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Infectious Diseases


Answer 2
  1. Stop vancomycin. Due to an increase in the emergence of vancomycin-resistant organisms (ie, vancomycin-resistant enterococci), the use of vancomycin should be restricted to specific indications. In the febrile patient with neutropenia, the recommended indications for the initial empiric use of vancomycin are: (1) suspected/confirmed catheter-related or skin-soft tissue infections (generally caused by gram-positive organisms), (2) blood culture positive for gram-positive bacteria at initiation of empiric therapy, (3) known colonization with methicillin-resistant Staphylococcus aureus or drug-resistant Streptococcus pneumoniae, and (4) septic shock. Because this patient is stable without any of the above-noted features, empiric vancomycin can be safely discontinued at this point. Antimicrobial therapy with cefepime should be continued, and if fever and neutropenia persist beyond 5 to 7 days, consideration should be given to initiating empiric antifungal therapy.

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