With positive blood cultures, an appropriate duration of therapy should be administered, which may involve home i.v. antibiotics. For fever with negative cultures, the IDSA Guidelines state that antimicrobial therapy may be discontinued when the ANC is 500 cells/mm3 or greater for two consecutive days, if the patient has become afebrile by day 3 of antibiotics.1 If the patient became afebrile after day 3 of antibiotic therapy, the guidelines suggest continuing therapy until the ANC has been 500 cells/mm3 or greater for 4-5 days. The more difficult question is what to do if the patient remains neutropenic. The IDSA Guidelines allow for discontinuation of therapy if the patient is afebrile 5-7 days, has defervesced by day 3, is persistently neu-tropenic by day 7 without positive cultures, and was initially low risk without subsequent complications. However, many centers will elect to trim the antibiotic regimen without complete discontinuation in such cases. In a patient who is at high risk, antibiotics should be continued. If the patient is still febrile on day 3, and later is afebrile but with a neutrophil count which is persistently less than 500 cells/mm3, the recommendation is to reassess and continue antibiotic therapy for two more weeks.1
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