Guay David R
College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA.
Hosp Pract (1995). 2012 Feb;40(1):44-74. doi: 10.3810/hp.2012.02.947.
Secondary antimicrobial prophylaxis involves the use of ≥ 1 antimicrobial agent just prior to the time when a diagnostic/therapeutic procedure, which may induce infection, is to be performed. In the context of this article, antimicrobial agent(s) are administered to patients with ≥ 1 implanted prosthetic device in order to prevent metastatic seeding of the device(s) during bacteremia induced by a diagnostic/therapeutic procedure. Antimicrobial agents used in this context are only administered periprocedurally. Secondary antimicrobial prophylaxis of endocarditis in recipients of cardiac prosthetic materials (including valves, shunts, conduits, and patches) has been reasonably well established. However, secondary antimicrobial prophylaxis in recipients of other types of prosthetic devices has been the subject of much controversy, with a wide variety of recommendations being made.
The purpose of this article was to conduct a narrative review of the published literature on the topic of secondary antimicrobial prophylaxis in recipients of noncardiac prosthetic devices and make evidence-based recommendations for each type of device, where possible.
Medline/PubMed and EMBASE databases were searched for English-language articles published from 1950 to the present (January 2012). Search terms included "prophylaxis," "antibiotics," "antimicrobials," "prosthetic devices," "prosthesis-related infections," "bacteremia," the names of the individual types of prosthetic devices, and the names of the individual procedures potentially inducing bacteremia. Articles dealing with any aspect relevant to this topic were eligible for review. The bibliographies of retrieved articles were also carefully scanned to identify any articles not previously identified.
Based on review of the available literature, secondary antimicrobial prophylaxis is justified in only a few specific circumstances. For recipients of prosthetic vascular grafts/stents, hemodialysis arteriovenous shunts, and ventriculoatrial/ventriculovenous shunts, prophylaxis is warranted during the initial 6 months, initial 6 weeks, and at all times after implantation/revision, respectively, when dental procedures capable of inducing high-level bacteremia are planned. Prosthetic joint recipients should receive prophylaxis in the following 3 circumstances: 1) patient is to undergo dental procedure(s) capable of inducing high-level bacteremia plus either the patient is still within 2 years of device implantation/revision or the patient has ≥ 1 risk factor for hematogenous prosthetic joint infection; 2) patient is to undergo genitourinary tract procedure(s) capable of inducing high-level bacteremia plus the patient has ≥ 1 risk factor for high-risk bacteriuria; and 3) patient is to undergo perforating dermatologic surgery on the oral mucosa or at skin sites at increased risk for surgical site infection plus patient has ≥ 1 risk factor for hematogenous prosthetic joint infection. The data are inadequate to justify secondary antimicrobial prophylaxis for recipients of other types of prosthetic devices. On the basis of 9 surveys of prescriber behavior, it is apparent that there exists, over a wide geographic area, a wide disconnect between clinical practice and the secondary antimicrobial prophylaxis guidelines issued by the professional organizations representing these prescribers. Antimicrobial agent overuse was especially problematic among orthopedic and colorectal surgeons, urologists, and family practitioners. Dentists and maxillofacial surgeons followed guidelines more closely.
Device-, procedure-, and patient characteristic-dependent factors elicited over many years have narrowed down the secondary antimicrobial prophylaxis recommendations for noncardiac prosthetic devices to a small number. Despite this, physician prescribers frequently do not follow prophylaxis guidelines established by their own professional organizations. Risk-benefit and cost-effectiveness studies have found that no prophylaxis is actually superior to universal prophylaxis, likely due to known antimicrobial toxicities, such as anaphylactic/anaphylactoid reactions and Clostridium difficile-associated disease. Much work remains in establishing and extending the scientific basis for secondary antimicrobial prophylaxis and transforming this knowledge into appropriate action by the clinician.
二级抗菌预防是指在即将进行可能引发感染的诊断/治疗操作前使用≥1种抗菌药物。在本文中，抗菌药物用于患有≥1个植入假体装置的患者，以防止在诊断/治疗操作引发的菌血症期间假体装置发生转移性播散。在此情况下使用的抗菌药物仅在围手术期给药。心脏人工材料（包括瓣膜、分流器、导管和补片）接受者的心内膜炎二级抗菌预防已得到合理的确立。然而，其他类型假体装置接受者的二级抗菌预防一直存在诸多争议，有各种各样的建议。
本文旨在对已发表的关于非心脏假体装置接受者二级抗菌预防主题的文献进行叙述性综述，并在可能的情况下针对每种装置类型提出基于证据的建议。
检索Medline/PubMed和EMBASE数据库，查找1950年至2012年1月发表的英文文章。检索词包括“预防”“抗生素”“抗菌药物”“假体装置”“假体相关感染”“菌血症”、各种假体装置类型的名称以及可能引发菌血症的各个操作的名称。涉及该主题任何相关方面的文章均符合综述条件。对检索到的文章的参考文献也进行了仔细筛选，以识别任何先前未识别的文章。
基于对现有文献的综述，仅在少数特定情况下二级抗菌预防是合理的。对于人工血管移植物/支架、血液透析动静脉分流器以及脑室心房/脑室静脉分流器的接受者，在计划进行可能引发高度菌血症的牙科操作时，分别在植入后的最初6个月、最初6周以及植入/翻修后的所有时间进行预防是必要的。人工关节接受者在以下3种情况下应接受预防：1）患者即将进行可能引发高度菌血症的牙科操作，且患者仍在装置植入/翻修后2年内，或患者有≥1个血源性人工关节感染的危险因素；2）患者即将进行可能引发高度菌血症的泌尿生殖道操作，且患者有≥1个高危菌尿的危险因素；3）患者即将在口腔黏膜或手术部位感染风险增加的皮肤部位进行穿透性皮肤科手术，且患者有≥1个血源性人工关节感染的危险因素。对于其他类型假体装置接受者，现有数据不足以证明二级抗菌预防的合理性。基于对处方者行为的9项调查，很明显，在广泛的地理区域内，临床实践与代表这些处方者的专业组织发布的二级抗菌预防指南之间存在很大脱节。抗菌药物的过度使用在骨科和结直肠外科医生、泌尿科医生以及家庭医生中尤其成问题。牙医和颌面外科医生更严格地遵循指南。
多年来得出的与装置、操作和患者特征相关的因素已将非心脏假体装置的二级抗菌预防建议缩小到少数几种情况。尽管如此，医生处方者经常不遵循其自身专业组织制定的预防指南。风险效益和成本效益研究发现，实际上不进行预防优于普遍预防，这可能是由于已知的抗菌药物毒性，如过敏/类过敏反应和艰难梭菌相关疾病。在建立和扩展二级抗菌预防的科学基础并将这些知识转化为临床医生的适当行动方面，仍有许多工作要做。
