# WikiJournal Preprints/Preventive antibiotics in cancer therapy: Evaluating life-saving benefits and associated risks

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## Article information

Authors: Alhamdu Dawa Bulus  , Esther Chidinma Ezeh  , Ritji Victor Goldim  , Odinaka Kingsley Obeta, Myaltong Datok, Uchechukwu Cynthia Ofoma
* ↑ Department of Molecular Biology and Genomics, Global Health and Infectious Diseases Control Institute, Nassarawa State University Keffi, Nigeria
* ↑ Department of Biochemistry, Faculty of Science, Federal University Gashua Yobe State, Nigeria
* ↑ Laboratory Department, Edoch Medical Services, Jos-South Plateau State, Nigeria
* ↑ Department of Health Policy, Planning and Financing Global Health and Infectious Diseases Institute (GHIDI), Nassarawa State University Keffi, Nigeria.
* ↑ Department of Public Health and Preventive Medicine, Ahmadu Bello University Distance Learning Centre Zaria, Kaduna State, Nigeria
* ↑ Polymer Chemistry; Department of Chemistry in Education, University of Jos Plateau State, Nigeria.
* ↑ ezehestherchidinma@gmail.com

## Abstract

care by re-evaluating present methods and embracing a more individualized approach, ensuring that it continues to be an advantageous tool rather than a liability.

## Introduction
### Overview of Infection Risk and Cancer Care

Patients with cancer, especially those undergoing rigorous treatments like radiation or chemotherapy, have weakened immune systems, which puts them at higher risk of infection. As a preventative step to lessen this risk, prophylactic antibiotics are frequently used (Tartari E. et al., 2017). Nevertheless, with antibiotic use growing, questions have been raised concerning the long-term safety and effectiveness of these drugs, particularly in light of the global increase in antimicrobial resistance (AMR) (WHO, 2020). The purpose of this study is to objectively examine whether preventive antibiotics in cancer care are a necessary precautionary measure or if they represent a serious risk that could ultimately jeopardize patient outcomes and public health. It aims to give a thorough knowledge of whether prophylactic antibiotics are a lifeline or liability in the context of cancer treatment by examining existing guidelines, clinical outcomes, and developing issues. Hence, the focus of this review is to assess prophylactic antibiotics' function in cancer care critically by weighing the dangers involved with using them against their potential to save lives.

### Rationale for Prophylactic Antibiotics in Cancer Care

Due to immune system weakness brought on by chemotherapy, radiation, or surgery, cancer patients are more vulnerable to infections (Freifeld AG. et al., 2010). Prophylactic antibiotics are used as a preventive measure since infections are a major source of morbidity and mortality among cancer patients (Rubenstein EB. et al., 2004). The goal of prophylactic antibiotics is to lower the risk of infection, especially in high-risk patients who are neutropenic (Bucaneve G. et al., 2005). Common antibiotics called fluoroquinolones have been shown to lower the frequency of febrile neutropenia (Gafter-Gvili A. et al., 2012). Prophylactic antibiotics have been demonstrated in studies to benefit patients with acute myeloid leukaemia, that receiving hematopoietic stem cell transplantation and certain cancer populations by significantly reducing infection rates and improving overall survival (Cullen M. et al., 2005; Pohlen M. et al., 2016).
A significant contributor to morbidity and mortality in cancer patients, especially those receiving intense chemotherapy or hematopoietic stem cell transplantation (HSCT), are infection-related problems. By concentrating on common bacteria, before they have a chance to cause infections, prophylactic antibiotics can reduce these dangers. Studies have indicated that this strategy lowers morbidity and death associated with infections (Freifeld AG. et al., 2010).
Preventive antibiotics can lessen the frequency and severity of infections, which can enhance the quality of life for cancer patients. Patients' overall quality of life is improved by preventing infections because it saves money on further treatments, hospital stays, and the discomfort that goes along with them (Pizzo PA. et al., 1984). Nonetheless, a major obstacle to the treatment of cancer is the emergence of bacteria that are resistant to antibiotics, which is associated with antibiotic overuse (Tacconelli E. et al., 2018; Kelly CR. et al., 2021); antibiotics can also disturb the normal microbiome, which might result in further issues such Clostridium difficile infections.

