PAEDIATRIC
PAEDIATRIC
CHEMOPROPHYLAXIS
In this topic:
Guidelines for prevention of surgical site infections (SSIs) have been published. General principles:
Agent used for antimicrobial prophylaxis should prevent SSIs and related morbidity and mortality
Reduce duration and cost of care
Produce no adverse effect
Minimise adverse consequences to the microbial flora
Timing:
Effective chemoprophylaxis occurs only when the appropriate antimicrobial drug is present in tissues at sufficient local concentration at the time of intra-operative bacterial contamination. Administration of antimicrobial agent is recommended within 60 minutes before surgical incision to ensure adequate tissue concentration at the start of the procedure. Agents that require longer administration time such as vancomycin should begin within 120 minutes before surgery begins. Adequate antimicrobial concentration should be maintained throughout the surgical procedure and in most instances, single dose of antimicrobial agent is sufficient and the duration of prophylaxis after any procedure should not exceed 24 hours. Intra-operative dosing is required if the duration of the procedure is greater than two times the half-life of the antimicrobial agent or if there is excessive blood loss.
S. epidermidis, S. aureus, Corynebacterium sp., Enteric Gram-negative bacilli
Preferred
Cefazolin 30 mg/kg IV; max. 2g
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hoursÂ
Alternative
If known to have MRSA/MRSE colonisation, use vancomycin 15mg/kg IVÂ
Comments
Antibiotic allergy:
Clindamycin 10mg/kg IV; max 900mg
Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours
Â
Refer to Appendix 3 for antibiotic allergy.
References:
Clinical Practical Guideline for Antimicrobial Prophylaxis for Surgery 2013. American Society of Hospital Pharmacists (ASHP) guideline, IDSA, Surgical Infection Society (SIS) and Society of Healthcare Epidemiology of America (SHEA). Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. American Journal of Health-system Pharmacy 2013. 70(3):195-283
Antibiotic Prophylaxis for Paediatric Surgery. Royal Hospital for Children Glasgow. 2018
Clean contaminated Surgery
(Examples: Gastroduodenal procedures, early appendicitis, closure of stoma)
Preferred
Cefazolin 30mg/kg IV; max. 2g
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hoursÂ
Alternative
Ampicillin/sulbactam 50mg/kg (of ampicillin component) IV
Recommended re-dosing interval from initiation of pre -operative dose: every 2 hours
Comments
Antibiotic allergy:
Clindamycin 10mg/kg IV; max 900mg
Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours
AND
Gentamicin 2.5 mg/kg IV
Â
Refer to Appendix 3 for antibiotic allergy.
References:
Clinical Practical Guideline for Antimicrobial Prophylaxis for Surgery 2013. American Society of Hospital Pharmacists (ASHP) guideline, IDSA, Surgical Infection Society (SIS) and Society of Healthcare Epidemiology of America (SHEA). Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. American Journal of Health-system Pharmacy 2013. 70(3):195-283.
Antibiotic Prophylaxis for Paediatric Surgery. Royal Hospital for Children Glasgow. 2018
Biliary tract
(Cholecystectomy, Choledochal cysts excision, On Table Cholangiogram)Â
Preferred
Cefazolin 30mg/kg IV; max. 2g
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours
OR
Ampicillin/sulbactam 50mg/kg (of ampicillin component) IV
Recommended re-dosing interval from initiation of pre -operative dose: every 2 hours
Alternative
Ceftriaxone 50-75mg/kg IV; max. 2g
OR
Cefotaxime 50mg/kg; max. 1g
Recommended re-dosing interval from initiation of pre -operative dose: every 3 hours
PLUS
Metronidazole 15 mg/kg IV
(For neonates less than 1200g, to give 7.5 mg/kg)
Comments
Antibiotic allergy:
Clindamycin 10mg/kg IV; max 900mg
Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours
PLUS
Gentamicin 2.5 mg/kg IV
Â
Refer to Appendix 3 for antibiotic allergy.
References:Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â
Clinical Practical Guideline for Antimicrobial Prophylaxis for Surgery 2013. American Society of Hospital Pharmacists (ASHP) guideline, IDSA, Surgical Infection Society (SIS) and Society of Healthcare Epidemiology of America (SHEA). Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. American Journal of Health-system Pharmacy 2013. 70(3):195-283.
