Prophylaxis

Prophylaxis

NCHD.ie©2019 Dr ÍOS

Prophylaxis-Endocarditis

Endocarditis prophylaxis is only recommended in the situations detailed below, as antibiotic prophylaxis may only be effective at preventing a very small number of endocarditis cases. Infective endocarditis is much more likely to be caused by frequent exposure to random bacteraemias than bacteraemias caused by dental, GI tract or GU tract procedures. The risk of antibiotic-related adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy.

Maintenance of optimal oral health and hygiene is important in reducing the risk of endocarditis from dental procedures

Cardiac conditions that require endocarditis prophylaxis:

Dental procedures:

Endocarditis prophylaxis recommended only in patients with the above cardiac conditions, for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of oral mucosa.

Endocarditis prophylaxis NOT recommended for the following:

Consult patient’s Cardiologist to confirm decision on prophylaxis. Discuss the risk of endocarditis with your patient. Explain the benefits and risks of antimicrobial prophylaxis.Record subsequent decision in patient’s notes.


For Dental procedures:

Given single dose 30-60 min. prior to procedure:
1st line option In penicillin allergy
Adults: Amoxicillin 2 grams po/iv Adults: Clindamycin 600mg po/iv

GI tract or GU tract procedures:

Endocarditis prophylaxis not recommended.

Respiratory procedures:

Endocarditis prophylaxis is only recommended in patients with the above cardiac conditions for patients undergoing the following:

NB: if the infection is known to be caused by S. aureus, use Flucloxacillin 1g po / iv single dose for prophylaxis. If caused by MRSA or penicillin allergic, use vancomycin 15mg/kg single dose iv infusion one hour prior to procedure.

Infected skin, skin structure and musculoskeletal tissue:

Endocarditis prophylaxis is only recommended in patients undergoing surgical procedures with the above cardiac conditions.

Flucloxacillin 1g iv / po should be given 30-60 mins prior to procedure.

If MRSA or penicillin allergic: give vancomycin 15mg/kg single dose iv infusion one hour prior to procedure.

NCHD.ie©2019 Dr ÍOS

Prophylaxis-Meningitis

Prophylaxis-Meningitis

Bacterial meningitis is a notifiable disease. Inform Public Health: Tel.: 021 4927601 or out of hours through ambulance service 0818 501999. Public Health will advise on chemoprophylaxis of contacts.

Meningococcal Infection

Adults and children >12 years 1st line: Rifampicin 600mg every 12 hours for 4 doses.
Or Ciprofloxacin 500mg po stat.
Female adults on the oral contraceptive pill Ciprofloxacin 500mg po stat
Pregnant women Ciprofloxacin 500mg po stat
Lactating Rifampicin Or Ciprofloxacin
Children: 1-12 years Rifampicin:
10mg/kg q12h (max. 600mg) po for 2 days
Age <1 year = 5mg/kg q12h po for 2 days
Or:
Ciprofloxacin:
5-12 years = a single oral dose 250mg stat
<5 years a single oral dose of 30mg/kg to a max of 125mg.
Infant <1 year Rifampicin syrup 5mg/kg every 12 hours for 4 doses

Haemophilus influenzae type b (Hib) infection

Chemoprophylaxis is rarely indicated in Hib infection; only when there are unvaccinated or incompletely vaccinated children or persons at increased risk (e.g. asplenia or complement deficiency) in the household. Unless the index case has received Ceftriaxone or cefotaxime in hospital, chemoprophylaxis should also be given to the patient prior to discharge. Seek advice from Public Health or microbiology if unsure.

Adults Rifampicin 600mg once daily for 4 days
Child:1-12yrs Rifampicin 20mg/kg (max 600mg) once daily for 4 days
Infant:<1 yr Rifampicin syrup 10mg/kg once daily for 4 days
Pregnant women Not indicated

Notes on Rifampicin: Rifampicin may colour urine / tears red and stain contact lenses – do not wear contact lenses for a few days after Rifampicin treatment. If on other drugs, check BNF, product data sheets on www.medicines.ie / consult pharmacy regarding drug interactions with Rifampicin

Vaccination
If Neisseria meningitidis Groups B, C, A, Y, W, 135 vaccination of contacts and index may be indicated. Please refer to Public Health for advice.
If Haemophilus influenzae type b or pneumococcal meningitis: vaccination of contacts and index may be indicated. Please refer to Public Health for advice.

