CHEMOPROPHYLAXIS: NON-SURGICAL

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Rheumatic fever

(Secondary Prevention)

Benzathine penicillin G

1.2MU (>27kg);

0.6MU (≤27kg)

IM every 3-4 weeks

Phenoxymethyl-penicillin (penicillin V) 250mg PO q12h

Penicillin allergy: Erythromycin ethylsuccinate 15-20mg/kg/dose PO q12h

Duration:

1. With carditis and residual heart disease (persistent valvular disease): 10 years since the last episode of ARF or 40 years of age whichever is longer. Consider lifelong prophylaxis.
2. With carditis but no residual heart disease (no valvular disease): 10 years since the last episode of ARF or 21 years of age whichever is longer.
3. Without carditis: 5 years since last ARF or until 21 years of age whichever is longer.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Infective Endocarditis (IE)

Amoxicillin 50mg/kg PO 30-60 minutes before procedure

OR

Ampicillin 50mg/kg IV 30-60 minutes before procedure

Penicillin allergy:

Clindamycin 20mg/ kg IV/PO 30-60 minutes before procedure

Other alternative:

Cefazolin 50mg/kg IV (cephalosporin should not be used in children with anaphylaxis, angioedema or urticaria)

IE prophylaxis is recommended for patients with the highest risk cardiac conditions undergoing procedures likely to result in bacteremia with microorganism that has the potential ability to cause bacterial endocarditis.

Prophylaxis always required for

1. Dental procedures that involve

• Periodontal procedure including surgery.
• Sub-gingival scaling.
• Root planning.
• Re-planting avulsed teeth.
• Other surgical procedure e.g. implant placement and apicectomy.

2. Incision and drainage of local abscess in the brain, skin, subcutaneous tissue (boils and carbuncle, eye (dacryocystitis), epidural, lung, orbital area, per rectal area, liver (pyogenic liver), tooth and surgical procedure through infected skin).

3. Percutaneous endoscopic gastrostomy.

• Prophylaxis is required in some circumstances.
• Maintenance of optimal oral hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Post splenectomy

At risk for

Pneumococcus,

Meningococcus,

Haemophilus spp.

Phenoxymethylpenicillin (Penicillin V)

125mg PO q12h for ≤5 years old

250mg PO q12h for >5 years old

Duration of chemoprophylaxis:

• Minimum 3 years post splenectomy or until 18 years of age OR at least 1 year post splenectomy

Asplenia attributable to other causes unknown most expert recommend throughout childhood and into adulthood

Amoxicillin 20mg/ kg/day (250-500mg PO q12h;

500mg daily if poor compliance i.e. adult dose)

Penicillin allergy: Erythromycin ethylsuccinate 15-20mg/kg/dose PO q12h

Risk of sepsis is lifelong but especially high in the first 2 years after splenectomy.

Important adjunct:

Immunization against Pneumococcus, Haemophilus, Meningococcus at least 14 days prior to splenectomy (if not possible then as soon as possible, 14 days or more after surgery).

Yearly influenza vaccine is also recommended.

Not all pneumococcal isolates are susceptible to these antibiotics. Limitation stressed to parents so that all febrile illness in this group of children are taken seriously since initial signs and symptoms of fulminant septicaemia can be subtle.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Haemophilus influenzae type b exposure

Rifampicin

< 1month of age:

10mg/kg/dose PO q24h for 4 days

Children:

20mg/kg/dose PO q24h for 4 days

Chemoprophylaxis is indicated for:
1. ALL household contacts in the
following circumstances (household
contact is defined as a person who
resides with the index patient or
who spent ≥4 hours with the index
patient for at least five of the seven
days before the day of hospital
admission of the index case): 

• Household with at least one contact <4 years old who is unimmunized or incompletely immunized.
• Household with a contact who is an immunocompromised child, regardless of that child’s Hib immunization status.
• Household with a child younger than 12 months who has not completed the primary Hib series.

2.      Nursery Contact

For ALL attendees in childcare and preschool (regardless of age or vaccination status) when unimmunized or incompletely immunized children attend the facility and two or more cases of Hib invasive disease have occurred within 60 days.

3.      Index case

Prior to discharge if did not receive at least ONE dose of Cefotaxime/ Ceftriaxone and infants younger than 2 years.

For contacts <2 years old who are not immunized: complete immunization.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Meningococcal exposure

Rifampicin

<1month old:

5mg/kg/dose PO q12h for 2 days

≥1 month old:

15-20mg/kg/dose (max. 600mg) PO q12h for 2 days

Ceftriaxone IM

<15 years old: 125mg stat

> 15 years old: 250mg stat

Chemoprophylaxis is provided to close contact at HIGH RISK which include:

• All household especially children younger than 2years old.
• Childcare or preschool contact at any time during 7 days before onset of illness.
• Direct exposure to index patient’s secretion through kissing or through sharing toothbrushes or eating utensils at any time during 7 days before onset of illness.
• Frequently slept in same place as index patient during 7 days before onset of illness.

