CASEONE: JT is a 5-year-old boy who was brought to the children's hospital emergency department by his parents after spiking a fever of 102.1°F overnight. JT's mother also informs the doctors that JT has had poor food intake since his last chemotherapy. This past week, JT was treated with vincristine, high-dose cyclophosphamide, and etoposide. This cycle was week 14 of 54 of the inductionphase chemotherapy for acute lymphoblastic leukemia. JT receives chemotherapy every other week in the hospital's outpatient clinic.

On this admission, the doctor obtained both a blood culture and complete blood count. The complete blood count for the patient showed a white blood count of 1.6, hemoglobin of 9.3, hematocrit 24.6, and platelets 80,000. On physical exam, the patient has grade II mucositis in the mouth. The patient was started on acetaminophen every 4 to 6 hours as needed for fever, vancomycin every 8 hours, and cefepime every 8 hours.

The doctor admits JT to pediatric oncology. While waiting for the results of the blood cultures, JT continues to spike a fever. When the pharmacist is reviewing JT's chart, she is concerned by the continued temperature spikes. She decides to discuss the issue during the oncology multidisciplinary rounds. She would like to broaden JT's antibiotic coverage.

What bacterial species should the pharmacist cover for? What antibiotic should the pharmacist recommend adding to the regimen to cover this species?

CASETWO: Despite adding gentamicin to his antibiotic therapy, JT is still spiking fevers after 5 days of treatment. On the preliminary results, the blood cultures did not grow any bacteria. During morning rounds, the attending physician asks the medical student what he would recommend. Because the medical student does not have an answer, the attending physician instructs him to look it up after rounds and page him when he has an answer. Immediately following rounds, the medical student approaches the pharmacist and asks for help.

The pharmacist reminds the medical student that JT is receiving coverage for gram-positive and gram-negative bacteria. In an attempt to encourage the medical student to think through the answer, she asks the student what is not being covered by the current regimen. Suddenly experiencing an epiphany, the medical student realizes that the current antibiotic therapy does not cover for yeast.

What additional antimicrobial coverage should the medical student recommend?

CASETHREE: Following discharge, JT returns to the oncology clinic for another round of chemotherapy with vincristine, high dose cyclophosphamide, and etoposide. The physician who normally treats JT is on vacation, so a covering physician is assigned to his case. He asks the pharmacist for assistance since she knows JT's case. Due to the high emetic potential of JT's regimen, the physician inquires if JT received antiemetic therapy. The pharmacist confirms that JT did receive antiemetics. She also informs him that JT suffers from anticipatory nausea and vomiting. The physician asks the pharmacist to recommend medications for both.

What medications should the pharmacist recommend?

Dr. Schlesselman is an assistant clinical professor at the University of Connecticut School of Pharmacy. Mr. Konecny is a PharmD candidate at the University of Connecticut School of Pharmacy.