**14. Types of route antibiotics administration according to risk of infection**

#### **14.1. Low risk neutropenic patients (Oral therapy)**

A recent review has reported that inpatient oral antibacterial therapy can be safely replaced with conventional intravenous treatment among low-risk patients with febrile neutropenia, namely, those who are clinically stable, who do not suffer from acute leukemia, pneumonia, severe soft tissue infection, and who do not have any evidence of organ failure. Among these patients single-agent quinolone was not inferior to combinations of quinolone with amoxicillin plus clavulanic acid, but the latter is preferred when laboratory test show gram-positive infections. Moreover, oral quinolone therapy should not be administered to patients who have already received quinolone as a prophylaxis [71].

#### **14.2. High risk neutropenic patients**

The majority of the treatment guidelines indicate that high-risk neutropenic patients need to be treated with using parenteral broad spectrum antibiotic therapy, that is using standard, hospital-based guidelines. For a long time, the most common approach was the selection and use of combination antimicrobial therapy (beta-lactam plus aminoglycoside antibiotics) [72].

#### **14.3. Duration of therapy**

According to the guidelines from the Infectious Society of America, neutropenic patients who remain febrile but show recovery in neutrophil cell count on the third day of antibiotic therapy could either continue with antibiotics treatment for 7 days or antibiotic treatments can be stopped on the fourth or fifth day.

For those neutropenic febrile patients with no recovery in the ANC it is preferred to continue antibiotics which could only be discontinued after 2 weeks when the examination and cultures show no bacterial growth [69].

#### **14.4. Antifungal drugs**

Fungal treatment is one of the most important steps for neutropenic patients. Even one positive blood culture for candida should be considered significant. Patients with disseminated candidiasis should be treated with fluconazole, which is as effective as amphotericin B and less toxic. If the patient is not stable and has already received fluconazole, amphotericin B is recommended. The treatment should continue until all signs of infections are resolved for a minimum of 2 weeks. Patients with invasive fungal infection are at risk of recurrent infection due to chemotherapy-induced neutropenia [73].

#### **14.5. Antiviral drugs**

The main characteristic of viruses is their simple structure, which helps them multiply. Viruses use the biochemical mechanisms of the host cell to produce new protein and genes. This makes the virus and the host cell identical and makes it difficult for the antiviral drug to distinguish the viral cell from the host cell. In the last couple of years, further information on the mechanism of viral multiplication has helped in the development of antiviral drugs such as acyclovir, which is effective against some herpes viruses. On the other hand, the increase in the use of immunosuppressive drugs had led to an increase in both bacterial and viral infections [74].