Healthcare staff

Routine prophylaxis is not recommended unless there is intimate exposure to respiratory secretion during mouth-to- mouth resuscitation, unprotected contact during intubation/ suctioning at any time 7 days before onset of illness or within 24 hours of initiation of effective antimicrobial therapy.

Give chemoprophylaxis to index case prior to discharge if treated with regimens other than Cefotaxime or Ceftriaxone. Chemoprophylaxis is ideally initiated within 24 hours after index patient is identified; prophylaxis is not indicated more than 2 weeks after exposure.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Neonatal Group B

Streptococcus infection

Intrapartum maternal prophylaxis:

Benzylpenicillin 5MU IV loading, then 2.5-3.0MU IV q6h till delivery

Ampicillin 2gm IV loading, then 1gm q6h till delivery

Penicillin allergy:

*Clindamycin 2gm IV loading, then 1gm IV q8h till delivery (according to susceptibility)

Treat during labour if previously delivered infant with invasive GBS, GBS bacteriuria or antenatal screening swabs positive OR if GBS status is not known AND any of the following:

• Preterm <37 weeks
• PROM >18 hours
• Intrapartum temperature >38°C

*For high risk of anaphylaxis from β-lactam antibiotics.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Malaria prophylaxis

*Mefloquine 5mg/kg once a week to maximum 250mg.

**Atovaquone/ Proguanil (Malarone) comes in pediatric preparation of 62.5/25mg once a day.

.*To start 2-3 weeks before arrival and continue for 4 weeks after leaving malaria-risk area.

**To start 1-2 days prior to travel and continue for 1 week after visit to malaria-risk area.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Pertussis (Post-exposure prophylaxis, PEP)

<1 month old: Azithromycin 10mg/kg/ day in a single dose q24h for 5 days

1-5 months old: Azithromycin 10mg/kg/ day as single dose q24h for 5 days.

6 months and older: Erythromycin ethylsuccinate 15-20mg/kg/dose PO q12h for 14 days.

OR

Azithromycin 10mg/kg/ day in a single dose on Day 1, then 5mg/kg/dose on Day 2 - Day 5.

Erythromycin is not preferred in young infants. *Use only if Azithromycin is not available

Erythromycin ethylsuccinate: 15-20mg/kg/dose PO q12h for 14 days.

2 months and older: Trimethoprim-sulfamethoxazole 8mg/kg/day in 2 divided doses for 14 days.

Drug of choice for PEP and treatment is a macrolide. Azithromycin is the preferred macrolide.

*Association between orally administered Azithromycin and Erythromycin with infantile hypertrophic pyloric stenosis (especially in infant <6 weeks) has been reported but Azithromycin remains the drug of choice in very young infants because the risk of developing severe disease outweighs the potential risk.

Antimicrobial prophylaxis is recommended for:

1. ALL household contacts of the index cases and other close contacts, including children in childcare, regardless of immunisation status. When considering borderline degree of exposure for a non-household contact, PEP should be administered if contact personally is at high risk or lives in a household with person at high risk of severe disease (e.g. young infant, pregnant women, person who has contact with infants). Close contacts who are unimmunised or underimmunised should have pertussis immunisation initiated or continued using age-appropriate products according to the recommended schedule as soon as possible (this include off-label TaP in children 7-9 years old who did not complete TaP series.)
2. High risk: Infant, women at third trimester of pregnancy and people with pre-existing health conditions that may be exacerbated by pertussis infection (not limited to immunocompromised individuals and those with moderate to severe asthma).

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Chicken pox (Post-exposure prophylaxis)

Potential interventions for people without evidence of immunity exposed to varicella (chicken pox) following significant exposure.

Exposure is significant if:

1. Household: Residing in the same household
2. Playmate: Face-to-face indoor play ≥ 1hour
3. Hospital: In same 2 to 4-bed room or adjacent beds in large ward, face-to-face contact with an infectious staff member or patients, or visit by a person deemed contagious
4. Newborn infant

1. Vaccine

Varicella vaccine:

Within 3-5 days of exposure for susceptible healthy adult/child 12 months old or older (followed by a second dose at age-appropriate interval)

Susceptible hosts include:

1. Immunocompromised children.
2. Pregnant women.
3. Newborns of mothers with Varicella shortly before or after delivery (i.e. 5 days before or within 2 days after delivery).
4. Premature infants born at ≥28 weeks of gestation who are exposed during their hospitalization and whose mothers do not have evidence of immunity.
5. Premature infants born at <28 weeks of gestation or birth weight ≤1000 g regardless of their mothers’ immunity.

2. When indicated and available, Varicella zoster immune globulin (VZIG)

For patients who are at high risk for severe infection and complications and significant exposure (and have contraindications to vaccine):

VZIG dose as per product information; weight-based as soon as possible after exposure up to 10 days after

OR

IVIG (400mg/kg) IV once if VZIG not available

OR

Acyclovir 20mg/kg/dose PO q6h (max.3200mg of daily dose) beginning 7-10 days after exposure and continue for 7 days.

Patients receiving monthly high dose IVIG (≥400mg/kg) are likely to be protected and probably do not require VZIG if most recent dose of IVIG was administered ≤3 weeks before exposure.

3. When VZIG not available