A 4-year-old with ALL (B-cell precursor) in complete remission is on maintenance chemotherapy. He develops fever 39°C, and absolute neutrophil count (ANC) is 300/µL. Blood culture grows Pseudomonas aeruginosa 24 hours later. What is the MOST important empirical antibiotic decision in febrile neutropenia in this high-risk child?

• A Oral amoxicillin-clavulanate as outpatient treatment since he appears well
• B Broad-spectrum anti-pseudomonal beta-lactam monotherapy (piperacillin-tazobactam or cefepime) as first-line ✓
• C Vancomycin empirically for all febrile neutropenia episodes
• D Intravenous ampicillin as empirical coverage for gram-negative bacteremia

Explanation

In high-risk febrile neutropenia (ANC <500/µL with expected prolonged neutropenia or hemodynamic instability), empirical broad-spectrum anti-pseudomonal beta-lactam monotherapy — piperacillin-tazobactam or cefepime (or carbapenem if clinically unstable/prior resistant organisms) — is the standard of care per IDSA guidelines. Pseudomonas aeruginosa is a major cause of mortality in neutropenic patients and must always be covered empirically. Oral therapy and ampicillin are inadequate. Vancomycin is NOT routinely added empirically (only if MRSA risk factors, catheter infection, hemodynamic instability, or preliminary gram-positive results).

Reference: Ghai Essential Pediatrics, 10th ed.

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