### The Debate: Lifeline or Liability?

The use of preventive antibiotics in cancer therapy presents a double-edged sword. On one hand, they serve as a critical safety net for immunocompromised patients, reducing the risk of life-threatening infections. For cancer patients undergoing treatments like chemotherapy or radiation, where immune function is severely weakened, antibiotics play a life-saving role by preventing bacterial infections, such as febrile neutropenia, which can significantly improve survival rates and treatment outcomes (Gafter-Gvili A. et al., 2012; Cullen M. et al., 2005). This is especially true for high-risk populations, such as those receiving hematopoietic stem cell transplants or intensive chemotherapy regimens, where infection risks are elevated (Freifeld AG. et al., 2010).
However, the benefits of prophylactic antibiotics are countered by significant risks. One major concern is the development of antimicrobial resistance (AMR), a global public health crisis exacerbated by the overuse and misuse of antibiotics (Tacconelli E. et al., 2018). Frequent use of broad-spectrum antibiotics, such as fluoroquinolones, can lead to the emergence of resistant bacterial strains, which complicates future treatments and reduces antibiotic efficacy (Paterson DL. Et al., 2006; Gudiol C. et al., 2010). This issue not only threatens individual patient outcomes but also presents a broader risk to public health, as resistant infections are becoming increasingly difficult to treat (Lode HM. et al., 2010).
Additionally, the use of antibiotics can disrupt the patient's microbiome, leading to complications such as Clostridium difficile infections, which have been linked to the overuse of antibiotics (Kelly CR. et al., 2021). Such disruptions to the microbiome can weaken immune defences, making patients more vulnerable to other infections and potentially affecting the effectiveness of cancer treatments (Montassier E. et al., 2015). Furthermore, antibiotics can cause adverse drug reactions, ranging from mild gastrointestinal issues to severe allergic responses and life-threatening conditions like Stevens-Johnson syndrome (Arora R. et al., 2021).
Thus, while prophylactic antibiotics are indispensable in managing infection risks for cancer patients, their use must be carefully balanced against the potential for harm. Determining when the benefits of antibiotic use outweigh the risks requires a more personalized approach, considering factors such as cancer type, treatment regimen, and individual patient health (Taplitz RA. et al., 2018). Without careful stewardship, the life-saving potential of antibiotics could be undermined by the very risks they pose, turning a safety net into a liability.

## Cancer and Infection Risk

Patients with cancer are frequently more susceptible to infections because of the illness itself as well as the therapies they receive, such as radiation and chemotherapy. Immunosuppression, neutropenia (a decrease in white blood cells), and disruption of mucosal barriers that often guard against infections are the main causes of this elevated risk.
Patients undergoing cancer therapies, such as radiation and chemotherapy, frequently experience immunosuppression, which leaves them extremely vulnerable to infections. Particularly, a higher risk of bacterial infections is linked to chemotherapy-induced neutropenia, a condition in which white blood cell numbers drastically decrease (Kuderer NM. et al., 2006). Antibiotics are essential in preventing potentially fatal infections in this immunosuppressed state, which calls for strict infection control measures.

### Immunosuppression in Cancer Patients

Cancer and its therapies might weaken the immune system in several ways. For instance, chemotherapy can harm cells that divide quickly, such as those in the bone marrow, which lowers the generation of immune cells like neutrophils, which are essential for battling infections. By changing bone marrow and immune cell synthesis, radiation therapy can also compromise immunological function.
Individuals, who suffer from haematological malignancies, including lymphoma or leukaemia, are more vulnerable because these illnesses affect blood cells, including immunological cells. Further suppression of immune function can result from treatments such as corticosteroids and some biologic medicines (e.g., rituximab, which targets B cells), leaving patients more vulnerable to infections by bacteria, fungi, and viruses (Nates JL. et al., 2024; Sharma A. et al., 2024).

### Common Infections in People with Cancer

Common bacteria like Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa are frequently involved in infections in cancer patients (Kuderer NM. et al., 2006). Bloodstream infections are very deadly because of their quick progression and high fatality rates. These infections can range in severity from moderate to severe.
Neutropenia, a common side effect of chemotherapy, raises the risk of bacterial infections, particularly bloodstream infections that can result in sepsis. This increases the likelihood of bacterial infections. If these infections are not treated right away, they may become fatal. Fungal infections are the result of immunosuppression, and individuals who have chronic neutropenia are more susceptible to opportunistic fungal infections. Immunosuppressed patients, particularly those receiving bone marrow or stem cell transplants, are susceptible to serious consequences from viruses including cytomegalovirus and herpes simplex virus (Nates JL et al., 2024).
Treatment is made more difficult by the existence of multidrug-resistant (MDR) organisms, which emphasizes the significance of efficient preventative measures (Gudiol C. et al., 2010).