Antibiotic Prophylaxis for Paediatric Surgery. Royal Hospital for Children Glasgow. 2018
Elective craniotomy & cerebrospinal fluid-shunting procedures
Preferred
Cefazolin 30mg/kg IV; max. 2g
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hoursÂ
Alternative
Cefuroxime 50mg/kg IV; max. 1.5g
Â
If known to have MRSA/MRSE colonisation, use vancomycin 15mg/kg IVÂ
Comments
Antibiotic allergy:
Clindamycin 10mg/kg; max. 900 mg
Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours
Â
Refer to Appendix 3 for antibiotic allergy.
References:
Clinical Practical Guideline for Antimicrobial Prophylaxis for Surgery 2013. American Society of Hospital Pharmacists (ASHP) guideline, IDSA, Surgical Infection Society (SIS) and Society of Healthcare Epidemiology of America (SHEA). Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. American Journal of Health-system Pharmacy 2013. 70(3):195-283
Antibiotic Prophylaxis for Paediatric Surgery. Royal Hospital for Children Glasgow. 2018
5.1 Clean Operations Involving Hand, Knee, or Foot & Not Involving Implantation of Foreign Materials
Surgical antibiotic prophylaxis not recommended.
5.2 Spinal Procedure with or without Instrumentation/Hip Surgery/ Implantation of Internal Fixation Devices (e.g.: nails, screws, plates, wires)
Preferred
Cefazolin 30mg/kg IV; max. 2g
Recommended re-dosing interval from initiation of pre -operative dose: q4h
Alternative
--
Comments
Antibiotic allergy:
Clindamycin 10mg/kg; max. 900 mg
Recommended re-dosing interval from initiation of pre -operative dose: q6h
Â
Refer to Appendix 3 for antibiotic allergy.
References:Â Â
                                                                                                           Â
Clinical Practical Guideline for Antimicrobial Prophylaxis for Surgery 2013. American Society of Hospital Pharmacists (ASHP) guideline, IDSA, Surgical Infection Society (SIS) and Society of Healthcare Epidemiology of America (SHEA). Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. American Journal of Health-system Pharmacy 2013. 70(3):195-283.
Antibiotic Prophylaxis for Paediatric Surgery. Royal Hospital for Children Glasgow. 2018.
6.1 CleanÂ
Tonsillectomy, adenoidectomy, tracheostomy, thyroglossal cyst excision, preauricular sinus, dermoid cyst, brachial anomaly, thyroidectomy, parotidectomy, lymph node biopsy etc.
Surgical antibiotic prophylaxis not recommended.
6.2 Clean with Placement of ProsthesisÂ
Excludes tympanostomy tubes
Preferred
Cefazolin 30mg/kg IV (max. 2g/dose)
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours
Alternative
Ampicillin/sulbactam 50mg/kg (of Ampicillin component; max.2g/dose) IV
Recommended re-dosing interval from initiation of pre-operative dose: every 2 hours
OR
Cefuroxime 50mg/kg IV; (max. 1.5g/dose)
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours
Comments
Antibiotic allergy:
Clindamycin 10mg/kg IV (max. 900mg)
Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours
Â
Refer to Appendix 3 for antibiotic allergy.
