364	A n t i b i o t i c E s s e n t i a l s

CHRONIC MEDICAL PROPHYLAXIS

Some infectious diseases are prone to recurrence/relapse and may benefit from intermittent or chronic suppressive therapy.. The goal of suppressive therapy is to minimize the frequency/severity of recurrent infectious episodes..

Table 6.4. Chronic Medical Prophylaxis

	Usual	Preferred	Alternate
Disorder	Organisms	Prophylaxis	Prophylaxis	Comments
Asplenia/	S.. pneumoniae	Amoxicillin	Respiratory	Long-term prophylaxis
impaired	H.. influenzae	1 gm (PO) q24h	quinolone* (PO)	effective. Vaccines may
splenic function	N.. meningitidis	indefinitely	q24h indefinitely	be given but are not
				always protective.. Use
				amoxicillin in children..
UTIs (recurrent)	Gram-negative	Nitrofurantoin	Amoxicillin	Prophylaxis for
	bacilli Enterococci	100 mg (PO)	500 mg (PO)	reinfection UTIs (≥ 3
		q24h × 6 months	q24h × 6 mos or	per year).. Relapse UTIs
			TMP–SMX 1 SS	should be investigated
			tablet (PO) q24h ×	for stones, abscesses, or
			6 months	structural problems..
Asymptomatic	Gram-negative	Nitrofurantoin	Amoxicillin 1 gm	Prophylaxis prevents
bacteriuria in	bacilli	100 mg (PO)	(PO) q24h × 1	symptomatic
pregnancy		q24h × 1 week	week	infections..
Prophylaxis	Candida albicans	Posaconazole		Prophylaxis given until
of fungal	Non-albicans	200 mg (PO)		neutropenia resolves
infections in	Candida	q8h or		(absolute neutrophil
neutropenic	Aspergillus	Itraconazole 200		count ≥ 500 cells/mm3)..
patients†		mg (PO) q12h
Recurrent	H.. simplex (HSV-2)	Famciclovir	Acyclovir 200 mg	Begin therapy as soon
genital herpes		125 mg (PO)	(PO) 5x/day × 5	as lesions appear.. (For
(< 6 episodes/		q12h × 5 days or	days	HIV disease, see Ch.. 5..)
year)		Valacyclovir 500		Famciclovir 1 gm (PO)
		mg (PO) q24h ×		q12h ×1 day ↓lesion
		5 days		progression by 2 days..
Recurrent	H.. simplex (HSV-2)	Famciclovir	Acyclovir 400 mg	Suppressive therapy is
genital herpes		250 mg (PO)	(PO) q12h × 1 year	indicated for frequent
(> 6 episodes/		q12h × 1 year		recurrences.. (For HIV
year)		or Valacyclovir		disease, see Ch.. 5..)
		1 gm (PO) q24h
		× 1 year

	Chapter 6.  Prophylaxis and Immunizations			365
Table 6.4. Chronic Medical Prophylaxis (cont’d)
	Usual	Preferred	Alternate
Disorder	Organisms	Prophylaxis	Prophylaxis	Comments
Acute	S.. pneumoniae H..	Moxifloxacin 400 mg or levofloxacin		Treat each episode
exacerbation	influenzae	500 mg or gatifloxacin 400 mg or		individually..
of chronic	M.. catarrhalis	gemifloxacin 320 mg (PO) q24h × 5
bronchitis		days or Amoxicillin/clavulanic acid
(AECB)		XR 2 tablets (PO) q12h × 5 days or
		Clarithromycin XL 1 gm (PO) q24h ×
		5 days or Doxycycline 100 mg (PO)
		q12h × 5 days or Azithromycin 500
		mg (PO) × 3 days
Acute	Group A	Benzathine	Amoxicillin 500 mg	Group A streptococcal
rheumatic fever	streptococci	penicillin 1..2 mu	(PO) q24h or	pharyngitis and acute
(ARF)		(IM) monthly	Azithromycin	rheumatic fever are
		until age 30	500 mg (PO) q72h	uncommon after
			until age 30	age 30..
Neonatal Group	Group B	Ampicillin 2 gm	Clindamycin	Indications: previous
B streptococcal	streptococci	(IV) q4h at onset	600 mg (IV) q8h	infant with GBS
(GBS) infection		of labor until	at onset of labor	infection, maternal GBS
(primary		delivery	until delivery	colonization/infection
prevention)			or	during pregnancy,
			Vancomycin 1 gm	vaginal/rectal culture
			(IV) q12h at onset	of GBS after week 35
			of labor until	of gestation, delivery ≤
			delivery	week 37 of gestation
				without labor/ruptured
				membranes, ruptured
				membranes ≥12 hrs,
				or intrapartum temp ≥
				100..4°F..

