Chapter 6.  Prophylaxis and Immunizations			377
Table 6.15. Malaria Prophylaxis (cont’d)
	Area of
Drug	Exposure	Adult Dose	Comments
Primaquine	Used for	30 mg base (52..6	Indicated for persons who have had
	presumptive	mg salt) orally, once/	prolonged exposure to P.. vivax and
	antirelapse	day for 14 days after	P.. ovale or both..
	therapy (terminal	departure from the	Contraindicated in persons
	prophylaxis) to	malarious area..	with G6PD† deficiency.. Also
	decrease the risk		contraindicated during pregnancy
	for relapses of		and lactation unless the infant being
	P.. vivax and		breastfed has a documented normal
	P.. ovale		G6PD level..

HDCV = human diploid cell vaccine, PCEC = purified chick embryo cell vaccine, RVA = rabies vaccine absorbed, RIG = rabies immune globulin.

†Glucose-6-phosphate dehydrogenase. . Those who take primaquine should have a normal G6PD level before starting the medication..

TETANUS PROPHYLAXIS

Current information suggests that immunity lasts for decades/life-time after tetanus immunization. A tetanus booster should not be routinely given for minor wounds, but is recom-

mended for wounds with high tetanus potential (e..g.., massive crush wounds, soil-­contaminated wounds, or deep puncture wounds)..

Table 6.16. Tetanus Prophylaxis in Routine Wound Management

History of Adsorbed
Tetanus Toxoid	Wound Type	Recommendations
Unknown or < 3 doses	Clean, minor wounds	Td‡ or Tdap‡
	Tetanus-prone wounds†	(Td‡ or Tdap‡) plus TIG
≥ 3 doses	Clean, minor wounds	No prophylaxis needed
	Tetanus-prone wounds†	Td‡ if > 10 years since last dose*

DT = diphtheria and tetanus toxoids adsorbed (pediatrics), DTP = diphtheria and tetanus toxoids and pertussis vaccine adsorbed, Td = tetanus and diphtheria toxoids adsorbed (adult), TIG = tetanus immune globulin, Tdap = tetanus and diphtheria toxoids and pertussis vaccine absorbed.

†For example, massive crush wounds; wounds contaminated with dirt, soil, feces, or saliva; deep puncture wounds; or significant burn wounds or frostbite..

‡For children < 7 years, DTP (DT if pertussis is contraindicated) is preferred to tetanus toxoid alone. . For children ≥ 7 years old and adults, Tdap is preferred to Td or tetanus toxoid alone..

*More frequent booster doses are unnecessary and can increase side effects. . Protection lasts > 20 yrs Adapted from: Centers for Disease Control and Prevention.. MMWR Rep 40 (RR-10):1–28.. 1991..

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

IMMUNIZATIONS

Immunizations are designed to reduce infections in large populations, and may prevent/ decrease the severity of infection in non-immunized individuals. Compromised hosts with altered immune systems may not develop protective antibody titers to antigenic components of various vaccines.. Immunizations are not fully protective, but are recommended (depending on the vaccine) for most normal hosts, since some protection is better than none..

Table 6.17. Adult Immunizations

Vaccine	Indications	Dosage	Comments
Bacille	Possibly beneficial for	Primary: 1 dose	Live attenuated vaccine induces
Calmette	adults at high-risk of	(intradermal)..	a positive PPD which may
Guérin	multiple-drug resistant	Booster not	remain positive for years/life..
(BCG)	tuberculosis..	recommended..	Contraindicated in immuno-
			compromised hosts.. Injection
			site infection or disseminated
			infection are rare..
Hemophilus	For those at increased	Primary: 0..5 mL dose	Capsular polysaccharide
influenzae	risk for invasive disease,	(IM).. Booster not	conjugated to diphtheria toxoid..
(type B)	e..g.., functional or	recommended..	Benefit uncertain.. Safety in
	anatomic asplenia,		pregnancy unknown.. Mild local
	HIV, immunoglobulin		reaction in 10%..
	deficiency, complement
	deficiency (C1-3), stem cell
	transplants, chemotherapy
	or radiation therapy..
Hepatitis A	All children beginning	Primary: 1 mL dose	Inactivated whole virus..
(HAV)	age 12 to 23 months and	(IM).. One-time	Pregnancy risk not fully
	adults at increased risk	booster ≥ 6 months	evaluated.. Mild soreness at
	of HAV..	later.. Booster	injection site.. Occasional
		not routinely	headache/malaise..
		recommended..
Hepatitis B	Household/sexual	Primary (3 dose	Recombinant vaccine comprised
(HBV)	contact with carrier, IV	series): Recombivax	of hepatitis B surface antigen.. For
	drug use, multiple sex	10 mcg (1 mL)	compromised hosts (including
	partners (heterosexual),	or Engerix-B 20	dialysis patients), use specially
	homosexual male	mcg (1 mL) IM	packaged Recombivax 40-mcg
	activity, blood product	in deltoid at 0, 1,	doses (1 mL vial containing 40
	recipients, hemodialysis,	and 6 months..	mcg/mL).. HBsAb titers should be
	occupational exposure	Alternate schedule	obtained 6 months after 3-dose
	to blood,	for Engerix-B: 4 dose	primary series.. Those with non-
		series at 0, 1, 2, and	protective titers (≤10 mIU/mL)
		12 months.. Booster	should receive 1 dose monthly

