Cefazolin 30 mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours 

If known to have MRSA/MRSE colonisation, use vancomycin 15mg/kg IV 

Antibiotic allergy:

Clindamycin 10mg/kg IV; max 900mg

Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours

Refer to Appendix 3 for antibiotic allergy.

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours 

Ampicillin/sulbactam 50mg/kg (of ampicillin component) IV

Recommended re-dosing interval from initiation of pre -operative dose: every 2 hours

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

Refer to Appendix 3 for antibiotic allergy.

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

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)

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

Refer to Appendix 3 for antibiotic allergy.

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours 

Cefuroxime 50mg/kg IV; max. 1.5g

If known to have MRSA/MRSE colonisation, use vancomycin 15mg/kg IV 

Antibiotic allergy:

Clindamycin 10mg/kg; max. 900 mg

Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours

Refer to Appendix 3 for antibiotic allergy.

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

--

Antibiotic allergy:

Clindamycin 10mg/kg; max. 900 mg

Recommended re-dosing interval from initiation of pre -operative dose: q6h

Refer to Appendix 3 for antibiotic allergy.

Cefazolin 30mg/kg IV (max. 2g/dose)

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

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

Antibiotic allergy:

Clindamycin 10mg/kg IV (max. 900mg)

Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours

Refer to Appendix 3 for antibiotic allergy.

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)

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 hours 

PLUS

Metronidazole 15mg/kg IV (max. 1.5g/day)

Antibiotic allergy:

Clindamycin 10mg/kg IV (max. 3.6g/day)

Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours

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

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

Antibiotic allergy:

Clindamycin 10mg/kg IV (max. 900mg)

Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours

Cloxacillin 25mg/kg IV; max. 1g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

--

Antibiotic allergy:

Clindamycin 10mg/kg IV; max. 900mg

Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours

Refer to Appendix 3 for antibiotic allergy.

Amoxicillin/clavulanate 30mg/kg; max. 1.2g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours 

--

Antibiotic allergy:

Clindamycin 10mg/kg; max. 900mg

Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours

Refer to Appendix 3 for antibiotic allergy.

Amoxicillin/clavulanate 30mg/kg; max. 1.2g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

--

Antibiotic allergy:

Clindamycin 10mg/kg; max. 900mg

Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours

Refer to Appendix 3 for antibiotic allergy.

Cefazolin 30mg/kg IV (max. 12g/day)

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

Ampicillin/sulbactam 50mg/kg (of Ampicillin component; max. 2g/dose) IV

Recommended re-dosing interval from initiation of pre -operative dose: every 2 hours

Antibiotic allergy:

Clindamycin 10mg/kg IV (max. 3.6g/day)

Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours

Refer to Appendix 3 for antibiotic allergy.

Trimethoprim 2mg/kg PO; max. 100mg

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h 

Antibiotic allergy:

Gentamicin 2.5mg/kg IV

Refer to Appendix 3 for antibiotic allergy.

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

Amoxicillin/clavulanate 30mg/kg IV; max 1.2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h 

UTI should be treated before procedure when possible.

Medical literature does not support continuing antimicrobial prophylaxis until urinary catheter have been removed.

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

Amoxicillin/clavulanate 30mg/kg IV; max 1.2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h 

Antibiotic allergy:

Gentamicin 2.5mg/kg IV

Refer to Appendix 3 for antibiotic allergy.

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h 

Amoxicillin/clavulanate 30mg/kg IV; max. 1.2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

--

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)

--

--

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

Amoxicillin/clavulanate 30 mg/kg IV; max. 1.2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h 

--

Benzathine penicillin

1.2MU (> 27kg);

0.6MU (≤ 27 kg)

IM every 3-4 weeks

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. 

Phenoxymethylpenicillin (Penicillin V) 250 mg PO q12h

Antibiotic allergy:

Erythromycin ethylsuccinate 15-20mg/kg/dose PO q12h (max. 4g/day)

Refer to Appendix 3 for antibiotic allergy.

Amoxicillin 50mg/kg PO (max. 2g) 30-60 minutes before procedure

OR

Ampicillin 50mg/kg IV (max. 2g) 30-60 minutes before procedure

Antibiotic allergy:

Clindamycin 20mg/kg IV/PO (max. 900mg) 30-60 minutes before procedure

Another alternative:

Cefazolin 50mg/kg IV (max. 2g) (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 a microorganism that has the potential ability to cause bacterial endocarditis. 

Prophylaxis is always required for:

1.     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.   Percutaneous endoscopic gastrotomy.

Prophylaxis is required in some circumstances. Please refer to Ministry of Health CPG for Prevention, Diagnosis & Management of Infective Endocarditis (2017).

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.

Refer to Appendix 3 for antibiotic allergy.

Phenoxymethylpenicillin (Penicillin V)

125mg PO q12h for ≤5 years old

250mg PO q12h for >5 years old

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.

Amoxicillin 20mg/kg/day (250 – 500mg PO q12h; 500mg daily if poor compliance i.e., adult dose)

Antibiotic allergy:

Erythromycin ethylsuccinate 15-20mg/kg/dose PO q12h (max. 4g/day)

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

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.

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.

Refer to Appendix 3 for antibiotic allergy.

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)

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.  

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.

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

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.

∞ 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).

If using Mefloquine: Start 2-3 weeks before, continue weekly during exposure and 4 weeks thereafter.

* 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).

*To carefully assess risk and benefit of starting antimalarial prophylaxis to any children to prevent development of drug resistance.

Rifampicin

≤ 1 month of age:

10mg/kg/dose PO q24h for 4 days

>1 month of age:

20mg/kg/dose PO q24h for 4 days (max. 600mg/dose)

--

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 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.

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.

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 immunised: complete immunisation.

Ciprofloxacin

< 1 year: 30mg per kg (max. 125mg) stat

1-4 years: 125mg stat

5-11 years: 250mg stat

≥ 12 years: 500mg stat

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

≥ 1 month old:

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

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.

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.

Intrapartum maternal prophylaxis:

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

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

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

Vancomycin 1g IV loading, then q12h till delivery (if clindamycin resistant)

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

Refer to Appendix 3 for antibiotic allergy.

*Azithromycin

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

6 months & older:                              

10mg/kg/day PO in a single dose on Day 1, (max. 500mg) then 5mg/kg/dose (max. 250mg) on Day 2-Day 5.  

OR

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 days 

*Erythromycin

<1 months: not preferred. Use only if azithromycin is not available.      

≥ 1 month till adult:

Erythromycin ethylsuccinate:

40-50mg/kg/day PO in 2 divided doses for 14 days (max. 2g/day)

Trimethoprim/sulfamethoxazole

2 months & older:

8mg (TMP)/kg/day PO in 2 divided doses for 14 days. (max. 320mg TMP/day)

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 & 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). 

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.)

∞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).

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) 

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 once 

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.

--

*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.