### Methods for Lowering the Risk of Infection

Prophylactic antibiotics, antifungals, and antiviral drugs are common preventive strategies used by high-risk individuals to reduce their chance of infection. Growth factors, such as granulocyte-colony stimulating factor (G-CSF), can be given to increase the production of white blood cells and shorten the period of neutropenia, which lowers the risk of infection (Nates JL. et al., 2024).
A complicated interaction between the disease's effects, treatment plans, and unique patient characteristics results in the immunological suppression seen in cancer patients. Monitoring closely, taking preventative measures, and using specialized treatment plans to strengthen the immune system when appropriate are all necessary to manage these risks.

## Antibiotic prophylaxis in oncology

In oncology, prophylactic antibiotics are mainly used to avoid infections in patients who are more vulnerable as a result of cancer treatments like radiation or chemotherapy, which can cause neutropenia, or a marked decrease in neutrophils, a subset of white blood cells. According to (Freifeld AG. et al., 2010), this elevated risk of infections might result in serious side effects including febrile neutropenia, which can postpone therapy and raise mortality.

### Present Recommendations

Prophylactic antibiotic treatment is advised in patients at high risk of febrile neutropenia, according to current guidelines from prominent health organizations including the Infectious Diseases Society of America (IDSA) and the National Comprehensive Cancer Network (NCCN) (Flowers CR, et al., 2013). According to (Taplitz RA. et al., 2018), the American Society of Clinical Oncology (ASCO) has guidelines that suggest prophylactic antibiotic usage in high-risk cancer patients. The guidelines highlight the necessity to weigh the advantages of infection prevention against the risks of resistance and undesirable effects.
These recommendations however do also highlight the necessity of weighing the advantages of infection control against the dangers of acquiring AMR.

### Types and Indications of Prophylactic Antibiotic Use

Patients who experience prolonged and severe neutropenia (absolute neutrophil count < 500 cells/µL), which is frequently observed in patients receiving chemotherapy for solid tumours or hematologic malignancies, as well as those receiving hematopoietic stem cell transplantation (HSCT), are generally advised to take prophylactic antibiotics (Freifeld AG. et al., 2010).
Due to their broad-spectrum activity against both grammeme-positive and grammeme-negative bacteria, fluoroquinolones—such as ciprofloxacin and levofloxacin—are the most often used preventive antibiotics in cancer therapy (Gafter–Gvili A, et al., 2007). Because fluoroquinolones, such as ciprofloxacin and levofloxacin, are effective against Gramme-negative bacteria, which are frequently linked to infections in patients with neutropenia, they are frequently used for bacterial prophylaxis (Gafter – Gvili A, et al., 2007).
To avoid infections, some pathogens, such as Pneumocystis jirovecii, employ alternative medicines, like sulfamethoxazole-trimethoprim. Its use is also beneficial for patients receiving other immunosuppressive therapy or high-dose corticosteroids (Freifeld AG. et al., 2010). The use of antifungal (fluconazole, for example) and antiviral (acyclovir, for example) prophylaxis may also be restricted by specific risk factors and institutional procedures (Freifeld AG. et al., 2010).

### Risks and Considerations

The emergence of antibiotic-resistant organisms as a result of extended and widespread use is a significant worry and is becoming a bigger problem in the field of oncology. According to (Freifeld AG. et al., 2010), side effects from prophylactic antibiotics include gastrointestinal distress, Clostridium difficile infection, and allergic responses.
There are a few things to think about when using preventative antibiotics including; practices for infection control and cross-infection, behaviour and psychological aspects, and Low-Resource and Global Configurations.

#### Practices for Infection Control and Cross-Infection

In oncology settings, infection control methods should be viewed more broadly when considering the inclusion of prophylactic antibiotics in cancer care. Antibiotics used prophylactically are one part of a comprehensive strategy to avoid infections, especially in people with impaired immune systems. To avoid unforeseen outcomes like cross-infection and the emergence of resistant organisms, we must carefully balance their use with other infection control strategies.

#### Protocols for isolation and environmental controls

Reducing infection risks in cancer wards is mostly dependent on infection control strategies like stringent environmental cleaning, frequent screening for multidrug-resistant organisms (MDROs), and the application of isolation techniques (Freifeld AG. et al., 2010). Prophylactic antibiotic use ought to supplement these methods rather than take their place, since depending just on: antibiotics can cause complacency in other crucial areas of infection control (Wilson BE, et al., 2020).

#### Handwashing practices and staff training

Reducing hospital-acquired infections (HAIs) in cancer patients requires ongoing staff education and a focus on hand hygiene. Improved hand hygiene compliance among healthcare workers has been demonstrated in studies to considerably lower the incidence of HAIs, particularly those brought on by bacteria resistant to antibiotics (Allegranzi B, et al., 2013). Prophylactic antibiotic use must be carefully managed to avoid compromising these efforts by giving rise to a false sense of security.