	Chapter 6.  Prophylaxis and Immunizations			379
Table 6.17. Adult Immunizations (cont’d)
Vaccine	Indications	Dosage	Comments
	residents/staff of	not routinely	up to a maximum of 3 doses and
	institutions for	recommended..	retest for HbsAb titers.. Pregnancy
	developmentally disabled,		not a contraindication in high-
	prison inmates, residence		risk females.. Mild local reaction
	≥ 6 months in areas of		in 10–20%.. Occasional fever,
	high endemicity, others at		headache, fatigue, nausea.. Twinrix
	high risk..		1 mL (IM) (combination of Hepatitis
			A inactivated vaccine and Hepatitis
			B recombinant vaccine) is available
			for adults on a 0, 1, and 6-month
			schedule or 0, 7 days, 21–30 days,
			and 12 month schedules..
Herpes	Adults ≥60 years to reduce	Primary: 0..65 mL	Duration of protection is at least
zoster (VZV)	the frequency of shingles/	(SC).. Need for	4 years.. Injection site reactions
	prevent post-herpetic	revaccination not	in 48%.. Contraindicated in
	neuralgia.. Use in those with	yet defined.. Vaccine	immunocompromised hosts
	previous H.. zoster is not yet	must be stored	(with immunosuppressive
	defined.. Protection best in	frozen and used	disorder or receiving
	60–69 year group; efficacy	within 30 minutes	immunosuppressive drug) or
	decreases with increasing	after thawing..	untreated TB.. Not indicated for
	age..		therapy of H.. zoster or post-
			herpetic neuralgia..
Influenza	All adults..	Annual vaccine..	High dose (HD) vaccine has 4 ×
		Single 0..5 mL dose	the antigen content as the
		(IM) before flu	standard dose (SD) vaccine..
		season is optimal,	Quadrivalent (2 A strains + 2 B
		but can be given	strain) and trivalent inactivated
		anytime during flu	whole and split virus vaccines
		season.. (2 A strains +	available.. Contraindications
		1 B strain)	include anaphylaxis to eggs or
			sensitivity to thimerosal.. Mild
			local reaction common.. Malaise/
			myalgias in some.. For pregnancy,
			administer in 2nd or 3rd trimester
			during flu season.. High titer (HD)
			inactivated vaccine indicated for
			adults ≥65 years, but enhanced
			protective efficacy (vs.. SD) not
			yet demonstrated..

