ANTIMICROBIAL PROPHYLAXIS IN BONE-MARROW TRANSPLANTATION

Objective: To review the efficacy of antimicrobial prophylaxis in bone marrow transplantation. Data Sources: English-language articles ident ified through a MEDLINE search (1975 to 1994) and through the bibliogr aphies of selected articles. Study Selection: Articles on the use of a ntimicrobial agents for the prevention of infections in bone marrow tr ansplant recipients and neutropenic patients with cancer. Data Synthes is: Use of quinolones reduces the incidence of gram-negative bacillary infections but increases the frequency of infections caused by strept ococci and staphylococci before marrow engraftment. Death associated w ith cu-hemolytic streptococcal bacteremia is of concern and may justif y the use of penicillin for prophylaxis. Conflicting data exist regard ing prophylaxis with vancomycin. Although ganciclovir has diminished t he incidence of infection and disease caused by cytomegalovirus in ser opositive recipients, drug-induced myelotoxicity, emergence of resista nt virus, and cost are major concerns. High-dose acyclovir may suppres s reactivation of cytomegalovirus. Acyclovir prevents herpes simplex v irus infection, but its prolonged use to prevent reactivation of varic ella-zoster virus is not cost-effective and remains controversial. Flu conazole prevents colonization and infection with Candida species othe r than C. krusei and Torulopsis glabrata before marrow engraftment. El evation of cyclosporine concentrations because of interaction between azoles and cyclosporine requires close monitoring of plasma drug level s. Optimal chemoprophylaxis is not available against aspergillus or fu ngal infections that develop after engraftment. Trimethoprim-sulfameth oxazole decreases the incidence of Pneumocystis carinii infection and ''late'' bacterial infections in recipients of allogeneic transplants who have chronic graft-versus-host disease. Conclusion: Available anti microbial agents can prevent common bacterial, viral, and ''early'' fu ngal infections. However, the few studies that address antimicrobial p rophylaxis in bone marrow transplantation have not always shown a surv ival benefit. Toxicity and cost-effectiveness of prophylactic strategi es should be critically evaluated.