Empirical and targeted antimicrobial therapy in patients with febrile neutropenia and haematological malignancy or after haematopoietic cell transplantation: recommendations from the 10th European Conference on Infections in Leukaemia.

Febrile neutropenia can lead to life-threatening infections in patients with haematological malignancies or after hematopoietic cell transplantation. Infection management is challenged by rising antibiotic resistance and regional differences in bacterial epidemiology. The 10th European Conference on Infections in Leukaemia panel recommends a personalised approach guided by local resistance patterns and individual risk factors. For patients who are haemodynamically stable without colonisation or infection by resistant Gram-negative bacteria in low-resistance prevalence settings, empirical monotherapy sparing carbapenems or novel β-lactams with or without β-lactamase inhibitors (BLI) is recommended. For patients who are critically ill or haemodynamically unstable, those with previous resistant Gram-negative bacteria colonisation or infection, or in high-resistance prevalence settings, broader-spectrum therapy is indicated. Treatment options include β-lactam plus aminoglycoside combinations, carbapenem with or without BLI, anti-pseudomonal cephalosporin and BLI combinations, or cefiderocol, individualised by local epidemiology and patient factors. Antimicrobial stewardship is recommended, including antimicrobial de-escalation once resistant Gram-negative bacteria infection is excluded; and antibiotic discontinuation regardless of neutrophil count, in patients who are afebrile and stable after completing the intended course. We provide treatment strategies for resistant Gram-negative bacteria infections.