Chapter 6. Prophylaxis and Immunizations |
353 |
Chapter 6 |
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Prophylaxis and Immunizations |
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Pierce Gardner, MD, John L. Brusch, MD |
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Jean E. Hage, MD, Ronald L. Nichols, MD |
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Staci A. Fischer, MD, Arthur Gran, MD |
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Muhammed Raza, MBBS, Burke A. Cunha, MD |
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Maria D. Mileno, MD |
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Surgical Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
354. |
Post-Exposure Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
358 |
Chronic Medical Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
364 |
HIV Pre-Exposure Prophylaxis (PrEP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
365. . . . . . . . . |
HIV Post-Exposure Prophylaxis (PEP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
366 |
HIV Opportunistic Infections . . . . . . . . . . . . . . . . . . . . |
366 |
Transplant Prophylaxis . . . . . . . . . . . . . . . . . . . . . . |
367 |
Endocarditis Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
369 |
Travel Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
371. . . . . . . . |
Malaria Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
375 |
Tetanus Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
377. . . . . . . . . |
Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
378 |
References and Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
382. . . . . . . . . |
* For additional information on the prophylaxis of opportunistic infections in HIV see Chapter 5, p.. 320..
354 |
A n t i b i o t i c E s s e n t i a l s |
SURGICAL PROPHYLAXIS
Antibiotic prophylaxis is designed to prevent infection for a defined period of time.. Prophylaxis is most likely to be effective when given for a short duration against a single pathogen with a known sensitivity pattern, and least likely to be effective when given
for a long duration against multiple organisms with varying/unpredictable sensitivity patterns
(Table 6..1).. It is a common misconception that antibiotics used for prophylaxis should not be used for therapy and vice versa.. The only difference between prophylaxis and therapy is the inoculum size and the duration of antibiotic administration: In prophylaxis, there
is no infection, so the inoculum is minimal/none and antibiotics are administered only for the duration of exposure/surgical procedure.. With therapy, the inoculum is large (infection already exists), and antibiotics are continued until the infection is eradicated..
Table 6.1. Factors Affecting the Efficacy of Surgical Antibiotic Prophylaxis
Number of |
Susceptibility |
Duration of |
Efficacy of |
Organisms |
Pattern |
Protection |
Prophylaxis |
|
|
|
|
Single organism |
Predictable |
Short |
Excellent |
|
|
|
|
Multiple organisms |
Predictable |
Short |
Excellent |
|
|
|
|
Single organism |
Unpredictable |
Short |
Good |
|
|
|
|
Single organism |
Predictable |
Long |
Good |
|
|
|
|
Multiple organisms |
Unpredictable |
Long |
Poor/none |
|
|
|
|
Antibiotic prophylaxis is designed to achieve effective antibiotic serum/tissue concentrations at the time of initial surgical incision, and is maintained throughout the “vulnerable period” of the procedure (i.e., time between skin incision and skin clo-
sure) (Table 6. .2). . If prophylaxis is given too early, antibiotic levels will be suboptimal/non-
existent when protection is needed. . Properly timed pre-operative antibiotic prophylaxis is desirable for optimal effectiveness since antibiotics given after skin closure are unlikely to be effective. When no infection exists prior to surgery (clean/clean contaminated surgery),
single-dose prophylaxis is preferred.. When infection is present/likely prior to surgery (“dirty” surgery, e..g.., perforated colon, TURP in the presence of positive urine cultures, repair of open fracture), antibiotics are given for > 1 day and represent early therapy, not true prophylaxis.. Parenteral cephalosporins are commonly used for surgical prophylaxis, and ordinarily given as a bolus injection/rapid IV infusion 15–60 minutes prior to the procedure.. Prophylaxis with vancomycin or gentamicin is given by slow IV infusion over 1–2 hours, starting ~1–2 hours prior to the procedure..
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Chapter 6. Prophylaxis and Immunizations |
355 |
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Table 6.2. Surgical Prophylaxis |
