Does my patient with a history of recurrent infections or immunocompromised status need antibiotics for barging (boating) to a high-risk location?

Prophylactic Antibiotics for Travel Are Not Routinely Indicated

For immunocompetent patients traveling by boat, prophylactic antibiotics are not recommended and should not be prescribed. There is no evidence-based indication for antibiotic prophylaxis in healthy individuals undertaking recreational boating activities, regardless of destination.

Clinical Decision Framework

Immunocompetent Patients

• No antibiotics needed for routine travel, including boating trips 1, 2, 3
• Standard travel precautions (water safety, sun protection, first aid supplies) are sufficient
• Prophylactic antibiotics would unnecessarily increase risk of:
  • Antibiotic-associated adverse events (4% increased odds per day of use) 4
  • Clostridioides difficile infection 4
  • Development of multidrug-resistant organism colonization 4
  • Altered gut microbiota 4

Severely Immunocompromised Patients Requiring Evaluation

Only consider antibiotics if your patient meets criteria for severe immunosuppression 4:

• Active cytotoxic chemotherapy for solid tumors or hematologic malignancies 4
• Recent chimeric antigen receptor T-cell therapy or hematopoietic cell transplant with neutropenia 4
• Any neutropenia (absolute neutrophil count <500 cells/μL) 4
• Severe primary immunodeficiency 4
• Advanced or untreated HIV infection (CD4 <200/mm³, AIDS-defining illness, or symptomatic HIV) 4

Management for Severely Immunocompromised Patients

Even in severely immunocompromised patients, prophylactic antibiotics for travel are not standard practice. Instead:

• Antibiotic prophylaxis is indicated only for specific recurrent infections 4
• For patients with recurrent infections and neutropenia, consider G-CSF or GM-CSF rather than prophylactic antibiotics 4
• Antibiotic prophylaxis should follow IDSA Guidelines for Prevention and Treatment of Cancer-Related Infections for splenectomized patients 4
• Vaccinations per NCCN Guidelines are more appropriate than prophylactic antibiotics 4

When Antibiotics ARE Indicated in Immunocompromised Patients

Therapeutic antibiotics (not prophylactic) are appropriate only when infection is present 4, 5, 6, 7:

• For neutropenic fever with skin/soft tissue findings: Vancomycin plus antipseudomonal antibiotics (cefepime, carbapenem, or piperacillin-tazobactam) 4
• For suspected bacterial infection: Immediate empirical therapy with aminoglycoside plus beta-lactam combination 5, 7
• Treatment should target documented infections, not prevent hypothetical ones 6, 7

Critical Pitfalls to Avoid

• Do not prescribe "just in case" antibiotics for travel—this increases harm without proven benefit 4
• Do not confuse therapeutic antibiotics for active infection with prophylactic antibiotics for travel 4, 5
• Recognize that immunocompromised patients requiring frequent antibiotics have diminished efficacy from additional prophylaxis 4
• Avoid creating antibiotic resistance through unnecessary prophylaxis, as multidrug-resistant organisms cause worse outcomes in immunocompromised hosts 4, 8

Appropriate Travel Preparation Instead of Antibiotics

Provide practical guidance rather than antibiotics:

• Ensure patient has access to medical care at destination
• Provide clear instructions on when to seek emergency care (fever >38°C, signs of infection, systemic symptoms) 1, 3
• For immunocompromised patients, ensure they know to contact their oncologist/transplant team immediately if fever develops 4
• Consider travel insurance with medical evacuation coverage for severely immunocompromised patients