#### Risk of Clostridium difficile infection (CDI)

Antibiotics used prophylactically may raise the risk of CDI, which is a serious issue in oncology units. By putting in place strict infection control procedures and antibiotic stewardship programs, oncology facilities can reduce this risk. Antibiotics should only be used when necessary (Tamma PD, et al., 2014).

#### Behaviour and psychological aspects to take into account

Prophylactic antibiotic use has the potential to change patient attitudes and behaviour, which can influence compliance with more comprehensive infection prevention measures. It is essential to comprehend these behavioural and psychological factors in order to maximize patient outcomes when receiving cancer treatment.

##### The sense of security

Prophylactic antibiotic recipients may believe they are immune to infections, which could result in less adherence to other preventive measures such eating a restricted diet or practicing good personal hygiene (Lederberg J., 2000). Healthcare professionals should inform patients about the drawbacks of antibiotics, as well as the value of a thorough infection prevention strategy.

##### Antibiotic Dependency and Perception of Resistance

Patients run the danger of becoming dependent on antibiotics, which could raise demand for the drugs even in situations where they are not medically necessary. The larger problem of antibiotic resistance may be exacerbated by this behaviour (Davis ME, et al., 2017). Teaching patients about the responsible use of antibiotics and the worldwide effects of antibiotic resistance can reduce these dangers.

##### Effect on Life Quality

Prophylactic antibiotic side effects, like gastrointestinal problems or allergic responses, can seriously impair a patient's quality of life. Additionally, the psychological weight of possible side effects may cause worry or worsen treatment compliance. Managing patient expectations and encouraging adherence to other protective behaviours need addressing these issues through counselling and clear communication.

#### Low-Resource and Global Configurations

In global and low-resource contexts, where the balance of benefits and dangers may fluctuate dramatically due to variations in healthcare infrastructure, antibiotic availability, and local resistance patterns, the use of prophylactic antibiotics in cancer therapy poses distinct problems.

##### Problems in Low-Resource Environments

Implementing preventive antibiotic treatments can be challenging in low-resource settings due to restricted access to medical facilities, diagnostic equipment, and medications. Furthermore, because of over-the-counter sales and a lack of regulatory control, these areas frequently have high rates of antibiotic resistance (Laxminarayan R, et al., 2013). When preventive antibiotics are used indiscriminately in certain conditions, resistance problems may worsen and the medications' effectiveness may be diminished when they are actually needed.

##### Customized Approaches

It is imperative to implement customized preventive interventions that take into account local resistance trends and epidemiology. To lessen dependency on broad-spectrum medications that fuel resistance, guidelines for instance, might advise using probiotics or immunomodulators as an alternative to antibiotic prophylaxis.

##### Issues of equity and access

In low-resource contexts, fairness in access to preventive measures such as prophylactic antibiotics is a major concern. Without worsening already-existing disparities, we should work to guarantee that cancer patients in these areas receive sufficient care for infection prevention. Collaborations with foreign organizations and regional administrations can assist in supplying the tools and instruction required to put into practice efficient infection control procedures.

##### Budgetary efficiency and resource distribution

In environments with limited resources, cost-effectiveness needs to be taken into account. Invest resources in regions where they can have the biggest impact, concentrating on patients who are most at risk of infection and who stand to gain the most from prophylaxis. We must make sure that healthcare resources and available antibiotics are used fairly and efficiently in order to provide the best results for patients (Bodey GP, et al., 1983).

## Advantages of Preventive Antibiotic Use

Preventive antibiotics, on the one hand, have been shown to dramatically cut the occurrence of infections, which lowers hospitalization rates and improves quality of life for cancer patients. Patients with severe neutropenia or those receiving bone marrow transplants, when there is a significant danger of infection, benefit most from them. Research has indicated that prompt use of antibiotics might avert potentially fatal consequences, making it an essential part of supportive cancer treatment.

### Preventing infections

Patients with cancer, particularly those receiving chemotherapy, are more vulnerable to infections because of neutropenia. Prophylactic antibiotics help these patients avoid bacterial infections; examples are trimethoprim-sulfamethoxazole, macrolides, and fluoroquinolones. Prophylactic fluoroquinolones decreased the risk of febrile episodes, recorded infections, and infection-related mortality in patients with neutropenia, according to a meta-analysis by (Gafter – Gvili A, et al., 2007). These results highlight the critical role that antibiotics play in protecting susceptible cancer patients from potentially fatal infections. Prophylactic usage of certain antibiotics is advised for patients with haematological malignancies in order to prevent certain infections, such as pneumocystis pneumonia (PCP). To avoid PCP, for example, these patients frequently take trimethoprim-sulfamethoxazole.

