Chapter 6.  Prophylaxis and Immunizations		371
Table 6.11. Endocarditis Prophylaxis for Below-the-Waist (Genitourinary,
Gastrointestinal) Procedures Involving an Infected Field*† (cont’d)
Prophylaxis	Reaction to Penicillin	Antibiotic Regimen
IV prophylaxis	None	Ampicillin 2 gm (IV) 30 minutes pre-procedure
		plus
		Gentamicin 80 mg (IM) or (IV) over 1 hour 60 minutes
		pre-procedure
	Non-anaphylactoid,	Vancomycin 1 gm (IV) over 1 hour 60 minutes
	anaphylactoid	pre-procedure
		plus
		Gentamicin 80 mg (IM) or (IV) over 1 hour 60 minutes
		pre-procedure

*Endocarditis prophylaxis is directed against E.. faecalis, the usual SBE pathogen below the waist..

†Seto TB.. The case for infectious endocarditis prophylaxis.. Arch Intern Med 167:327–330, 2007..

Harrison JL, Hoen B, Prendergast BD. . Antibiotic Prophylaxis for Infective Endocarditis. . Lancet 371: 1317–1319, 2008..

Table 6.12. Q Fever Endocarditis Prophylaxis

Prophylaxis	Antibiotic Regimen
PO prophylaxis (for significant	Doxycycline 100 mg (PO) of q12 h × 12 months
valvulopathy* in acute Q fever	Plus
	Hydroxychloroquine 200 mg (PO) q8h × 12 months

*Significant valvulopathy: history of rheumatic fever, aortic bicuspid valve, ≥2 valve stenosis/ regurgitation, MVP, remodeled/thickened valve..

TRAVEL PROPHYLAXIS

Travelers may acquire infectious diseases from ingestion of fecally-contaminated water/ food, exchange of infected body secretions, inhalation of aerosolized droplets, direct inoculation via insect bites, or from close contact with infected birds/animals.

  Recommendations to prevent infection in travelers consist of general travel precautions (Table 6..12), and specific travel prophylaxis regimens (Table 6..13)..

Table 6.13. General Infectious Disease Travel Precautions

Exposure

Risk

Precautions

Unsafe water	Diarrhea/
(fecally-	dysentery, viral
contaminated)	hepatitis (HAV)

•Avoid ingestion of unbottled/unpotable water.. Be sure bottled water has an unbroken seal and has not been opened/refilled with tap water..

•Avoid ice cubes made from water of uncertain of origin/ handling, and drinking from unclean glasses..

•Drink only pasteurized bottled drinks.. Be sure bottles/cans are opened by you or in your presence..

372		A n t i b i o t i c E s s e n t i a l s
Table 6.13. General Infectious Disease Travel Precautions (cont’d)
Exposure		Risk		Precautions
			• Avoid drinking unpasteurized/warm milk; beer, wine, and
			pure alcoholic beverages are safe..
			• Eat only canned fruit or fresh fruit peeled by you or in your
			presence with clean utensils..
			• Avoid eating soft cheeses..
			• Avoid eating raw tomatoes/uncooked vegetables that
			may have been exposed to contaminated water..
			• Avoid using hotel water for tooth brushing/rinsing unless
			certain of purity.. Many hotels use common lines for bath/
			sink water that is unsuitable for drinking..
			• Avoid wading/swimming/bathing in lakes or rivers..
Food-borne		Diarrhea/	• Eat only seafood/poultry/meats that are freshly cooked
(fecally-		dysentery	and served hot.. Avoid eating at roadside stands or small
contaminated)			local restaurants with questionable sanitary practices..
			• “Boil it, peel it, or forget it..”
Body fluid		Viral hepatitis	• Do not share utensils/glasses/straws or engage in “risky
secretions		(HBV, HCV, etc..),	behaviors” involving body secretion exchange..
		STDs, HIV/other	• Avoid blood transfusion (use blood expanders instead)..
		retroviruses	• Treat dental problems before travel..
Animal bite		Animal bite-	• Do not pet/play with stray dogs/cats.. Rabies and other
		associated	infections are common in wild (and some urban) animals..
		infections
Flying insects		Malaria,	• Avoid flying/biting insects by wearing dark protective
		arthropod-	clothing (long sleeves/pants) and using insect repellent on
		borne infections	clothes/exposed skin, especially during evening hours..
			• Minimize dawn-to-dusk outdoor exposure..
			• Use screens/mosquito nets when possible..
			• Do not use perfume, after shave, or scented deodorants/
			toiletries that will attract flying insects..
Table 6.14. Travel Prophylaxis Regimens
		Usual	Prophylaxis
Exposure		Pathogens	Regimens	Comments
		E.. coli Salmonella	Doxycycline 100 mg	Observe without prophylaxis and
		Shigella	(PO) q24h for duration	treat mild diarrhea symptomatically
		Non-cholera	of exposure	with loperamide (2 mg).. Persons with
		vibrios	or	medical conditions adversely affected
		V.. cholerae	Any quinolone (PO) for	by dehydration caused by diarrhea
		Aeromonas	duration of exposure	may begin prophylaxis after arrival
		Plesiomonas	or	in country and continue for 1 day
		Rotavirus	TMP–SMX 1 SS tablet	after returning home.. Should severe
		Norwalk virus	(PO) q24h for duration	diarrhea/dysentery occur, continue/
		Giardia lamblia	of exposure	switch to a quinolone, maximize oral
		Campylobacter		hydration, and see a physician if possible..