6.3 Clean-contaminated Procedures with the Exception of Tonsillectomy & Functional Endoscopic Sinus ProcedureÂ
Preferred
Cefazolin 30mg/kg IV (max. 12g/day)
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours
PLUS
Metronidazole 15mg/kg IV (max. 1.5g/day)
Alternative
Ampicillin/sulbactam 50mg/kg (of ampicillin component; max. 8g/day) IV
Recommended re-dosing interval from initiation of pre -operative dose: every 2 hours
OR
Cefuroxime 50mg/kg IV; (max. 6g/day)
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hoursÂ
PLUS
Metronidazole 15mg/kg IV (max. 1.5g/day)
Comments
Antibiotic allergy:
Clindamycin 10mg/kg IV (max. 3.6g/day)
Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours
6.4 Clean-contaminated Cancer Surgery
Preferred
Cefazolin 30mg/kg IV (max. 12g/day)
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours
PLUS
Metronidazole 15mg/kg IV (max. 1.5g/day)
Recommended re-dosing interval from initiation of pre -operative dose: every 8 hours
Alternative
Ampicillin/sulbactam 50mg/kg (of ampicillin component) IV (max. 8g/day)
Recommended re-dosing interval from initiation of pre -operative dose: every 2 hours
OR
Cefuroxime 50mg/kg IV (max. 6g/day)
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours
PLUS
Metronidazole 15mg/kg IV (max. 1.5g/day)
Recommended re-dosing interval from initiation of pre -operative dose: every 8 hours
Comments
Antibiotic allergy:
Clindamycin 10mg/kg IV (max. 900mg)
Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours
References:
Clinical Practical Guideline for Antimicrobial Prophylaxis for Surgery 2013. American Society of Hospital Pharmacists (ASHP) guideline, IDSA, Surgical Infection Society (SIS) and Society of Healthcare Epidemiology of America (SHEA). Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. American Journal of Health-system Pharmacy 2013. 70(3):195-283
Antibiotic Prophylaxis for Paediatric Surgery. Royal Hospital for Children Glasgow.2019
Children’s Health Queensland Paediatric Antibiocard: Empirical Antibiotic Guidelines 2022
American Academy of Paediatrics. Commitee on Infectious Diseases. Red Book: Report of the committee on Infectious Diseases (2018)
British National Formulary for Children 2022-2023
Micromedex Pediatric Reference version 5.5.0(485)
7.1 Elective Soft Tissue SurgeryÂ
No prophylaxis unless complex prolonged procedure
Â
If complex, Cloxacillin 25mg/kg IV; max. 1g
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours
7.2 Elective Hand or Foot Surgery Involving Bone
Preferred
Cloxacillin 25mg/kg IV; max. 1g
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours
Alternative
--
Comments
Antibiotic allergy:
Clindamycin 10mg/kg IV; max. 900mg
Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours
Â
Refer to Appendix 3 for antibiotic allergy.
7.3 Cleft lip & palate surgery
Preferred
Amoxicillin/clavulanate 30mg/kg; max. 1.2g
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hoursÂ
Alternative
--
Comments
Antibiotic allergy:
Clindamycin 10mg/kg; max. 900mg
Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours
Â
Refer to Appendix 3 for antibiotic allergy.
7.4 Excision & Grafting SurgeryÂ
Preferred
Amoxicillin/clavulanate 30mg/kg; max. 1.2g
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours
Alternative
--
Comments
Antibiotic allergy:
Clindamycin 10mg/kg; max. 900mg
Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours
Â
Refer to Appendix 3 for antibiotic allergy.
References:Â Â Â
                                                                                                                           Â
Clinical Practical Guideline for Antimicrobial Prophylaxis for Surgery 2013. American Society of Hospital Pharmacists (ASHP) guideline, IDSA, Surgical Infection Society (SIS) and Society of Healthcare Epidemiology of America (SHEA). Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. American Journal of Health-system Pharmacy 2013. 70(3):195-283.
Antibiotic Prophylaxis for Paediatric Surgery. Royal Hospital for Children Glasgow. 2018.
Non-cardiac including lobectomy, pneumonectomy, segmentectomy, lung biopsy & thoracotomy Â
Preferred
Cefazolin 30mg/kg IV (max. 12g/day)
Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours
Alternative
Ampicillin/sulbactam 50mg/kg (of Ampicillin component; max. 2g/dose) IV
Recommended re-dosing interval from initiation of pre -operative dose: every 2 hours
Comments
Antibiotic allergy:
Clindamycin 10mg/kg IV (max. 3.6g/day)
Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours
Â
Refer to Appendix 3 for antibiotic allergy.
References:
Clinical Practical Guideline for Antimicrobial Prophylaxis for Surgery 2013. American Society of Hospital Pharmacists (ASHP) guideline, IDSA, Surgical Infection Society (SIS) and Society of Healthcare Epidemiology of America (SHEA). Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. American Journal of Health-system Pharmacy 2013. 70(3):195-283.