### Decreased Chance of Sepsis

One frequent and dangerous side effect of chemotherapy is febrile neutropenia, which can result in infections that could be fatal. According to (Cullen M. et al., 2005), preventive antibiotics can reduce the frequency of febrile neutropenia, enabling continuous cancer treatment regimens.

### Decreased Death and Morbidity

Prophylactic antibiotics lower hospital admissions, intensive care unit stays, and overall death rates in cancer patients by preventing infections. According to (Freifeld AG. et al., 2010), this can greatly enhance both the overall results of treatment and quality of life. Fluoroquinolone prophylaxis in neutropenic individuals was shown to significantly reduce all-cause mortality, according to a study by (Cullen M. et al., 2005). Patients receiving intense chemotherapy gain the most from this, as they are at the biggest risk of developing deadly infections.

### Life Quality

By lowering the frequency of hospital stays, fever episodes, and the need for further therapies, infection prevention by preventive antibiotic use can also enhance the quality of life for cancer patients. Patients can stick to their treatment plans and avoid the mental and physical effects of serious diseases by avoiding infections.

## Use of Prophylactic Antibiotics: Drawbacks and Hazards

However, frequent use of antibiotics carries a number of hazards, such as the development of organisms resistant to several drugs, which can make future treatments more difficult to implement and worsen the prognosis for patients. Antibiotic resistance is a global public health concern that is exacerbated by the careless use of antibiotics, thus its use in cancer treatment must be more tailored and prudent.

### Development of Antimicrobial Resistance

Prophylactic antibiotic treatment carries a number of major dangers, one of which is antimicrobial resistance (AMR). The selective pressure that promotes the emergence of resistant strains, especially in Gramme-negative bacteria, is exacerbated by the extensive use of antibiotics in cancer treatment (Paterson DL. Et al., 2006). Multidrug-resistant organisms can colonize and infect cancer patients receiving preventive antibiotic treatment, according to studies (Gudiol C. et al., 2010).
Antibiotic overuse and misuse can result in the formation of multidrug-resistant organisms, which are dangerous for patient health and the public since they are difficult to treat (Lode HM. et al., 2010).

### Adverse Reactions to Drugs

Antibiotics can bring on side effects from mild (such gastrointestinal distress and allergic responses) to severe (like a Clostridium difficile infection, which can result in severe diarrhoea and colitis). These responses may impair the health of the patient and make cancer treatment more difficult (Bartlett JG, et al., 2002).
Antibiotic side effects in cancer patients who use them frequently or for an extended period can range from minor gastrointestinal issues to serious, life-threatening illnesses like Stevens-Johnson syndrome (Arora R. et al., 2021). These adverse effects may make managing cancer more difficult and lower patients' tolerance to treatment as a whole.

### The Microbiome Is Disrupted

Preventive antibiotics have the potential to upset the balance of the microbiome, leading to dysbiosis and a host of unfavourable consequences, including Clostridium difficile infections (Alexander JL, et al., 2017). This may weaken the immune system, make one more vulnerable to infections, and even affect how well cancer treatments work (Montassier E. et al., 2015).
Since there is growing evidence that a healthy microbiome influences how the body reacts to treatments like immunotherapy, alteration of the gut microbiota may also impact the effectiveness of cancer medicines (Gopalakrishnan V, et al., 2018).

### Price and Utilization of Resources

Due to the cost of the medications themselves, side effect monitoring, and addressing issues resulting from antibiotic resistance or bad effects, the use of prophylactic antibiotics can result in higher healthcare expenses.

## Juggling the Benefits and Risks

A thorough evaluation of each patient's risk for infection, the possibility of side effects, and the possibility of antibiotic resistance is necessary to weigh the advantages and disadvantages of prophylactic antibiotic use in cancer treatment. The decision to take prophylactic antibiotics should be guided by clinical guidelines, patient-specific considerations, and a multidisciplinary approach comprising infectious disease specialists, pharmacists, and oncologists.