*Levofloxacin 500 mg (PO) or gatifloxacin 400 mg (PO) q24h or moxifloxacin 400 mg (PO)..

†During induction chemotherapy for acute myelogenous leukemia (AML) or myelodysplastic syndrome (MDS)..

Table 6.5. HIV Pre-Exposure Prophylaxis (PrEP)

	Usual	Preferred	Alternate
Disorder	Organisms	Prophylaxis	Prophylaxis	Comments
Repeated	HIV	Truvada 1 tablet		Avoid if CrCl < 60 ml/
potential HIV		(PO) q24h × 90		min.. Avoid if breast
exposures		days (recheck		feeding..
		HIV status)

366					A n t i b i o t i c E s s e n t i a l s
Table 6.6. HIV Post-Exposure Prophylaxis (PEP)
		Preferred			Recommended			Alternate recommended
Exposure		regimen					regimen			regimen	Comments
HIV		Truvada		Truvada 1 tablet (PO)				Truvada 1 tablet (PO) q24h			…
		1 tablet		q24h [tenofovir (TDF)				[tenofovir (TDF) 300 mg
		(PO) q24h		300 mg (PO) q24h +				(PO) q24h +emtricitabine
		[tenofovir		emtricitabine (FTC)				(FTC) 200 mg (PO) q24h] ×
		(TDF) 300 mg		200 mg (PO) q24h] × 4				4 weeks
		(PO) q24h +		weeks			plus			plus
		emtricitabine						Zidovudine (ZDV) 300 mg
		(FTC) 200 mg		(one of the following)				(PO) q12h × 4 weeks
		(PO) q24h] ×		Darunavir (DRV) 800 mg						or
		4 weeks		(PO) q24h × 4 weeks				Truvada 1 tablet (PO)
		plus either					or	q24h [tenofovir (TDF) 300
		Raltegravir		Atazanavir (ATZ) 300 mg				mg (PO) q24h +
		(RAL) 400 mg		(PO) q24h × 4 weeks				emtricitabine (FTC) 200 mg
		(PO) q12h ×					or	(PO) q24h] × 4 weeks
		4 weeks		Fosamprenavir (FPV)1400						plus
		or		mg (PO) q24h ×4 weeks				Kaletra 2 tablets (PO)
		Dolutegravir					plus	q12h [lopinavir (LPV)
		(DTG) 50 mg		Ritonavir (RTV) 100 mg				200 mg (PO) q12h
		(PO) q24h ×		(PO) q24h × 4 weeks				+ritonavir (RTV) 50 mg (PO)
		4 weeks						q12h] × 4 weeks
Table 6.7. HIV: Prophylaxis of Opportunistic Infections
							Indication for
Disorder		Usual organism					Prophylaxis			Intervention
HIV		PCP			CD	4	< 200/mm3			TMP-SMX: 1 SS tablet or 1 DS
										tablet (PO) q24h or Atovaquone 1500
										mg (PO) q24h
		TB			PPD > 5 mm (current or					INH: 300 mg (PO) q24h × 9 months
					past) or contact with active					Rifabutin: Dose based on concomitant
					case					ART × 4 months
		Toxoplasmosis			IgG (+) and CD < 100/mm3					TMP-SMX: 1 DS tablet (PO) q24h
							4
		MAI			CD	4	< 50/mm3			Azithromycin: 1200 mg (PO) q week
		S..pneumoniae			CD	4	> 200/mm3			Pneumococcal vaccine
		Hepatitis B (HBV)			Susceptible patients					Hepatitis B vaccine
		Hepatitis A (HAV)			Susceptible patients					Hepatitis A vaccine
		Influenza			All patients					Annual influenza vaccine
		VZV			CD	4	> 200/mm3, VZV			VZV vaccine
					antibody negative

