Is there any role for empiric coverage of resistant Gram-positive bacteria in febrile neutropaenia?

Vancomycin is still frequently started empirically in febrile neutropaenia, especially when patients are severely ill. Yet randomized evidence concerning anti-Gram-positive agents as a class shows no mortality benefit from routine empirical coverage, and contemporary cohort studies consistently link early shock and death to Gram-negative bacilli, inadequate Gram-negative coverage, pneumonia, septic shock and candidaemia rather than to Gram-positive bacteraemia or inadequate Gram-positive coverage. MRSA nasal screening further supports avoiding empirical anti-MRSA therapy in screen-negative patients. The default response to febrile neutropaenia should therefore be rapid, locally informed anti-pseudomonal beta-lactam therapy, with vancomycin reserved for documented infection or narrowly defined syndromes with a high pre-test probability of resistant Gram-positive disease.