### Stratification of Risk

It is essential to stratify patients according to their unique infection and AMR risk factors in order to optimize the advantages of prophylactic antibiotics while reducing the hazards. Patients with high-risk factors—such as those experiencing prolonged and profound neutropenia (absolute neutrophil count < 100 cells/µL for more than seven days), which is commonly observed in patients receiving intense chemotherapy for acute leukaemia or undergoing hematopoietic stem cell transplantation—are generally advised to take prophylactic antibiotics; low-risk patients, on the other hand, may be treated with different approaches.
According to (Taplitz RA. et al., 2018), patients with solid tumours undergoing less rigorous chemotherapy may not require routine prophylactic antibiotics due to their decreased likelihood of severe neutropenia. This could minimize unnecessary exposure and the potential for resistance.
Patients receiving high-intensity chemotherapy or those with haematological malignancies are more susceptible to infections and may benefit more from taking preventive antibiotics. Individuals with severe neutropenia, such as an absolute neutrophil count below 500 cells/µL, may need to take preventative antibiotics (Klastersky J, et al., 2006).

### Selecting the Appropriate Antibiotic

The local epidemiology of infections and patterns of resistance should be taken into consideration while choosing antibiotics. Given that fluoroquinolones are frequently used to treat Gram-negative bacteria, it is important to take the patient's history of colonization or infection into account (Gafter – Gvili A, et al., 2007).
To reduce the likelihood of selecting for resistant organisms and to prevent disruption of the patient's normal flora, utilize narrow-spectrum antibiotics whenever possible (Freifeld AG. et al., 2010).
Prophylactic use of narrow-spectrum antibiotics can help reduce the likelihood of resistance. Compared to broad-spectrum antibiotics, narrow-spectrum drugs focus on particular pathogens and have less of an effect on the microbial ecology as a whole.

### Monitoring for Adverse Effects

In order to identify and treat any side effects, such as gastrointestinal disorders, allergic responses, or Clostridium difficile infection, patients using prophylactic antibiotics must be regularly monitored. If side effects outweigh the advantages, this diligence aids in quickly stopping or switching antibiotics (Freifeld AG. et al., 2010).

### Restricting the Prophylactic Duration

Restrict prophylaxis to times when there is a high risk, like during a period of acute neutropenia. Steer clear of extended use to reduce the possibility of resistance and other negative effects (Freifeld AG. et al., 2010).
A more individualized strategy may be possible in certain situations where the length of prophylaxis is modified in response to the patient's clinical status and neutrophil count recovery (Taplitz RA. et al., 2018).

### Personalized Medicine Approach

Tailored prophylaxis based on patient-specific characteristics, including the type of cancer, the chemotherapy regimen, and the patient's overall health status. This tailored strategy minimizes potential side effects, such as the possibility of bacterial strains becoming resistant, while maximizing the advantages of prophylaxis. Prophylactic techniques can be optimized with a tailored strategy to antibiotic use that takes the patient's immunological condition, treatment regimen, and microbiome into account. While still offering sufficient defence against infections, personalized medication may lessen needless antibiotic exposure and lessen the dangers associated with antimicrobial resistance (AMR).

### Antimicrobial Stewardship Integration

Antimicrobial stewardship programs (ASP) are essential for maximizing the use of preventive antibiotics in oncology settings. These initiatives keep an eye on patterns of antibiotic resistance inside the facility and guarantee that prophylaxis is used appropriately, considering patient-specific risks as well as current guidelines (Freifeld AG. et al., 2010).
The creation of regional policies ought to be aided by the stewardship program. The incidence of resistant organisms and the unique requirements of the patient group should be considered when developing evidence-based, regionally tailored guidelines for the use of antibiotics. The concepts of antimicrobial stewardship, which include knowing the importance of using antibiotics appropriately and the hazards associated with resistance, are taught to healthcare practitioners. In order to guarantee adherence to standards and make necessary adjustments to practices, ASPs put in place systems for tracking the use of antibiotics and giving feedback to healthcare practitioners (Bodey GP, et al., 1983).

### Shared Decision-Making and Patient Education

Talking with patients about the advantages and disadvantages of preventive antibiotics might help customize the treatment to their unique needs and preferences. A collaborative approach to therapy is facilitated by educating patients about potential side effects, the significance of adhering to prescribed medications, and infection signs (Taplitz RA. et al., 2018).

## Alternative Strategies to Avoid Infections

By utilizing the body's immune system, advantageous microbes, or compounds that directly inhibit dangerous bacteria without causing antibiotic resistance, these tactics provide alternatives to antibiotics. Given the rise in antibiotic resistance, other approaches to antibiotic prophylaxis warrant consideration.

