Prophylactic Antibiotics

Routine antibacterial prophylaxis is controversial and has been attempted primarily with sulfamethoxazole trimethoprim (SMZ-TMP) and quinolones. SMZ-TMP offers improved prophylaxis for gram-positive organisms compared with quinolones while quinolones are more effective prophylaxis against gram-negative infections. The 2002 Infectious Diseases Society of America (IDSA) guidelines for the use of antimicrobial agents in cancer do not recommend the use of these agents for routine prophylaxis.19 Reasons for this recommendation include the lack of a clear benefit on mortality rates and concerns regarding increasing antibiotic resistance. One exception is that SMZ-TMP is recommended for prophylaxis of Pneumocystis jirovesi ( formerly Pneumocystis carini) pneumonitis (PCP) in all at-risk patients (i.e., bone marrow transplant recipients, AIDS), regardless of the presence of neutropenia.

Two recent meta-analyses add fuel to the controversy of routine antibiotic pro-

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phylaxis. ' Decreases in infection-related mortality and gram-negative bacteremia were demonstrated with the use of quinolones, however overall adverse events were higher and most of the studies were conducted in patients with hematologic malignancies (an inherently high-risk group). Although two additional randomized trials in patients with both solid tumors and hematologic malignancies demonstrated lower rates of FN, infection, and hospitalization with oral prophylactic levofloxacin compared to placebo, the NCCN only recommends prophylactic levofloxacin for patients with expected duration of neutropenia (defined as an ANC less than 1,000/|L) for more than 7 days due to the:

• Unknown long-term consequences on the development of resistant organisms

• Emergence of Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) from fluoroquinolone overuse

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• Ability to treat lower risk patients on an outpatient basis

Therefore, the use of prophylactic quinolones in patients who are at high risk for infection (i.e., hematologic malignancies) is reasonable, however, use should not be routine for low-risk patients. If prophylactic quinolone use is adopted, changes in local patterns of resistance should be closely monitored.

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