Antibiotic Prophylaxis for Paeditric Surgery. Royal Hospital for Children Glasgow. 2018
9.1 Low Tract Instrumentation with Risk Factors for InfectionsÂ
Preferred
Trimethoprim 2mg/kg PO; max. 100mg
Alternative
Cefazolin 30mg/kg IV; max. 2g
Recommended re-dosing interval from initiation of pre -operative dose: q4hÂ
Comments
9.2 Clean without entry into urinary tract/clean with entry into urinary tract (e.g.: hypospadias surgery)Â Â
Preferred
Cefazolin 30mg/kg IV; max. 2g
Recommended re-dosing interval from initiation of pre -operative dose: q4h
Alternative
Amoxicillin/clavulanate 30mg/kg IV; max 1.2g
Recommended re-dosing interval from initiation of pre -operative dose: q4hÂ
Comments
UTI should be treated before procedure when possible.
Medical literature does not support continuing antimicrobial prophylaxis until urinary catheter have been removed.
9.3 Clean-contaminatedÂ
Entering gastrointestinal tract
Preferred
Cefazolin 30mg/kg IV; max. 2g
Recommended re-dosing interval from initiation of pre -operative dose: q4h
PLUS
Metronidazole 15 mg/kg IV; max. 500mg
Alternative
Amoxicillin/clavulanate 30mg/kg IV; max 1.2g
Recommended re-dosing interval from initiation of pre -operative dose: q4hÂ
Comments
References:Â Â Â Â
                                                                                                                                                                                          Â
Clinical Practical Guideline for Antimicrobial Prophylaxis for Surgery 2013. American Society of Hospital Pharmacists (ASHP) guideline, IDSA, Surgical Infection Society (SIS) and Society of Healthcare Epidemiology of America (SHEA). Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. American Journal of Health-system Pharmacy 2013. 70(3):195-283.
Antibiotic Prophylaxis for Paediatric Surgery. Royal Hospital for Children Glasgow. 2018.
10.1 Percutaneous Endoscopic Gastrostomy (PEG) or Jejunostomy (PEJ) or Nephrostomy Tube Placement
Preferred
Cefazolin 30mg/kg IV; max. 2g
Recommended re-dosing interval from initiation of pre -operative dose: q4hÂ
Alternative
Amoxicillin/clavulanate 30mg/kg IV; max. 1.2g
Recommended re-dosing interval from initiation of pre -operative dose: q4h
Comments
--
10.2 Micturating Cystourethrogram (MCUG)
Preferred
Trimethoprim 2mg/kg PO; max. 150 mg
(If patient is already on existing antibiotic UTI prophylaxis, increase antibiotic to therapeutic dose for a single dose prior procedure)
Alternative
--
Comments
--
10.3 Tenckhoff Peritoneal Dialysis Catheter InsertionÂ
Preferred
Cefazolin 30mg/kg IV; max. 2g
Recommended re-dosing interval from initiation of pre -operative dose: q4h
Alternative
Amoxicillin/clavulanate 30 mg/kg IV; max. 1.2g
Recommended re-dosing interval from initiation of pre -operative dose: q4hÂ
Comments
--
10.4 BurnsÂ
Surgical antibiotic prophylaxis not recommended.
References:
Clinical Practical Guideline for Antimicrobial Prophylaxis for Surgery 2013. American Society of Hospital Pharmacists (ASHP) guideline, IDSA, Surgical Infection Society (SIS) and Society of Healthcare Epidemiology of America (SHEA). Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. American Journal of Health-system Pharmacy 2013. 70(3):195-283.
Antibiotic Prophylaxis for Paediatric Surgery. Royal Hospital for Children Glasgow. 2018.
1.1 Rheumatic FeverÂ
Secondary prevention
Preferred
Benzathine penicillin
1.2MU (> 27kg);
0.6MU (≤ 27 kg)
IM every 3-4 weeks
Â
Duration:
1. With carditis & 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.Â
Alternative
Phenoxymethylpenicillin (Penicillin V) 250 mg PO q12h
Â
Antibiotic allergy:
Erythromycin ethylsuccinate 15-20mg/kg/dose PO q12h (max. 4g/day)
Comments
Refer to Appendix 3 for antibiotic allergy.
