Not discussed in this chapter; please refer to information on specific disease entities (eg, traveler’s diarrhea, Chapter 6) or pathogens (eg, malaria, Chapter 10). Updated, current information for travelers about prophylaxis and current worldwide infection risks can be found on the Centers for Disease Control and Prevention Web site at www.cdc.gov/travel (accessed November 14, 2013).
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• Abbreviations: ACOG, American College of Obstetricians and Gynecologists;
amox/clav, amoxicillin/clavulanate; bid, twice daily; CDC, Centers for Disease Control and Prevention; CMV, cytomegalovirus; div, divided; GI, gastrointestinal; HSV, herpes simplex virus; IGRA, interferon-gamma release assay; IM, intramuscular; INH, isoniazid;
IV, intravenous; MRSA, methicillin-resistant Staphylococcus aureus; MRSE, methicillin- resistant S epidermidis; PO, orally; PPD, purified protein derivative; qd, once daily;
qid, 4 times daily; TB, tuberculosis; tid, 3 times daily; TIG, tetanus immune globulin;
TMP/SMX, trimethoprim/sulfamethoxazole; UTI, urinary tract infection.
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A. POSTEXPOSURE PROPHYLAXIS Prophylaxis CategoryTherapy (evidence grade)Comments Bacterial Bites, animal and human1–4 (Pasteurella multocida [animal], Eikenella corrodens [human], Staphylococcus spp and Streptococcus spp) Amox/clav 45 mg/kg/day PO div tid (amox/clav 7:1, see Chapter 1, Aminopenicillins) for 5–10 days (AII) OR ampicillin and clindamycin (BII)
Consider rabies prophylaxis for animal bites (AI); consider tetanus prophylaxis. Human bites have a very high rate of infection (do not close open wounds routinely). S aureus coverage is only fair with amox/clav and provides no coverage for MRSA. For penicillin allergy, consider ciprofloxacin (for Pasteurella) plus clindamycin (BIII). Endocarditis Prophylaxis5: Given that (1) endocarditis is rarely caused by dental/GI procedures and (2) prophylaxis for procedures prevents an exceedingly small number of cases, the risks of antibiotics most often outweigh benefits. However, some “highest risk” conditions are currently recommended for prophylaxis: (1) prosthetic heart valve (or prosthetic material used to repair a valve); (2) previous endocarditis; (3) cyanotic congenital heart disease that is unrepaired (or palliatively repaired with shunts and conduits); (4) congenital heart disease that is repaired but with defects at the site of repair adjacent to prosthetic material; (5) completely repaired congenital heart disease using prosthetic material, for the first 6 months after repair; or (6) cardiac transplant patients with valvulopathy. Routine prophylaxis no longer is required for children with native valve abnormalities. Follow-up data suggest that following these new guidelines, no increase in endocarditis has been detected.6 –In highest risk patients: dental procedures that involve manipulation of the gingival or periodontal region of teeth
Amoxicillin 50 mg/kg PO 1 h before procedure OR ampicillin or ceftriaxone or cefazolin, all at 50 mg/kg IM/IV 30–60 min before procedure
If penicillin allergy: clindamycin 20 mg/kg PO (60 min before) or IV (30 min before); OR azithromycin 15 mg/kg or clarithromycin 15 mg/kg, 1 h before –Genitourinary and gastrointestinal proceduresNoneNo longer recommended
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A. POSTEXPOSURE PROPHYLAXIS (cont) Prophylaxis CategoryTherapy (evidence grade)Comments Bacterial (cont) Meningococcus (Neisseria meningitidis)7For prophylaxis of close family contacts or child care contacts, or for those having contact with respiratory secretions from an infected patient, in the 7 days before symptom onset in the index case: Rifampin Children <1 mo: 5 mg/kg PO q12h for 4 doses Children >1 mo: 10 mg/kg PO q12h for 4 doses (max 600 mg/dose) OR Ceftriaxone Children <15 y: 125 mg IM once Children ≥16 y: 250 mg IM once OR Ciprofloxacin 500 mg PO once (adolescents and adults)
A few cipro-resistant strains have now been reported. Insufficient data to recommend azithromycin at this time. Pertussis8,9Azithromycin 10 mg/kg/day once daily for 5 days OR clarithromycin (for infants >1 mo) 15 mg/kg/day div bid for 7 days OR erythromycin (estolate preferable) 40 mg/kg/day PO div qid for 14 days (AII) Alternative: TMP/SMX 8 mg/kg/day div bid for 14 days (BIII) Prophylaxis to family members and close contacts. Azithromycin and clarithromycin are better tolerated than erythromycin (see Chapter 5); azithromycin is preferred in exposed young infants to reduce pyloric stenosis risk.
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Tetanus (Clostridium tetani)10,11Need for tetanus vaccine or TIG Clean woundContaminated wound Number of past tetanus vaccine dosesNeed for tetanus vaccineNeed for TIG 250 U IMNeed for tetanus vaccineNeed for TIG 250 U IM <3 dosesYesNoYesYes ≥3 dosesNo (if <10 y) Yes (if ≥10 y)NoNo (if <5 y) Yes (if ≥5 y)No For deep, contaminated wounds, wound debridement is essential. For wounds that cannot be fully debrided, consider metronidazole 30 mg/kg/day PO div q8h until wound healing is underway and anaerobic conditions no longer exist, as short as 3–5 days (BIII). Tuberculosis (Mycobacterium tuberculosis) Exposed infant <4 y, or immunocompromised patient (high risk of dissemination)12,13
Exposed infant <4 y, or immunocompromised patient (high risk of dissemination): INH 10–15 mg/kg PO daily for 2–3 mo after last exposure AND with repeat skin test or IGRA test negative (AIII) If PPD or IGRA remains negative at 2–3 mo and child remains well, consider stopping empiric therapy. However, tests at 2–3 mo may not be reliable in immunocompromised patients. This regimen is to PREVENT infection in a compromised host after exposure, rather than to treat latent asymptomatic infection.
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