### Non-Antibiotic Prophylaxis

Granulocyte-colony stimulating factors (G-CSFs), which increase the formation of white blood cells and shorten the duration of neutropenia, are an alternative strategy for preventing infections in cancer patients (Smith TJ, et al., 2015). Antibiotic prophylaxis would otherwise be necessary to prevent infections that can be prevented by vaccination. As an illustration, vaccinations against influenza, meningococcus, and pneumococcus lower the incidence of illnesses (Plotkin SA, et al., 2014).
Other approaches to preventing infections without antibiotics include:

#### Hygiene and Infection Control Measures

To lower the risk of infections, strict hygiene measures such as handwashing and sterile procedures must be followed. Infection control techniques should be taught to patients and healthcare professionals (Pizzo PA. et al., 1984).

#### Assistive Healthcare

To improve patients' general health and resistance to infections, improve supportive care strategies include treating comorbidities and offering nutritional support.

### The Microbiome's Function

Without the use of antibiotics, maintaining and repairing the gut microbiota is showing promise as a means of preventing infections. Probiotics, faecal microbiota transplantation, and dietary modifications are being investigated by researchers as ways to help cancer patients maintain a healthy microbiome and lower their risk of infection. Probiotics, or good bacteria, can aid in the prevention of infections by strengthening the immune system, creating antimicrobial compounds, and competing with pathogens for resources and adhesion sites (Ouwehand AC, et al., 2016).

### Immunotherapy

The development of immunotherapy has created new opportunities for preventing infections. Therapies such checkpoint inhibitors, which strengthen the patient's immune system, may lessen the need for preventative antibiotics. Immunomodulatory treatments strengthen the immune system's ability to fend against infections without going after the bacteria directly. Furthermore, continuing studies into cutting-edge antimicrobial agents, including antimicrobial peptides and bacteriophages, may offer substitutes for conventional infection management strategies in cancer settings (Czaplewski L, et al., 2016). Antimicrobial peptides (AMPs) are a component of the innate immune system that damage bacterial membranes to stop infections (Zasloff M, et al., 2002).
Viral agents known as "bacteriophages" target only bacteria, providing a focused method of preventing infections without interfering with the body's natural flora (Abedon ST, et al., 2017).

### Silver Nanoparticles

Silver nanoparticles offer broad-spectrum antibacterial characteristics that can be used in medical device coatings to prevent infections (Rai M, et al., 2009).

### Plant-Derived Compounds

Plant extracts and essential oils are examples of compounds with antibacterial qualities that can operate as substitute preventive measures (Burt S, et al., 2004).
By inhibiting bacterial adhesion to the urinary system lining, cranberry extracts are used by researchers to prevent urinary tract infections (Jepson RG, et al., 2012). Prebiotics strengthen the body's defences against infections by encouraging the growth of good bacteria (Slavin J, et al., 2013).

## Policy and Practice Implications

In cancer care, antibiotic prophylaxis is essential for preventing infections, particularly in patients with impaired immune systems. The approach however does, also bring up issues with patient safety, antibiotic resistance, and the requirement for evidence-based practices, policies, and standards.

### Guidelines Updates

Clinical guidelines need to be reviewed and maybe revised in light of the dangers associated with prophylactic antibiotic usage. This will allow them to incorporate the most recent findings on antimicrobial resistance (AMR) and infection control measures in cancer care. According to (Paul M, et al., 2014), guidelines ought to prioritise the prudent use of antibiotics and promote the incorporation of non-antibiotic prophylactic techniques when applicable.
Specific antibiotic prophylaxis regimens are recommended based on the patient's risk of infection and the type of cancer treatment, according to guidelines such as those from the Infectious Diseases Society of America (IDSA). According to (Freifeld AG. et al., 2010), these recommendations aid in standardizing care and lowering the overuse of antibiotics.

### Antibiotics Stewardship in Oncology

Fighting antimicrobial resistance (AMR) requires the implementation of antibiotic stewardship programs designed especially for oncology settings. The goals of these initiatives ought to be to monitor patterns of resistance, optimize the use of antibiotics, and inform medical professionals about the dangers of misuse (MacDougall C, et al., 2005).

### Global Health Perspective

The obstacles associated with the proactive use of antibiotics in cancer treatment are especially severe in low- and middle-income countries (LMICs), where there is restricted access to both effective antibiotics and cancer treatment. Global health programs in these environments need to give top priority to creating context-specific infection and antimicrobial resistance management plans for cancer patients (Pramesh CS, et al., 2022).
A one-size-fits-all strategy for prophylactic antibiotics might not be practical in environments with limited resources. Rather, healthcare professionals to identify the patients who stand the best chance of benefiting from prophylaxis should use risk stratification.

### Infection Surveillance and Frequent Evaluations

Early identification of infection trends and resistance patterns is facilitated by the deployment of surveillance systems to track infections and antibiotic use in cancer patients. Clinical results can be enhanced and policy changes can be informed by consistent reporting and feedback. We should routinely evaluate and update preventative procedures in light of new therapeutic choices, changing clinical practices, and emerging evidence on resistance patterns in order to maintain their efficacy and relevance.