1.2 Infective Endocarditis (IE)
Preferred
Amoxicillin 50mg/kg PO (max. 2g) 30-60 minutes before procedure
OR
Ampicillin 50mg/kg IV (max. 2g) 30-60 minutes before procedure
Alternative
Antibiotic allergy:
Clindamycin 20mg/kg IV/PO (max. 900mg) 30-60 minutes before procedure
Â
Another alternative:
Cefazolin 50mg/kg IV (max. 2g) (cephalosporin should not be used in children with anaphylaxis, angioedema or urticaria)
Comments
IE prophylaxis is recommended for patients with the highest risk cardiac conditions undergoing procedures likely to result in bacteremia with a microorganism that has the potential ability to cause bacterial endocarditis.Â
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Prophylaxis is always required for:
1. Â Â Dental procedures that involve
Extraction
Periodontal procedure including surgery
Subgingival scaling
Root planning
Re-planting avulsed teeth
Other surgical procedure e.g.: implant placement & apicectomy
2. Incision & drainage of local abscess in the brain, skin, subcutaneous tissue (boils & carbuncle, eye (dacryocystitis), epidural, lung, orbital area, per rectal area, liver (pyogenic liver), tooth & surgical procedure through infected skin.
3. Â Percutaneous endoscopic gastrotomy.
Â
Prophylaxis is required in some circumstances. Please refer to Ministry of Health CPG for Prevention, Diagnosis & Management of Infective Endocarditis (2017).
Â
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.
Â
Refer to Appendix 3 for antibiotic allergy.
References:
Clinical Practice Guidelines for the Prevention, Diagnosis and Management of Infective Endocarditis. 2017.
American Academy of Paediatrics. Committee on Infectious Diseases. Red Book: Report of the Committee on Infectious Diseases. 2021.
2.1 Post splenectomy
At risk for infection caused by Pneumococcus, Meningococcus, Haemophilus sp.
Preferred
Phenoxymethylpenicillin (Penicillin V)
125mg PO q12h for ≤5 years old
250mg PO q12h for >5 years old
Â
Duration of chemoprophylaxis:
Minimum 1 – 3 years post splenectomy
Life-long prophylaxis for those with other cause of asplenia, previous episode of sepsis and remain immunocompromised.
Alternative
Amoxicillin 20mg/kg/day (250 – 500mg PO q12h; 500mg daily if poor compliance i.e., adult dose)
Â
Antibiotic allergy:
Erythromycin ethylsuccinate 15-20mg/kg/dose PO q12h (max. 4g/day)
Comments
Risk of sepsis is lifelong but especially high in the first 2 years after splenectomy.
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Important adjunct:
Immunisation 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).
Pneumococcal conjugate vaccine is preferred for better immunogenicity
Yearly influenza vaccine is also recommended.
Â
Not all pneumococcal isolates are sensitive to these antibiotics. Limitation stressed to parents so that all febrile illness in this group of children are taken seriously since initial signs & symptoms of fulminant septicaemia can be subtle.
Â
Refer to Appendix 3 for antibiotic allergy.
References:
Grace M. Lee; Preventing infections in children and adults with asplenia. Hematology Am Soc Hematol Educ Program 2020; 2020 (1): 328–335.
3.1 Malaria Prophylaxis
Preferred
For chloroquine-sensitive area:
Chloroquine dose: 5mg/kg base (8.3mg/kg salt) orally, once weekly, up to maximum adult dose of 300mg base (begin 1-2 weeks before travelling and take weekly through-out and 4 weeks after leaving area)
Â
For chloroquine-resistant area:
Mefloquine∞: weekly dose by weight in kg (tablet with 250 mg base, 274 mg salt)
≤ 9 kg – 5mg/kg weekly
>9-19 kg – 1/4 adult tablet weekly
>19-30 kg – ½ adult tablet weekly
>30-45 kg – ¾ adult tablet weekly
>45 kg – 1 adult tablet weekly
Start 2-3 weeks before, continue weekly during exposure and for 4 weeks thereafter. Â
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Age >8 years old:
Doxycycline 2.2mg/kg once daily up to 100mg/day. Take 1-2 days before, during and 4 weeks after travelling.