380	A n t i b i o t i c E s s e n t i a l s
Table 6.17. Adult Immunizations (cont’d)
Vaccine	Indications	Dosage		Comments
Measles	Adults born after 1956	Primary: 0..5 mL dose		Live virus vaccine (usually given
	without live-virus	(SC).. A second dose		in MMR).. Contraindicated in
	immunization or measles	(≥ 1 month later)		compromised hosts, pregnancy,
	diagnosed by a physician	is recommended		history of anaphylaxis to eggs
	or immunologic test.. Also	for certain adults		or neomycin.. Ineffective if
	indicated for revaccination	at increased		given 3–11 months after blood
	of persons given killed	risk of exposure		products.. Side effects include
	measles vaccine between	(e..g.., healthcare		low-grade fever 5–21 days
	1963–67..	workers, travelers		after vaccination, rash, and
		to developing		local reactions in if previously
		countries).. No		immunized with killed vaccine
		routine booster..		(1963–67)..
Meningo-	Patients with splenic	Meningococcal		Also used in epidemic control
coccus	dysfunction­ or with	conjugate vaccine		of N.. meningitides serogroups A,
(invasive	complement defects	0..5 mL (IM).. Primary:		C, Y, and W-135.. For sero-
disease)	(C7-9) laboratory workers..	0..5 mL (IM) then		group B use meningococcal
	May be given to 1st year	again at months 2		group B vaccine..
	college students living in	and 6 (3 dose series)
	dormitories..
Mumps	Non-immune adults..	Primary: 0..5 mL dose		Live attenuated vaccine (usually
		(SC).. No routine		given in MMR).. Contraindicated
		booster..		in immunocompromised hosts,
				pregnancy, history of anaphylaxis
				to eggs or neomycin..
Papilloma	Females up to 26 years	Primary: 0..5 mL		Quadrivalent HPV vaccine to
(human)	of age.. Contraindicated	(IM).. Second dose:		prevent cervical, vulvar, vaginal
Virus (HPV)	in pregnancy.. Suggested	2 months after 1st		and cancers caused by HPV types
	for males up to 26 years	dose.. Third dose:		6, 11, 16, 18.. 9 valent HPV vaccine
	of age..	6 months after 1st		includes HPV types 52, 58, 31, 33,
		dose..		45, 6, 11, 16, 18..
Pertussis	Use Tdap instead of Td in	A Single Tdap		Recommended since adults may
	booster dose..	booster dose 0..5		get pertussis or transmit it to
		mL (IM)..		susceptible infants..

	Chapter 6.  Prophylaxis and Immunizations			381
Table 6.17. Adult Immunizations (cont’d)
Vaccine	Indications	Dosage	Comments
Pneumo-	Immunocompetent hosts	PPSV-23	Pneumococcal vaccine naïve
coccus	≥ 65 years old, or > 19	PCV-13	persons aged ≥ 65.. Give PCV-13,
(S.. Pneumo­	years old with diabetes,	Primary: 0..5 mL dose	then give PPSV-23 6-12 months
niae)	CSF leaks, or chronic	(IM).. No booster..	later (minimal interval 8 weeks)..
	cardiac, pulmonary or	Primary: 0..5	Persons who previously received
	liver disease.. Also for	mL dose (SC or	PPSV-23 at age ≥ 65.. Give PCV-13
	immunocompromised	IM).. A one-time	>1 year later after PPSV-23 given..
	hosts > 19 years old with	booster at 5 years	Persons who previously received
	functional/anatomic
		is recommended	PPSV-23 before age 65 years who
	asplenia,* leukemia,
		for immuno –	are now age ≥ 65.. Give PCV-13
	lymphoma, multiple
		compromised hosts	when ≥ 65 years give > 1 year
	myeloma, widespread
		> 2 years old and for	later (minimum interval between
	malignancy, chronic renal
	failure, bone marrow/	those who received	sequential administration of
		the vaccine before	PCV-13 and PPSV-23 is 8 weeks)..
	organ transplant, or on
		age 65 for high-risk	If this window is missed, PPSV-23
	immunosuppressive/
		conditions..	can be given 6-12 months after
	steroid therapy..
			PCV-13..
Rubella	Non-immune adults,	Primary: 0..5 mL dose	Live virus (RA 27/3 strain)
	particularly women of	(SC).. No routine	vaccine (usually given in MMR)..
	childbearing age..	booster..	Contraindicated in immuno-
			compromised hosts, pregnancy,
			history of anaphylactic reaction
			to neomycin.. Joint pains and
			transient arthralgias in up to
			40%, beginning 3–25 days after
			vaccination and lasting 1–11 days;
			arthritis in < 2%..
Tetanus-	Adults	Primary: Td two 0..5	Adsorbed toxoid vaccine..
diphtheria		mL doses (IM), 1–2	Contraindicated if
		months apart; third	hypersensitivity/neurological
		dose 6–12 months	reaction or severe local
		after second dose..	reaction to previous doses.. Side
		Booster: a single	effects include local reactions,
		Tdap 0..5 mL (IM)	occasional fever, systemic
		is recommended..	symptoms, Arthus-like reaction
		Tdap should be	in persons with multiple previous
		substituted for one of	boosters, and systemic allergy
		the three Td doses..	(rare)..

PCV-13 = 13 valent pneumococcal conjugate vaccine (contains strains: 1, 3, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F)

PPSV-23 = 23 valent pneumococcal polysaccharide vaccine (contains strains: 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, 33F)..

*Pneumococcal polysaccharide vaccine may be given before splenectomy, but is in effective post-splenectomy, the conjugate vaccine is more effective..