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Ectopic Pregnancy (Stable) — USMLE Step 2 CK MCQ

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HardObstetrics & GynecologyEctopic Pregnancy (Stable)USMLE Step 2 CK

A 47-year-old woman receiving induction chemotherapy for acute myeloid leukemia has chills and a temperature of 38.6°C (101.5°F). Absolute neutrophil count is 70/mm³ and is expected to remain below 100/mm³ for more than 7 days. Blood pressure is 112/68 mm Hg. Examination shows no focal source, and blood cultures have been obtained. Which is the most appropriate next step?

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Correct answer: E — Admit and begin intravenous cefepime immediately

This is high-risk febrile neutropenia because the absolute neutrophil count is profoundly low and prolonged neutropenia is expected. She requires hospitalization and immediate empiric intravenous antipseudomonal beta-lactam therapy; cefepime is an appropriate first-line agent. Cultures should be obtained promptly, but antibiotics should begin within about 1 hour of triage because inflammatory findings can be minimal and gram-negative bacteremia can progress rapidly. Piperacillin-tazobactam or an antipseudomonal carbapenem are alternatives according to local resistance and allergy history. Vancomycin is added only for specific indications such as hemodynamic instability, pneumonia, a suspected catheter infection, or a skin and soft-tissue focus; none is present here. Colony-stimulating factor does not replace antibiotics. A profoundly neutropenic patient is not suitable for azithromycin or routine outpatient observation. Empiric antifungal therapy is considered when fever persists after several days of broad antibacterial treatment, not as sole therapy for the initial episode.

Reference: Freifeld AG, et al. IDSA Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients With Cancer. Clin Infect Dis. 2011;52:e56-e93. https://www.idsociety.org/practice-guideline/neutropenic-patients-with-cancer/