Alternative
Atovaquone-proguanil (Malarone®)*
Paediatric dose:
5-8 kg –  ½ paediatric tablet daily
9-10 kg – ¾ paediatric tablet daily
11-20 kg – 1 paediatric tablet daily
21-30 kg – 2 paediatric tablets daily
31-40 kg – 3 paediatric tablets daily
> 40 kg – 1 adult tablet daily
Â
Start prophylactic treatment with Malarone® 1 or 2 days before entering a malaria-endemic area and continue daily during the stay and for 7 days after return.
Comments
∞ Mefloquine: Not recommended if there are cardiac conduction abnormalities, seizures or psychiatric disorders. E.g.: depression, psychosis.
(Black box warning: Neuropsychiatric reactions may persist even after discontinuation).
Â
If using Mefloquine: Start 2-3 weeks before, continue weekly during exposure and 4 weeks thereafter.
Â
* Atovaquone/proguanil is another drug used in malaria prophylaxis in children (for chloroquine-resistance) BUT not yet registered in Blue Book (available commercially in Malaysia).
 Â
*To carefully assess risk and benefit of starting antimalarial prophylaxis to any children to prevent development of drug resistance.
References:
The Management Guidelines of Malaria in Malaysia 2013.
American Academy of Paediatrics. Committee on Infectious Diseases. Red Book: Report of the Committee on Infectious Diseases (2021).
The Sanford guide to antimicrobial therapy 2023.
4.1 Haemophilus influenza B ExposureÂ
Preferred
Rifampicin
Â
≤ 1 month of age:
10mg/kg/dose PO q24h for 4 days
Â
>1 month of age:
20mg/kg/dose PO q24h for 4 days (max. 600mg/dose)
Alternative
--
Comments
Chemoprophylaxis is indicated for:
Â
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 unimmunised or incompletely immunised.
Household with a contact who is an immunocompromised child, regardless of that child's Hib immunisation status.
Household with a child younger than 12 months who has not completed the primary Hib series.
Â
2.Nursery Contact
For ALL attendees in childcare & preschool (regardless of age or vaccination status) when unimmunised or incomplete immunised children attend the facility and two or more cases of Hib invasive disease have occurred within 60 days.
Â
3. Index case
Prior to discharge if did not receive at least ONE dose of  cefotaxime/ ceftriaxone and infants younger than 2 years.
Â
For contacts < 2 years old who are not immunised: complete immunisation.
4.2 Meningococcal ExposureÂ
Preferred
Ciprofloxacin
Â
< 1 year: 30mg per kg (max. 125mg) stat
1-4 years: 125mg stat
5-11 years: 250mg stat
≥ 12 years: 500mg stat
Alternative
Ceftriaxone IM
< 15 years old: 125mg stat
≥ 15 years old: 250mg stat
OR
Rifampicin
< 1 month old:
5mg/kg/dose PO q12h for 2 days
   Â
≥ 1 month old:
15-20mg/kg/dose (max. 600mg/dose) PO q12h for 2 daysÂ
Comments
Chemoprophylaxis is provided to close contact at HIGH RISK which include:
All household especially children younger than 2 years 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.
Â
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.
Â
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.
4.3 Neonatal Group B Streptococcus Infection
Preferred
Intrapartum maternal prophylaxis:
Benzylpenicillin 5 million units IV loading, then 2.5-3.0 million units IV q6h till delivery
Alternative
Ampicillin 2g IV loading, then 1g IV q6h till delivery
Â
Antibiotic allergy:
Low risk anaphylaxis
Cefazolin 2g IV loading then 1g IV q8h till delivery
High risk anaphylaxis
Clindamycin 900mg IV q8h till delivery
OR
     Â
Vancomycin 1g IV loading, then q12h till delivery (if clindamycin resistant)
Comments
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 >38ºC
Â
Refer to Appendix 3 for antibiotic allergy.
