INFECTION PROPHYLAXIS









Endocarditis prophylaxis for procedures

Whom to treat

AHA 2007 recommendations
  • Prophylaxis is "reasonable" for dental, respiratory tract, skin, and musculoskeletal procedures in the following patients:
    • Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
    • Previous episode of infective endocarditis
    • Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
    • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
    • Repaired Congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
    • Cardiac transplantation recipients who develop cardiac valvulopathy
Prophylaxis is NOT recommended for gastrointestinal and genitourinary procedures [1]
NICE 2008 recommendations
  • Antibiotic prophylaxis for dental, gastrointestinal, genitourinary, and respiratory procedures is not recommended for patients at risk for endocarditis [2]

Treatment regimens (AHA 2017)

Adults
  • Amoxicillin 2 grams 30 - 60 minutes before procedure
  • Ceftriaxone 1 gram IM 30 - 60 minutes before procedure
  • Cephalexin 2 grams 30 - 60 minutes before procedure (penicillin allergic without severe reaction)
  • Clindamycin 600 mg 30 - 60 minutes before procedure (penicillin allergic)
  • Azithromycin or clarithromycin 500 mg 30 - 60 minutes before procedure (penicillin allergic)
Pediatric
  • Amoxicillin 50 mg/kg (max 2 grams) 30 - 60 minutes before procedure
  • Ceftriaxone 50 mg/kg (max 1 gram) IM 30 - 60 minutes before procedure
  • Cephalexin 50 mg/kg (max 2 grams) 30 - 60 minutes before procedure (penicillin allergic without severe reaction)
  • Clindamycin 20 mg/kg (max 600 mg) 30 - 60 minutes before procedure (penicillin allergic)
  • Azithromycin or clarithromycin 15 mg/kg (max 500 mg) 30 - 60 minutes before procedure (penicillin allergic) [17]

Studies

  • No randomized controlled trials of antibiotic prophylaxis for endocarditis have been performed
  • The AHA guidelines in 2007 recommended cessation of prophylaxis in moderate-risk patients, and the NICE guidelines in 2008 recommended cessation of all prophylaxis
  • A number of observational studies have compared endocarditis incidence rates between time periods before the new guidelines to time periods after. In the U.S., these studies have found no increased incidence of endocarditis. In the U.K. where the NICE guidelines are typically followed, studies have been mixed. The most recent study that spanned 5 years post-NICE guidelines found a significant increase in the incidence of endocarditis in the U.K. [PMID 25467569]

Orthopedic implant infection prophylaxis for dental procedures

  • In 2017, the AAOS published guidelines for infection prophylaxis in patients with orthopedic implants who were undergoing dental procedures
  • The information is available on a webpage that makes a recommendation based on patient characteristics that are entered in a form

Postexposure prophylaxis for HIV, Hepatitis B, and Hepatitis C

Occupational exposure

  • The University of California at San Francisco provides free, rapid expert consultation and advice on management of occupational HIV, Hepatitis C, and Hepatitis B exposure. They can be contacted by phone or email at this link - UCSF website.
  • A quick summary of treatment recommendations is available at this link - Quick Guide for Occupational Exposures (HIV, Hep B, Hep C)

Nonoccupational exposure to HIV (IV drug abuse, sex, etc.)

CDC recommendations (2005)
  • If ≤ 72 hours since exposure, treat for 28 days with one of the following:
    • NNRTI-based regimen
      • Efavirenz 600 mg daily at bedtime +
      • Lamivudine (150 mg twice daily or 300 mg once daily) OR emtricitabine (200 mg once daily) +
      • Zidovudine (200 mg three times daily or 300 mg twice daily) OR tenofovir (300 mg once daily)
    • Protease inhibitor-based regimen
      • Lopinavir/ritonavir (Kaletra®) 3 tablets twice daily +
      • Lamivudine (150 mg twice daily or 300 mg once daily) OR emtricitabine (200 mg once daily) +
      • Zidovudine (200 mg three times daily or 300 mg twice daily)

  • Complete CDC recs are available here - CDC website



Pricing legend
  • $ = 0 - $50
  • $$ = $51 - $100
  • $$$ = $101 - $150
  • $$$$ = > $150
  • Pricing based on one month of therapy at standard dosing in an adult
  • Pricing based on information from GoodRX.com®
  • Pricing may vary by region and availability