NCHD.ie©2019 Dr ÍOS

Surgical
Prophylaxis Principles

Principles of surgical prophylaxis

  1. Prophylaxis should be given within 60 minutes prior to surgical incision. Please note that certain antibiotics (e.g. vancomycin, gentamicin 5mg/kg, clindamycin and metronidazole) cannot be given as bolus injections. It is important that the infusions are completed before incision. Reduce gentamicin dose to 3mg/kg iv if CrCl <30ml/min.
  2. Always check previous microbiology cultures and sensitivities (MC&S) to guide choice of antibiotic for surgical prophylaxis. Consult micro. If recent Hx of MRSA, vancomycin should be given as part of surgical prophylaxis.
  3. Prophylaxis should be confined to the peri-operative period (i.e. immediately before and during procedure). The administration of additional doses of antibiotic after the end of procedure provides little or no additional prophylactic benefit. Post operative doses of antibiotics will further disturb normal microbiological flora and increase the risk of Clostridium difficile.
  4. An additional peri-operative prophylactic dose should be considered by the surgeon for procedures lasting >4 hours for cefuroxime and co-amoxiclav, or if there is blood loss >1500ml or haemodilution >15ml/kg
  5. Antimicrobial therapy administered in the setting of contaminated wounds is not considered prophylactic; in such cases, a therapeutic course of antimicrobial therapy is warranted.
NCHD.ie©2019 Dr ÍOS

Asplenic

Splenectomised and hyposplenic patients are at increased risk of life-threatening infections due to encapsulated micro-organisms such as Streptococcus pneumoniae (90%), Neisseria meningitidis, and Haemophilus influenzae as well as certain parasitic infections such as Malaria and Babesiosis. The risk of sepsis is probably lifelong but can be reduced with simple measures, such as immunisation, the prophylactic administration of antibiotics, and patient education.

Hyposplenic patients should be immunised as soon as the diagnosis is made. Where a patient has had a splenectomy in the past, and has not received the required vaccines at the time, they should be immunised at the earliest possible opportunity. Advice is available from Public Health on 021 4927601.

Elective splenectomy:

Recommended vaccines should be completed at least 2 weeks and preferably 4 weeks or more before surgery (see below table for the details of individual vaccines)

On admission ensure the patient has had the following:

Emergency procedures:

In the case of an emergency splenectomy or if immunisation is overlooked or incomplete pre operatively, recommended vaccines should be given at least 2 weeks post operatively, (the response to pneumococcal vaccine is poorer if given within 2 weeks of splenectomy).

Post-operatively (adult doses):

Patient should be prescribed either:
Benzylpenicillin 1.2g q12h iv
or
Oral:
either Phenoxymethylpenicillin 666mg po q12h or Amoxicillin 250-500mg q12h po.

In penicillin allergy: Clarithromycin* 250mg q12h po/iv. To be continued post-discharge from hospital – refer to chemoprophylaxis section for further information.

*Clarithromycin: several drug interactions – always check (following list not exhaustive): Statins: Increased risk of rhabdomyolysis. Simvastatin contraindicated with clarithromycin. Atorvastatin: max. 20mg /day, Pravastatin max. 40mg/day. Monitor for muscle pain and weakness. Warfarin: significant increase in INR with clarithromycin - INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary. Novel oral anticoagulants (NOAC): check individual NOAC SPCs.

Vaccination Who should be immunised Vaccination required When should vaccine be given Re-immunisation
Pneumococcal Conjugate Vaccine
PCV
( Prevenar 13®)
(13 serotypes)
Aged under 2 years Immunise with PCV13 vaccine in accordance with the routine schedule (2, 6 and 12 months).
One additional dose PCV13 two months after last routine dose
If incompletely immunised contact Public Health for specialist advice.
If a second dose is indicated, it should be given two months after first dose.
Course of Pneumococcal Conjugate Vaccine should be completed before receiving Pneumococcal Polysaccharide Vaccine.

