A patient undergoing chemotherapy develops neutropenic fever. Blood cultures grow Viridans group Streptococcus. Which antibiotic combination should be used empirically pending susceptibility results?

• A Vancomycin alone — all viridans streptococci are susceptible to vancomycin
• B Beta-lactam-based regimen (piperacillin-tazobactam) as first line; add vancomycin if penicillin-resistant or haemodynamically unstable ✓
• C Daptomycin — superior activity against viridans streptococci in pulmonary infections
• D Fluconazole — viridans streptococci are fungal-like commensals

Explanation

Viridans streptococcal bacteraemia in neutropenic patients (typically from oral/gut mucosal breakdown from chemotherapy) is managed with empirical beta-lactam therapy (piperacillin-tazobactam or cefepime for gram-negative coverage is standard). Vancomycin is added if the patient is haemodynamically unstable, has mucositis, or if the strain is known to be penicillin-resistant. Routine addition of vancomycin from the start is discouraged to preserve efficacy and reduce adverse effects. Daptomycin is inactivated by pulmonary surfactant, making it unsuitable for respiratory infections.

Reference: Ananthanarayan & Paniker's Textbook of Microbiology, 11th ed.

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