	Chapter 6.  Prophylaxis and Immunizations			373
Table 6.14. Travel Prophylaxis Regimens (cont’d)
	Usual	Prophylaxis
Exposure	Pathogens	Regimens	Comments
Traveler’s	Yersinia		Anti-spasmodics may be used for
diarrhea	Cryptosporidium		symptomatic relief of mild, watery
	Cyclospora		diarrhea but are contraindicated in
	Enteroviruses		severe diarrhea/dysentery.. Bismuth
	Amebiasis		subsalicylate is less effective than
			antibiotic prophylaxis.. Most cases are
			due to enterotoxigenic E.. coli.. TMP–
			SMX is active against some bacterial
			pathogens and Cyclospora, but not
			against E.. histolytica or enteroviral
			pathogens (e..g.., Rotavirus, Norwalk
			agent).. Doxycycline is active against
			most bacterial pathogens and E..
			histolytica, but misses Campylobacter,
			Cryptosporidium, Cyclospora, Giardia,
			and enteroviral pathogens.. Rifaxamin
			only active against E..coli.. Antibiotics
			are inactive against viral/parasitic
			pathogens causing diarrhea..
Meningococcal	N.. meningitidis	Pre-travel prophylaxis	Acquired via close face-to-face
meningitis		Meningococcal	contact (airborne aerosol/droplet
		conjugate vaccine	exposure).. Vaccine is highly
		0..5 mL (IM) ≥ 1 month	protective against N.. meningitidis
		prior to travel to	serotypes A, C, Y, and W-135, but
		endemic/epidemic	misses serotype B.. For areas with
		areas	serogroup B may use meningococcal
		Post-exposure	group B vaccine.. Alternately, consider
			chemoprophylaxis..
		prophylaxis
		See p.. 358
Hepatitis A	Hepatitis A virus	HAV vaccine 1 mL (IM)	HAV vaccine is better than immune
(HAV)		prior to travel, then	globulin for prophylaxis.. Take care
		follow with a one-time	to avoid direct/indirect ingestion
		booster 3, 6 months	of fecally contaminated water.. HAV
		later	vaccine is recommended for travel to
			all developing countries.. Protective
			antibody titers develop after 2 weeks..
Typhoid fever	S.. typhi	ViCPS vaccine 0..5 mL	For the oral vaccine, do not
		(IM).. Booster every	co-administer with antibiotics..
		2 years for repeat	Contraindicated in compromised
		travelers	hosts and children < 6 years old..

374		A n t i b i o t i c E s s e n t i a l s
Table 6.14. Travel Prophylaxis Regimens (cont’d)
	Usual		Prophylaxis
Exposure	Pathogens		Regimens	Comments
			or	Take oral capsules with cold water..
			Oral Ty21a vaccine 1	Degree of protective immunity is
			capsule (PO) q48h ×4	limited with vaccine.. Some prefer
			doses.. Booster every	chemoprophylaxis the same as for
			5 years for repeat	Traveler’s diarrhea (p.. 373)..
			travelers
Yellow fever	Yellow fever		Yellow fever vaccine	Vaccine is often required for travel
	virus		0..5 mL (SC).. Booster	to or from Tropical South America or
			every 10 years for	Tropical Central Africa.. Administer
			repeat travelers	1 month apart from other live
				vaccines.. Contraindicated in
				children < 4 months old; caution in
				children < 1 year old.. Reactions may
				occur in persons with egg allergies..
				Immunity is probably life long, but a
				booster every 10 years is needed for
				vaccination certification by some
				countries..
Japanese	Japanese		JE vaccine 1 mL (SC)	Recommended for travelers
encephalitis	encephalitis		on days 0, 7, and 14 or	planning prolonged (> 3 week) visits
(JE)	virus		30.. Booster schedule	during the rainy season to rural,
			not established	endemic areas of Asia (e..g.., Eastern
				Russia, Indian subcontinent, China,
				Southeast Asia, Thailand, Korea,
				Laos, Cambodia, Vietnam, Malaysia,
				Philippines).. Administer 3, 2 weeks
				before exposure.. Children < 3 years
				may be given 0..5 mL (SC) on same
				schedule as adults..
Rabies	Rabies virus		HDCV, PCEC, or RVA	Avoid contact with wild dogs/
			1 mL (IM) on days 0,	animals during travel.. Dose of rabies
			7, and 21 or 28 prior	vaccine for adults and children are
			to travel	the same.. A booster dose prior to
				travel is recommended if antibody
				levels are measured and are low..

