regimen (used in patients with expected neutropenia <7 days, no comorbidities, hemodynamically stable, and able to take oral meds); this patient with acute leukemia and ANC <500 is high-risk and warrants IV monotherapy.