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Chemoprophylaxis

SAKET.S.DAOKAR

The basis of effective , true


chemoprophylaxis is the use of a drug in
an healthy patient to prevent infection by
one organism of a certain susceptibility to
the administered drug.

e.g. Benzylpenicillin
against a group A streptococci.

It should be used in circumstances in


which efficacy is demonstrated and
benefits outweigh the risk of prophylaxis

Categories in which chemoprophylaxis is


recommended:

True prevention of a primary infection :- e.g. Rheumatic


fever,
recurrent urinary tract infections.

Prevention of opportunistic infections :- e.g. Due to


commensals getting into the wrong place (bacterial
endocarditis after surgery and peritonitis after bowel
surgery), immunocompromised patients can benefit from
chemoprophylaxis.

Suppression of existing infection before it causes overt


disease :- e.g. tuberculosis , malaria , animal bites ,
trauma.

Prevention of spread among contacts :- e.g. If there is a


case of pertussis in the family a nonimmune young fragile
child may benefit from erythromycin.

Problems commonly encountered on the use of chemoprophylaxis

Attempts to use prophylactic drugs for pneumonia in the


unconscious or in the patients with heart failure , in the
newborn after prolonged labour, and in patients with long
term urinary catheters have not only failed but have
sometimes encouraged infections with less susceptible
organisms.

Attempts routinely used to prevent bacterial infection


secondary to viral infections e.g. in respiratory tract
infections measles have not been sufficiently successful to
outweigh the disadvantages of drug allergy and infection
with drug resistant bacteria.

So in these situations it is generally better to be alert for


complications and then to treat them vigorously instead of
trying to prevent them.

There are two types of chemoprophylaxis:-

Surgical Prophylaxis

Nonsurgical Prophylaxis

Surgical Prophylaxis

Surgical site infections (SSIs) are a major site of nosocomical infections. The
estimated annual cost of nosocomical infections in the US is $1.5 billion.

General principles of antimicrobial surgical prophylaxis includes:

1.

The antibiotic should be effective against common surgical wound


pathogen, unnecessarily broad coverage should be avoided as it may lead to
resistance.

2.

The antibiotic has proved efficacy in the clinical trials.

3.

The antibiotic must achieve concentrations greater than the MIC of suspected
pathogens, and these concentrations must be present at the time of the
incision.

4.

The shortest possible course, ie ideally a single dose of the most effective
and least toxic antibiotic should be used.

5.

The newer broad spectrum antibiotics should be reserved for the therapy of
resistant infections.

6.

If all the other factors are equal, the least expensive antibiotic should be
used.

The National Research Council (NRC) wound classification


criteria have served as the basis for recommending
antimicrobial prophylaxis.

The Study of the efficacy of the Nosocomical Infection


Control (SENIC) identified four risk factors for post operative
wound infections:

1.

Operations on the abdomen.

2.

Operations lasting more than 2 hours.

3.

Contaminated or the dirty wound classification of the NRC.

4.

Surgeries for complications which had 3 medical diagnoses.

Patients with at least 2 SENIC risk factors who undergo


clean surgical procedures have an increased risk of developing
surgical wound infection and must receive antimicrobial
prophylaxis.

The surgical procedures that


necessitate the use of
antimicrobial chemoprophylaxis
are:
1.

Contaminated and clean contaminated


operations.

2.

Selected operations in which post


operative infection may be catastrophic
like open heart surgery.

3.

Clean procedures that involve


placement of prosthetic materials.

4.

Any procedures in an immunocompromised host.

Certain points should be kept in mind before administering


prophylactic antimicrobials.

1.

Local wound infection patterns should be considered


before administering antimicrobials.

2.

The selection of vancomycin over cefazolin must be


considered in hospitals with high rates of methicillin
resistant staph aureus or staph epidermidis infections.

3.

In cesarean section antimicrobial is administered after


umbilical cord clamping.

4.

If short acting drugs like cefoxitin are used then the drug
should be re-administered after 3-4 hrs of procedure.
Other wise the parenteral administration till the time of
incision is sufficient.

Nonsurgical Prophylaxis

Nonsurgical prophylaxis includes the administration of


antimicrobials to prevent colonization or asymptomatic
infection as well as the administration of drugs following
colonization by or inoculation of pathogens but before
the development of disease.

Nonsurgical prophylaxis is indicated in individuals who


are at high risk for temporary exposure to selected
virulent pathogens and in patients who are at increased
risk for developing infection because of underlying
disease (e.g. immunocompromised hosts).

Prophylaxis is most effective when directed against


organisms that are predictably susceptible to
antimicrobial agents.