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|
|
|
|
|
Usual |
Preferred |
Alternate |
|
Procedure |
Organisms |
Prophylaxis |
Prophylaxis |
Comments |
|
|
|
|
|
CNS shunt (VP/ |
S.. epidermidis |
MRSA/MRSE |
MRSA/MRSE unlikely |
Administer |
VA) placement, |
(CoNS) |
unlikely Ceftriaxone |
Cefotaxime 2 gm |
immediately prior |
craniotomy, |
S.. aureus |
1 gm (IV) × 1 dose |
(IV) × 1 dose |
to procedure.. |
open CNS |
(MSSA) |
|
or |
Vancomycin |
trauma |
|
MRSA/MRSE likely |
Ceftizoxime 2 gm |
protects against |
|
|
Linezolid 600 mg |
(IV) × 1 dose |
wound infections, |
|
|
(IV) × 1 dose |
MRSA/MRSE likely |
but may not prevent |
|
|
|
CNS infections.. Give |
|
|
|
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Linezolid 600 mg |
|
|
|
|
vancomycin slowly |
|
|
|
|
(PO) × 1 dose |
|
|
|
|
IV over 1 hour prior |
|
|
|
|
or |
|
|
|
|
to procedure.. |
|
|
|
|
Vancomycin 1 gm |
|
|
|
|
|
|
|
|
|
(IV) × 1 dose |
|
|
|
|
or |
|
|
|
|
Minocycline 200 mg |
|
|
|
|
(IV) ×1 dose |
|
|
|
|
|
|
Thoracic |
S.. aureus |
Cefazolin 1 gm |
Cefotaxime 2 gm |
Administer |
(non-cardiac) |
(MSSA) |
(IV) × 1 dose |
(IV) × 1 dose |
immediately prior to |
surgery |
|
or |
or |
procedure.. |
|
|
Ceftriaxone 1 gm |
Ceftizoxime 2 gm |
|
|
|
(IV) × 1 dose |
(IV) × 1 dose |
|
|
|
|
|
|
Cardiac valve |
S.. epidermidis |
Vancomycin 1 gm |
Linezolid 600 mg |
Administer |
replacement |
(MSSE/MRSE) |
(IV) × 1 dose |
(IV) × 1 dose |
vancomycin and |
surgery |
S.. aureus |
plus |
plus |
gentamicin slowly IV |
|
(MSSA/MRSA) |
Gentamicin 120 mg |
Gentamicin 120 mg |
over 1 hour prior to |
|
Enterobacter |
(IV) × 1 dose |
(IV) × 1 dose |
procedure.. |
|
|
|
|
|
Coronary |
S.. aureus |
Cefazolin 2 gm |
Cefotaxime 2 gm |
Administer |
artery bypass |
(MSSA) |
(IV) × 1 dose |
(IV) × 1 dose |
immediately prior to |
graft (CABG) |
|
or |
or |
procedure.. Except for |
surgery |
|
Ceftriaxone 1 gm |
Ceftizoxime 2 gm |
ceftriaxone, repeat |
|
|
(IV) × 1 dose |
(IV) × 1 dose |
dose intraoperatively |
|
|
|
|
for procedures |
|
|
|
|
lasting |
|
|
|
|
> 3 hours.. |
Biliary tract |
E.. coli |
Meropenem 1 gm |
Ampicillin/ |
Administer |
surgery |
Klebsiella |
(IV) × 1 dose |
sulbactam 3 gm (IV) |
immediately prior |
|
E.. faecalis |
or |
× 1 dose |
to procedure |
|
(VSE) |
Piperacillin 4 gm |
|
(anaerobic coverage |
|
|
(IV) × 1 dose |
|
unnecessary).. |
356 |
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A n t i b i o t i c E s s e n t i a l s |
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Table 6.2. Surgical Prophylaxis (cont’d) |
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|
|
|
|
|
|
Usual |
Preferred |
Alternate |
|
Procedure |
Organisms |
Prophylaxis |
Prophylaxis |
Comments |
|
|
|
|
|
Hepatic |
E.. coli |
Ampicillin/ |
Meropenem 1 gm |
Administer |
surgery |
Klebsiella |
sulbactam 3 gm |
(IV) × 1 dose |
immediately prior to |
|
E.. faecalis |
(IV) × 1 dose |
or |
procedure.. |
|
(VSE) |
or |
Moxifloxacin |
|
|
B.. fragilis |
Piperacillin 4 gm |
400 mg (IV) × 1 dose |
|
|
|
(IV) × 1 dose |
|
|
|
|
|
|
|
Stomach, |
S.. aureus |
Ceftriaxone 1 gm |
Cefotaxime 2 gm |
Administer |
upper small |
(MSSA)Group |
(IV) × 1 dose |
(IV) × 1 dose |
immediately prior |
bowel surgery |
A streptococci |
or |
or |
to procedure |
|
|
Cefazolin 1 gm |
Ceftizoxime 2 gm |
(anaerobic coverage |
|
|
(IV) × 1 dose |
(IV) × 1 dose |
unnecessary).. |
|
|
|
|
|
Distal small |
E.. coli |
Oral |
Piperacillin 3 gm (IV) |
Administer |
bowel, colon |
Klebsiella |
Neomycin* |
× 1 dose |
immediately prior |
surgery |
B.. fragilis |
plus either |
or |
to procedure.. Give |
|
|
Erythromycin base* |
Cefoxitin 2 gm (IV) × |
gentamicin slowly IV |
|
|
or |
1 dose |
over 1 hour.. |
|
|
Metronidazole* |
or combination |
|
|
|
Parenteral |
therapy with |
|
|
|
Metronidazole 1 gm |
|
|
|
|
Ertapenem 1 gm |
|
|
|
|
(IV) × 1 dose |
|
|
|
|
(IV) × 1 dose |
|
|
|
|
plus either |
|
|
|
|
|
|
|
|
|
|
Ceftriaxone 1 gm |
|
|
|
|
(IV) × 1 dose |
|
|
|
|
or |
|
|
|
|
Levofloxacin 500 mg |
|
|
|
|
(IV) ×1 dose |
|
|
|
|
or |
|
|
|
|
Gentamicin 240 mg |
|
|
|
|
(IV) × 1 dose |
|
|
|
|
|
|
Pelvic |
Aerobic |
Ceftriaxone 1 gm |
Cefotetan 2 gm |
Administer |
(OB/GYN) |
GNBs |
(IV) × 1 dose plus |
(IV) × 1 dose or |
immediately prior to |
surgery |
Anaerobic |
Metronidazole |
Cefoxitin 2 gm |
procedure.. |
|
streptococci |
1 gm (IV) × 1 dose |
(IV) × 1 dose or |
|
|
B.. fragilis |
|
Ceftizoxime 2 gm |
|
|
|
|
(IV) × 1 dose |
|
|
|
|
|
|
*After appropriate diet and catharsis give either neomycin 1 gm (PO) plus erythromycin base 1 gm (PO) at 1 pm, 2 pm, and 11 pm, or give neomycin 2 gm (PO) plus metronidazole 2 gm (PO) at 7 pm and 11 pm the day before an 8 am operation..
