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After completing this case study, the reader should be able to:

  • Construct a prudent empiric antibiotic regimen for a febrile neutropenic patient.

  • Determine appropriate situations to use vancomycin in empiric antimicrobial regimens for treatment of febrile neutropenic episodes.

  • Describe situations in which antibiotic monotherapy versus combination therapy would be warranted for empiric treatment of febrile neutropenia.


Chief Complaint

“I have a fever and chills.”


Scarlet Hives is a 60-year-old woman with a history of IgG kappa multiple myeloma who is undergoing an autologous hematopoietic cell transplant. Her stem cells were collected by peripheral blood collection, which were mobilized with cyclophosphamide and filgrastim. During collection she developed a vesicular rash involving her left lower abdominal quadrant, which was documented by PCR analysis to be herpes zoster. This was treated with valacyclovir. Her preparative regimen for transplant was high-dose melphalan, followed by stem cell rescue with her peripheral blood stem cells. Eight days after stem cell infusion, she spiked a fever of 38.6°C (101.5°F). She now also complains of chills and nausea.


IgG kappa multiple myeloma





Peripheral neuropathy

Type 2 DM

Chronic back pain

Surgical History

Hysterectomy—17 years ago


Mother died of CAD at early age; father died at age 67 from lung cancer; has one sister and one brother, both living and well.


High school cafeteria manager of 22 years; now retired. She is married and lives with her husband. She has three children. Denies smoking or alcohol use.


Esomeprazole 40 mg PO once daily

Atorvastatin 80 mg PO once daily

Fentanyl patch 75 mcg Q 48 H

Neurontin 800 mg PO TID

Lisinopril 5 mg PO once daily

Metoprolol 75 mg PO BID

Multivitamin PO once daily

Oxycodone IR 15 mg Q 6 H PRN pain

Pioglitazone 15 mg PO once daily

Promethazine 25 mg PO Q 6 H PRN nausea

Valacyclovir 500 mg PO once daily, after previously completing 1000 mg TID × 7 days for treatment course

Fluconazole 400 mg PO once daily

Levofloxacin 500 mg PO once daily

Senna-docusate capsule ...

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