	Chapter 6.  Prophylaxis and Immunizations			375
Table 6.14. Travel Prophylaxis Regimens (cont’d)
	Usual	Prophylaxis
Exposure	Pathogens	Regimens	Comments
		or
		HDCV 0..1 mL (ID) on
		days 0, 7, and 21 or 28
		prior to travel
Tetanus	C.. tetani	Tdap 0..5 ml (IM)	Tdap preferred to Td since Tdap also
Diphtheria	C.. diphtheriae		boosts pertussis immunity..
Pertussis	B.. pertussis
Table 6.15. Malaria Prophylaxis
	Area of
Drug	Exposure	Adult Dose	Comments
Atovaquone/	Prophylaxis in all	Adult tablets contain	Begin 1–2 days before travel to
proguanil	areas	250 mg atovaquone	malarious areas.. Take daily at the
(Malarone)		and 100 mg proguanil	same time each day while in the
		hydrochloride.. 1 adult	malarious area and for 7 days after
		tablet orally, daily	leaving such areas.. Contraindicated
			in persons with severe renal
			impairment (creatinine clearance
			< 30 mL/min).. Atovaquone/
			proguanil should be taken with food
			or a milk drink.. Not recommended
			prophylaxis for pregnant women,
			and women breastfeeding..
Chloroquine	Prophylaxis only	300 mg base (500 mg	Begin 1–2 weeks before travel to
phosphate	in areas with	salt) orally, once/week	malarious areas.. Take weekly on the
(Aralen and	chloroquine-		same day of the week while in the
generic)	sensitive malaria		malarious area and for 4 weeks after
			leaving such areas..
Doxycycline	Prophylaxis in all	100 mg orally, (with	Begin 1–2 days before travel to
	areas	food) daily	malarious areas.. Take daily at the same
			time each day while in the malarious
			area and for 4 weeks after leaving such
			areas.. Contraindicated in children < 8
			years and in pregnancy..

376	A n t i b i o t i c E s s e n t i a l s
Table 6.15. Malaria Prophylaxis (cont’d)
	Area of
Drug	Exposure	Adult Dose	Comments
Hydroxy­	An alternative to	310 mg base (400 mg	Begin 1–2 weeks before travel to
chloroquine	chloroquine for	salt) orally, once/week	malarious areas.. Take weekly on the
sulfate	prophylaxis only		same day of the week while in the
(Plaquenil)	in areas with		malarious area and for 4 weeks after
	chloroquine-		leaving such areas..
	sensitive malaria
Mefloquine	Prophylaxis	228 mg base (250 mg	Begin at least 2 weeks before
(Larium)	in areas with	salt) orally, once/week	travel to malarious areas.. Take
	mefloquine-		weekly on the same day of the
	sensitive malaria		week while in the malarious area
	(mefloquine		and for 4 weeks after leaving
	resistance in SE		such areas.. Contraindicated in
	Asia)		persons allergic to mefloquine or
			related compounds (e..g.., quinine,
			quinidine) and in persons with
			active depression, a recent history
			of depression, generalized anxiety
			disorder, psychosis, schizophrenia,
			other major psychiatric disorders,
			or seizures.. Use with caution
			in persons with psychiatric
			disturbances or a previous history
			of depression.. Not recommended
			for persons with cardiac
			conduction abnormalities..
Primaquine†	Prophylaxis for	30 mg base (52..6 mg	Begin 1–2 days before travel to
	short-duration	salt) orally, daily	malarious areas.. Take daily at the
	travel to areas		same time each day while in the
	with principally		malarious area and for 7 days after
	P.. vivax		leaving such areas..
			Contraindicated in persons with
			G6PD deficiency, pregnancy and
			breastfeeding unless the infant being
			breastfed has a documented normal
			G6PD level..