If Pneumococcal Polysaccharide Vaccine has been given wait at least 1 year before giving Pneumococcal Conjugate Vaccine
There is no data to support reimmunisation at the present time
Aged 2 years and over
  • Patients who have never received a pneumococcal vaccine: Give two doses of PCV13, two months apart.
  • Patients who have previously received PCV: Give one dose of PCV13 at least 2 months after last dose.
Pneumococcal
Polysaccharide vaccine
(PPV) (Pneumovax II®
23 serotypes)
All unimmunised patients aged 2 years and over, and those who received Pneumovax II® more than 5 years ago Give single dose.
A once only booster is recommended 5 years after first dose.
Course of Pneumococcal Conjugate Vaccine (PCV13) should be completed before receiving Pneumococcal Polysaccharide Vaccine (PPV).

Pneumococcal Polysaccharide Vaccine (PPV) can be given 8 weeks after last Pneumococcal Conjugate Vaccine (PCV13)
Antibody levels may decline more rapidly, particularly in patients with sickle cell anaemia or lymphoproliferative disorders. If age >65 years whgen received first dose, no booster recommended.
The need for and benefit of repeated booster doses is unclear and not routinely recommended.
Influenza Vaccine All patients, annually Annually for all patients. Give a second dose one month later if aged <9 years and the first year of receipt of influenza vaccine First dose at the same time as other vaccines (at a different site of injection). Second dose (if indicated) one month later Annually for hyposplenia or asplenic patients ideally at the start of flu season (September to October)
Haemophilus influenzae serotype B (HiB) Aged under 13 months Immunise with Hib vaccine in accordance with the routine schedule (2,4,6 and 13 months)
  • First dose at same time as Pneumococcal vaccine (at a different site of injection)
  • Second dose (if indicated) - two months later.
  • Those who have completed a primary series (2, 4, 6 and 13 months) should have an additional dose at least 2 months after last dose.
There are no data to support routine reimmunisation at the present time.
All patients aged 13 months or older who were previously unimmunised Give two doses of Hib vaccine, two months apart
Previously immunised patients who develop splenic dysfunction Give one additional dose of Hib vaccine a minimum of 2 months after the last Hib dose given
Meningococcal
Quadruvalent conjugate
Vaccine
ACYW135(MenACWY)   (Menveo® or
Nimenrix®)
Aged 2-11 month
Give two doses of Men ACWY

MenACWY can replace the MenC if the child requires MenACWY at the same time as the routine MenC
  • First dose at same time as Pneumococcal vaccine (at different site of injection)
  • Second dose - two months later
Additional booster at age ≥12 months at least 2 months after last dose then every 5 years.
Aged 1 year and over Give two doses of MenACWY at least two months apart
  • First dose at same time as Pneumococcal vaccine (at a different site of injection)
  • Second dose – at least two months later
Booster every 5 years
Meningococcal B vaccine* (Bexsero®) Aged 2-<12 months Immunise with MenB in accordance with the routine schedule (2, 4 and 12 months)
  • In accordance with the routine schedule (2, 4 and 12 months)
Increased risk of fever in children under 12 months –paracetamol prophylaxis recommended
The need for additional doses in high risk groups has not been clearly established - not recommended for the present.
12 months and older if previously unimmunised 2 doses 2 months apart
  • First dose at same time as Pneumococcal vaccine (at a different site of injection)
  • Second dose – at least two months later

Chemoprophylaxis

The risk for invasive pneumococcal infection is elevated throughout life but highest for those <16 and > 50 years of age. At minimum and regardless of immunisation status, antibiotic prophylaxis is recommended for children with asplenia (congenital absence or surgical removal) or sickle cell disease until 5 years of age and for otherwise healthy patients post splenectomy for a minimum of 1 to 2 years post splenectomy. Although the risk of infection decreases over time, continuing antibiotic prophylaxis throughout childhood and, for those considered at higher risk of infection, for life is recommended.

High risk patients include poor clinic attendees, patient with sickle cell disease with surgical splenectomy, splenectomised patient with malignancy, and those with poor antibody response to pneumococcal vaccination. Physicians may elect to use antibiotic prophylaxis in other hyposplenic states.