4.4 PertussisÂ
Post-exposure prophylaxis (PEP)
Preferred
*Azithromycin
<1 month old till 5 months old: 10mg/kg/day PO in a single dose q24h for 5 days
Â
6 months & older: Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â
10mg/kg/day PO in a single dose on Day 1, (max. 500mg) then 5mg/kg/dose (max. 250mg) on Day 2-Day 5. Â
Â
OR
Â
Clarithromycin
< 1 month: not recommended
≥ 1 month till 12 years: 15mg/kg/day PO q12h (max. 1g/day)
≥ 12 years till adult: 1g per day PO q12h for 7 daysÂ
Alternative
*Erythromycin
<1 months: not preferred. Use only if azithromycin is not available.     Â
Â
≥ 1 month till adult:
Erythromycin ethylsuccinate:
40-50mg/kg/day PO in 2 divided doses for 14 days (max. 2g/day)
Â
Trimethoprim/sulfamethoxazole
2 months & older:
8mg (TMP)/kg/day PO in 2 divided doses for 14 days. (max. 320mg TMP/day)
Comments
Drug of choice for PEP and treatment is a macrolide. Azithromycin is the preferred macrolide.Â
*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.
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Antimicrobial prophylaxis is recommended for:
1. Â ALL household contacts of the index cases & other close contacts, including children in childcare, regardless of immunisation status.
2. 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).Â
3. Close contacts who are unimmunised or under immunised should have pertussis immunisation initiated or continued using age-appropriate products according to the recommended schedule as soon as possible (this include off-label Tdap in children 7-9 years old who did not complete DTaP series.)
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∞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 & those with moderate to severe asthma).
4.5 Varicella (Chicken pox)
Post-exposure prophylaxis
Preferred
Potential interventions for people without evidence of immunity exposed to varicella (chicken pox) following significant exposure*:
1. 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)Â
2. When indicated & available, Varicella zoster immune globulin (VZIG)**:
VZIG dose as per product information; weight-based as soon as possible after exposure up to 10 days after
AND
Acyclovir 20mg/kg/dose PO q6h (max. 3200mg/day) beginning 7-10 days after exposure & continue for 7 days to prevent breakthrough VZV after VZIG or IVIG if no contraindications.
3. When VZIG not available:
****IVIG (400mg/kg) IV onceÂ
AND
Acyclovir 20mg/kg/dose PO q6h (max. 3200mg/day) beginning 7-10 days after exposure & continue for 7 days to prevent breakthrough VZV after VZIG or IVIG if no contraindications.
Alternative
--
Comments
*Exposure is significant if:
1.Household: Residing in the same household
2.Playmate: Face-to-face indoor play ≥1 hour
3.Hospital: In same 2 to 4-bed room or adjacent beds in a large ward, face-to-face contact with an infectious staff member or patient, or visit by a person deemed contagious
4.Newborn infant
**For patients who are at high risk for severe infection & complications*** & significant exposure* (and have contraindications to vaccine).
***Susceptible hosts include:
1.Immunocompromised children
2.Pregnant women, newborns of mothers with Varicella shortly before or after delivery (i.e.: 5 days before or within 2 days after delivery)
3.Premature infants born at ≥28 weeks of gestation who are exposed during their hospitalization & whose mothers do not have evidence of immunity
4.Premature infants born at <28 weeks of gestation or birth weight ≤1000 g regardless of their mothers' immunity.
****Patients receiving monthly high dose IVIG (≥400 mg/kg) are likely to be protected & probably do not require VZIG if the most recent dose of IVIG was administered ≤3 weeks before exposure.Â
References:
WHO Guidelines for Malaria 2022.
The Management Guidelines of Malaria in Malaysia 2013.
American Academy of Paediatrics. Committee on Infectious Diseases. Red Book: Report of the Committee on  Infectious Diseases (2021).
The Sanford guide to antimicrobial therapy 2023.
Guidance for the public health management of meningococcal disease in the UK. Updated August 2019, Public  Health England
Verani JR, McGee L, Schrag SJ, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease--revised guidelines from CDC, 2010. MMWR Recomm Rep 2010; 59:1Â
Guideline on post exposure prophylaxis (PEP) for varicella or shingles (January 2023). UK Health Security Agency
Tejpratap T, Trudy VM, Johd M, et al. National Immunization Program. Recommended Antimicrobial Agents for the Treatment and Postexposure Prophylaxis of Pertussis. 2005 CDC Guidelines. MMWR Recomm Rep 2005; 1-16Â
Frank Shann, 2017