### Education of Patients and Healthcare Providers

Guidelines compliance and stewardship initiatives can be strengthened by educating patients and healthcare professionals on the proper use of prophylactic antibiotics and the dangers of overusing them. When appropriate, policies should promote the use of narrow-spectrum antibiotics to lower the likelihood of resistance development. Broad-spectrum antibiotics only should be used in high-risk situations, or when the pathogen is unclear (Pizzo PA, et al., 1993).

## Future Research Directions

Since cancer, patients frequently have weakened immune systems because of their illness or therapies like chemotherapy, prophylactic antibiotics are used in cancer care to prevent infections. Subsequent investigations in this field need to focus on optimizing the application of these antibiotics to enhance patient results, diminish the incidence of infections during cancer treatment, and tackle the worldwide predicament of antibiotic resistance. The long-term effects of prophylactic antibiotic usage on cancer recurrence and the function of the microbiome in modifying cancer outcomes are two areas of the existing literature that need more research. To create and validate risk classification instruments that can direct individualized preventative measures, more study is required.
Subsequent investigations ought to delve into inventive methods of averting infections, like employing nanotechnology to administer specific antibacterial treatments or creating immunizations against germs that are resistant to several drugs. Research on the impact of incorporating antibiotic stewardship into standard cancer therapy, and how it affects patient outcomes might also be beneficial (Willyard C, et al., 2017).

### Tailored Prevention

Based on the unique risk variables of each patient, such as their microbiome, treatment plan, cancer kind, and genetic susceptibility, creating more personalized ways to antibiotic prophylaxis is a way forward. This is because patients with cancer who get prophylactic antibiotics may have altered gut microbiomes, which may have an impact on treatment response, infection risk, and cancer progression (Montassier E. et al., 2015).

### Long-Term Outcomes

To give a thorough picture of the advantages and disadvantages, the long-term effects of antibiotic prophylaxis, including the influence on cancer recurrence, survival, and quality of life has to be thoroughly examined.

### Novel Antibiotics and their substitutes

Investigating non-antibiotic options, such as bacteriophages, probiotics, or immunomodulatory treatments, to avoid infections, or investigating novel antibiotics that are efficient against resistant organisms (Schooley RT, et al., 2017). In order to improve patient selection criteria, researchers are finding biomarkers that can detect which patients are most likely to become infected and would benefit most from preventive antibiotics.

### Mitigating Infections in Particular Populations

Prophylactic techniques unique to cancer populations are also a way forward in oncology care especially for patients receiving immunotherapy, those having bone marrow transplants, and those with solid tumours as opposed to haematological malignancies (Baden LR, et al., 2016).

### Clinical Trials and Empirical Data

In addition to gathering real-world data to inform clinical practice, carrying out extensive clinical trials to assess the safety and effectiveness of various preventive regimens is a vital recommendation that should be looked at (Gudiol C. et al., 2010).

### Economic Efficiency Studies

To make sure that the advantages of antibiotic prophylaxis exceed the dangers and expenses related to its usage, evaluating the cost-effectiveness of different preventative measures is crucial especially for patients with cancer (Flowers CR, et al., 2013).

## Conclusion

In the treatment of cancer, preventive antibiotics are both a lifesaver and a liability. Although they are essential for preventing infections and enhancing patient outcomes, abuse of them exacerbates the issue of antimicrobial resistance (AMR) and may have unfavourable effects on other aspects of health. Optimizing prophylactic antibiotic benefits while minimizing hazards requires a well-rounded strategy that incorporates risk classification, personalized therapy, and the incorporation of alternative infection prevention techniques. Ongoing research and policy revisions will be essential to guarantee that prophylactic antibiotic use remains a useful tool in oncology care as the landscape of cancer treatment continues to change.

## Additional information
### Author Contributions

Alhamdu Dawa Bulus made significant contributions to the planning, coordination, critically reviewing, and supervising of this review. Ritji Victor Goldim took the responsibility of literature search, gathering of relevant informations, and drafting the work. Esther Chidinma Ezeh critically revised, and edited the work as the corresponding author. Odinaka Kingsley Obeta, Myaltong Datok, Uchechukwu Cynthia Ofoma proofread the work and final approval of the version to be published. All authors agree to be accountable for all aspects of this work in ensuring that questions related to the accuracy or integrity of any part of this work are appropriately investigated and resolved.

### Competing interests

The authors declare that they have no conflict of interest to disclose.