Antibiotic prophylaxis should only be discontinued if the patient is fully immunized and education and counselling is given regarding the risks of pneumococcal, meningococcal and haemophilus B infection and the need for prompt early management of febrile illness (refer to general information below)

Antibiotics prophylaxis Prophylaxis Dose Treatment Doses
(adult)*
Notes
Phenoxymethylpenicillin
Penicillin V
1 month to < 6 years: 125mg po q12h
6 years to < 12 years: 250mg po q12h
≥12 years: 666mg po q12h (Calvepen®) (666mg po q24h can be given if compliance is a problem)
Oral absorption of phenoxymethylpenicillin can be unpredictable and plasma concentrations variable so it should not be used for serious infections. For emergency self initiated therapy of a suspected systemic infection, treatment doses of amoxicillin are preferable (see below).  
Amoxicillin 20mg/kg po q24h (max 500mg po q24h) 500-1000mg po q8h If need H. influenzae cover
Clarithromycin* 250mg po q12h
(500mg LA po q24h if compliance a problem)
For dosing in children seek specialist advice
500mg po q12h If penicillin allergic

*Clarithromycin: several drug interactions – always check (following list not exhaustive): Statins: Increased risk of rhabdomyolysis. Simvastatin contraindicated with clarithromycin. Atorvastatin: max. 20mg /day, Pravastatin max. 40mg/day. Monitor for muscle pain and weakness. Warfarin: significant increase in INR with clarithromycin - INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary. Novel oral anticoagulants (NOAC): check individual NOAC SPCs.


general information for all patients

Other information


*Clarithromycin: several drug interactions – always check (following list not exhaustive): Statins: Increased risk of rhabdomyolysis. Simvastatin contraindicated with clarithromycin. Atorvastatin: max. 20mg /day, Pravastatin max. 40mg/day. Monitor for muscle pain and weakness. Warfarin: significant increase in INR with clarithromycin - INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary. Novel oral anticoagulants (NOAC): check individual NOAC SPCs.

References:

Guide©2018 Dr ÍOS

Surgical
Prophylaxis

List of procedures requiring antibiotic prophylaxis is not exhaustive.

NCHD.ie©2019 Dr ÍOS

Appendix 1

CUMH Surg. prophylaxis

Indications

Surgical antibiotic prophylaxis is recommended for the following procedures:

Surgical prophylaxis is not routinely necessary for other laparoscopic procedures, minor operations or diagnostic hysteroscopies.

Timing

Antibiotic prophylaxis should be started ideally within 60 minutes prior to incision for all surgery, including Caesarean section.

Ensure that the antibiotic prophylaxis administered is documented.

Additional doses

Prophylaxis should be confined to the peri-operative period (i.e. immediately before and during procedure). The administration of additional doses of antibiotic after the end of procedure provides little or no additional prophylactic benefit.

An additional peri-operative prophylactic dose should only be considered by the surgeon for:

If clinical findings are suggestive of infection, a course of appropriate antimicrobial treatment should be prescribed.

Surgical prophylaxis for C-section

Single dose Cefuroxime 1.5g IV within 60 minutes prior to incision.

In penicillin allergy: single dose of Clindamycin 900mg iv plus Gentamicin 5mg/kg iv (Max dose 480mg), within 60 minutes prior to incision.

Surgical prophylaxis excluding C-section

Single dose Co-amoxiclav 1.2g IV within 60 minutes prior to incision.

In penicillin allergy: single dose of Clindamycin 900mg iv plus Gentamicin 5mg/kg IV (Max dose 480mg), within 60 minutes prior to incision.

Endocarditis prophylaxis

No longer indicated for vaginal deliveries. Refer to appropriate surgical prophylaxis protocol if undergoing surgery.

MRSA

If recent history of MRSA colonisation, vancomycin 15mg/kg should be given as part of surgical prophylaxis. See Vancomycin dosing, administration and monitoring.

Guide©2018 Dr ÍOS

Header


Empiric treatment

You have updated - please navigate from the home icon (top right)

In penicillin allergy

You have updated - please navigate from the home icon (top right

Duration

You have updated - please navigate from the home icon (top right

Comments

You have updated - please navigate from the home icon (top right
©CKICC 2019 Dr ÍOS