INFECTION PROPHYLAXIS









Endocarditis prophylaxis for procedures

Whom to treat

AHA 2020 recommendations
  • Dental procedures
    • Antibiotic prophylaxis is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with valvular heart disease who have any of the following:
      • Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts
      • Previous episode of infective endocarditis
      • Prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips
      • Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device
      • Cardiac transplant with valve regurgitation attributable to a structurally abnormal valve
  • Nondental procedures
    • In patients with valvular heart disease who are at high risk of infective endocarditis, antibiotic prophylaxis is not recommended for nondental procedures (eg, TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection [4]
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

Occupational exposure to HIV, HBV, and HCV (UCSF recs)

  • 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)

Occupational exposure to HCV (CDC 2020)

Overview
  • The risk of HCV transmission from percutaneous exposure is 0.2% and from mucocutaneous exposure is 0%
  • Because of the very low transmission rate, the CDC does not recommend post-exposure prophylaxis with medications

Testing
  • All initial testing should be done as soon as possible, preferably within 48 hours
  • Source patient
    • Nucleic acid testing (viral load) is preferred. If nucleic acid testing is not available, then HCV antibody test should be performed.
    • If nucleic acid test or the antibody test is negative, no further testing is necessary
    • Detectable nucleic acid levels usually occur within 1 - 2 weeks after exposure. Positive antibody tests occur 4 - 10 weeks after exposure.
  • Healthcare professional (if source patient is positive)
    • Baseline test: Perform baseline HCV antibody test with reflex to nucleic acid test (viral load) if positive
    • 3 - 6 weeks post-exposure: Perform nucleic acid test 3 - 6 weeks after exposure
    • 4 - 6 months post-exposure: Perform HCV antibody test with reflex to nucleic acid test (viral load) if positive [3]

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

CDC recommendations (2016)
  • Complete CDC recommendations are available in pdf format at this link - CDC HIV PEP guidelines after nonoccupational exposure
    • Important pages
      • Page 23 - Whom to treat algorithm
      • Page 27 - Recommended lab testing and follow-up
      • Pages 31 and 32 - Recommended PEP drug regimens



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