	Chapter 6.  Prophylaxis and Immunizations						367
Table 6.8. Transplant Prophylaxis (BMT/SOT)
	Usual	Preferred			Alternate
Exposure	organism	prophylaxis			prophylaxis	Comments
Herpes simplex	Herpes	HSV →< 6				Acute prophylaxis
(HSV)	simplex	recurrences/year				Nearly all post-tranplant HSV
		Valacyclovir 500			Acyclovir	infections occur < 1 month..
		mg (PO) q24h ×			400 mg (PO)	Transplants receiving CMV
		30 days			q8h ×	prophylaxis with ganciclovir,
			or		30 days post-	or valganciclovir are protected
		Famciclovir 1 g			BMT	against HSV (see CMV
		(PO) q12 × 30				prophylaxis)..
		days
		HSV → > 6				Chronic prophylaxis
		recurrences/year				Valacyclovir 500 mg (PO) q12h
		Valacyclovir 1 gm			Acyclovir 400	or
		(PO) q24h × 90			mg (PO) q8h	Famciclovir 500 mg (PO) q12h
		days			× 90 days	or
			or		post-BMT	Acyclovir 400 mg (PO) q8h
		Famciclovir 250
		mg (PO) q12 ×
		30 days
Varicella zoster	Varicella	VZV seropositive			Acyclovir	Post-transplant VZV infections
virus (VZV)	zoster virus	recipient			400 mg (PO)	occur later than HSV..
		Valacyclovir 500			q8h post-	> 95% of adults are VZV
		mg (PO) q12h			transplant x	seropositive.. In transplants,
		post-transplant x			4–24 months	most VZV infections are due
		4–24 months				to reactivation rather than
						primary infection.. Patients
						may develop shingles after
						prophylaxis is discontinued..
		VZV			Acyclovir	Transplant recipients on CMV
		seronegative			800mg (PO)	prophylaxis with gangciclovir
		recipient (VZV			5x/day post-	or valganciclovir do not
		seropositive			transplant x	require VZV prophylaxis..
		graft)			4–24 months
		Valacyclovir 1 g
		(PO) q8h post-
		transplant x
		4–24 months

368		A n t i b i o t i c	E s s e n t i a l s
Table 6.8. Transplant Prophylaxis (BMT/SOT) (cont’d)
	Usual	Preferred		Alternate
Exposure	organism	prophylaxis		prophylaxis	Comments
Cytomegalovirus	Transplants	Valganciclovir		Ganciclovir	Alternately, preemptive
(CMV)	(SOT)	900 mg (PO)		5 mg/kg (IV)	therapy may be used.. When
	D+/R-, D+/	q24h × 3–6		q24h × 3–6	quantitative CMV PCR/pp 65
	R+, D-/R+	months		months	antigenemia levels become
					+/↑.
					D-/R- patients should receive
					CMV negative blood and
					leukocyte depleted RBCs
					but do not require antiviral
					prophylaxis..
PCP	SOT/BMT	TMP-SMX		TMP-SMX	See Drug Summaries for drug-
	(with	1 DS tablet (PO)		1 SS tablet	drug interactions..
	GVHD)	q week × 12		(PO) q24h ×
		months		12 months
				or
				Atovaquone
				1500 mg
				(PO) q24h ×
				12 months
				(with a meal)
Toxoplasmosis	Heart	TMP-SMX		Atovaquone	See Drug Summaries for drug-
	transplants	1 DS tablet (PO)		1500 mg	drug interactions..
		q24h		(PO) q24h
				(take with
				a meal)
Candida sp.	Liver/	Fluconazole 400		Posacona­	See Drug Summaries for drug-
	pancreas	mg (IV/PO)		zole 200 mg	drug interactions..
	transplants	q24h × 4 weeks		(PO) q8h × 4
				weeks
Aspergillus sp.	Allogeneic	Voriconazole 200		Posacona­	Until engrafted (BMT);
	BMT/lung	mg (PO) q12h		zole 200 mg	duration in lung transplants
	transplants			(PO) q8h	unclear..
					See Drug Summaries for drug-
					drug interactions..

GVHD = graft vs.. host disease..