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ANTIMICROBIAL PROPHYLAXIS IN ADULTS

SYMPOSIUM ON ANTIMICROBIAL THERAPY

Antimicrobial Prophylaxis in Adults
Mark J. Enzler, MD; Elie Berbari, MD; and Douglas R. Osmon, MD, MPH

Antimicrobial prophylaxis is commonly used by clinicians for the prevention of numerous infectious diseases, including herpes simplex infection, rheumatic fever, recurrent cellulitis, meningococcal disease,recurrent uncomplicated urinary tract infections in women, spontaneous bacterial peritonitis in patients with cirrhosis, influenza, infective endocarditis, pertussis, and acute necrotizing pancreatitis, as well as infections associated with open fractures, recent prosthetic joint placement, and bite wounds. Perioperative antimicrobial prophylaxis is recommended for various surgical procedures to preventsurgical site infections. Optimal antimicrobial agents for prophylaxis should be bactericidal, nontoxic, inexpensive, and active against the typical pathogens that can cause surgical site infection postoperatively. To maximize its effectiveness, intravenous perioperative prophylaxis should be administered within 30 to 60 minutes before the surgical incision. Antimicrobial prophylaxis should be ofshort duration to decrease toxicity and antimicrobial resistance and to reduce cost. Mayo Clin Proc. 2011;86(7):686-701
AAOS = American Association of Orthopedic Surgeons; ADA = American Dental Association; ANP = acute necrotizing pancreatitis; AP = antimicrobial prophylaxis; AUA = American Urological Association; CP = chemoprophylaxis; FDA = US Food and Drug Administration; HIV = humanimmunodeficiency virus; IDSA = Infectious Diseases Society of America; IE = infective endocarditis; IS = Information Statement; MRSA = methicillin-resistant Staphylococcus aureus; PJI = prosthetic joint infection; PJR = prosthetic joint replacement; RF = rheumatic fever; SBP = spontaneous bacterial peritonitis; SCIP = Surgical Care Improvement Project; Tdap = tetanus toxoid, reduced diphtheria toxoid, andacellular pertussis vaccine, adsorbed; UGI = upper gastrointestinal; UTI = urinary tract infection

antimicrobial agents are not approved by the US Food and Drug Administration (FDA) for prophylaxis. Current full prescribing information available in the package insert of each drug should be consulted before prescribing any product. Detailed information on individual topics can be found in the citedreferences. The potential risks and benefits of AP should be discussed in detail with the patient. Potential risks include allergic reactions that may be severe or life-threatening as well as colitis with the use of antibacterial agents.2 Patients taking fluoroquinolones should be warned of the risk of developing tendinitis, including Achilles tendon rupture.3 For all antibiotic dosing recommendedin this article, normal hepatic and renal function are assumed. NONSURGICAL AP RHEUMATIC FEVER Rheumatic fever (RF), which is associated with tonsillopharyngitis caused by the group A β-hemolytic streptococci, may result in carditis with or without valvulopathy. Primary prevention of RF involves prompt and appropriate antibiotic treatment of group A β-hemolytic streptococcal pharyngitis with apenicillin (drug of choice) or alternative antibiotic.4 Continuous secondary AP prevents recurrent episodes of RF, which could otherwise lead to worsening of the severity of rheumatic heart disease that developed after the initial attack or the development of rheumatic carditis in those who did not develop carditis with the initial RF episode. Guidelines for secondary AP of RF have recently beenupdated (recommendations for AP regimens are summarized in Table 1).4 Penicillins are the antibiotics of choice for secondary prophylaxis for RF, and intramusFrom the Division of Infectious Diseases, Mayo Clinic, Rochester, MN. Address correspondence to Mark J. Enzler, MD, Division of Infectious Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (enzler.mark@mayo.edu). Individual...