Prophylaxis guidelines

HIV post-exposure prophylaxis

Sunnybrook’s policy and procedures for management of exposure to HIV can be found on Sunnynet by searching Sunnynet with the keywords “HIV” or “PEP” or “bloodborne.” It can also be accessed by using the following series of links from the home page:

Policies & Standards > Infection Prevention & Control > Safety Policies for Staff > Bloodborne Pathogens

Following an occupational exposure, chemoprophylaxis with antiretroviral agents may be offered or recommended based on an evaluation of risk following assessment of the type of exposure, the source material, and the HIV status of the source patient (see below).

Immunization for asplenic patients

Individuals with anatomical or functional asplenia are at risk for serious infection caused by ubiquitous encapsulated bacteria such as pneumococci (Streptococcus pneumoniae), meningococci (Neisseria meningitidis) and Haemophilus influenzae type b (“Hib”).

The lifetime risk of overwhelming infection is 5% and mortality is 50 – 80%.

These individuals should therefore be vaccinated against these organisms and they should also receive annual influenza virus vaccination.

NOTE: All of the vaccines recommended above can be administered at the same time, provided that each product is injected at distinct body sites using a separate syringe.

* For ELECTIVE SPLENECTOMY

• Give all necessary vaccines as soon as possible, at least 2 weeks before surgery.
• If pre-op splenectomy immunization is missed and patient is within 2 weeks from planned surgery, an emergency splenectomy immunization schedule should be followed.

^ For EMERGENCY SPLENECTOMY

• Initial vaccines are best given 2 weeks after the splenectomy for optimal response.  If a person is discharged earlier and there is a concern that she or he might not return, vaccines should be given before discharge.

^ Pneumococcal vaccination

• If Pneumovax is given as the initial dose, the next required dose would be a booster at 5 years (no need for a dose at 8 weeks and no need to provide any Prevnar®)
• Although this regimen may not be optimal, it will provide adequate protection

+ Meningococcal Vaccination

• Bexsero contains latex in tip cap of syringe. In those with non-severe latex allergy, it can be given with close monitoring afterwards. Bexsero should be avoided in those reporting anaphylaxis to latex.

Endocartis prophylaxis

The 2007 American Heart Association (AHA) Guidelines for Prevention of Infective Endocarditis have been endorsed by the Infectious Diseases Society of America (IDSA) and approved by the American Dental Association (ADA).

Endocarditis prophylaxis is only recommended for those patients with the specific cardiac conditions listed below AND undergoing one of the selected procedures listed below that warrants prophylaxis.

Prophylaxis in complex malignant hematology

The 2016 Consensus Statement on Dental Patients with Total Joint Replacement has been endorsed by the Canadian Orthopedic Association (COA), the Canadian Dental Association (CDA) and the Association of Medical Microbiology and Infectious Disease (AMMI) Canada. The current best available evidence on the effectiveness of dental antibiotic prophylaxis in the reduction of orthopedic prosthetic joint infections was reviewed, in the context of the issue of emerging antimicrobial resistance.

Recommendations regarding antibiotic prophylaxis:

1. Routine antibiotic prophylaxis is NOT indicated for dental procedures in patients with total joint replacements or orthopedic pins, plates and screws.
2. Patients should be in optimal oral health prior to having total joint replacement and should maintain good oral hygiene and oral health following surgery.
3. Orofacial infections in all patients, including those with total joint prostheses, should be treated to eliminate the source of infection and prevent its spread.

Guiding principles for open fracture management

• An open fracture typically involves the long joints (excluding the digits), resulting in soft tissue injury and communication with the outside environment. Open lower extremity fractures (particularly tibial shaft) are associated with a higher risk of infection compared to open fractures of the skull, face, hands, or upper extremities.
• Prophylactic antibiotic therapy is one component of open wound fracture management which includes tetanus immunization, wound irrigation, and surgical intervention.
• American College of Surgeons Trauma Quality Improvement Plan recommends initiation of antibiotics within 1 hour of presentation to reduce risk of infection.

Recommended prophylaxis based on clinical grading

*only If severe non-IgE-mediated reaction (e.g. Steven-Johnson Syndrome) to beta-lactams OR anaphylaxis/urticaria to cefazolin.
ǂ for patient with severe hemorrhage requiring multiple blood transfusions, re-dosing ceftriaxone 1g IV post-operatively is recommended ABW=Actual Body Weight

Recommended prophylaxis based additional circumstances

* only if severe Ig-E mediated reaction to penicillin or severe non-IgE-mediated reaction (e.g. Steven-Johnson Syndrome) to any beta-lactam
^prior MRSA infection, prior MRSA nasal carriage, wound(s), living in shelter or communal setting, recent prolonged health care exposure.

References

1. Abubaker AO, Rollert MK. Postoperative antibiotic prophylaxis in mandibular fractures: a preliminary randomized, double-blind, and placebo-controlled clinical study. J Oral Maxillofac Surg 2001;59:1415-1419.
2. Carsenti-Etesse H, Doyon F, Desplaces N, et al. Epidemiology of bacterial infection during management of open leg fractures. Eur J Clin Microbiol Infect Dis 1999;18:315-23.
3. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type 3 (severe) open fractures: a new classification of type 3 open fractures. J Trauma.1984; 24: 742-746
4. Jager M, Maier D, Kern WV, Sudkamp NP. Surgical Infection Society guidelines. Prophylatic antibiotic in open fracture: an evidence based guideline. Surg Infect 2006; 7: 379-405.
5. Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res 1997;339:71-5.
6. Noonburg G. Management of Extremity Trauma and Related Infections Occuring in the Aquatic Environment. Journal of the American Academy of Orthopaedic Surgeons 2005;13(4):243-253.
7. Olson SA, Finkemeier CG, Moehring ND. Open Fractures. In: Bucholz RW, Heckman JD, editors. Rockwood and Greene’s fractures in adults. 5th ed. Philadelphia: Lippincott, Williams and Wilkins 2001; pp. 285-318.
8. Peacock KC, Hanna DP, Kirkpatrick K, Breidenbach WC, Lister GD, Firrell J. Efficacy of perioperative cefamandole with postoperative cephalexin in the primary outpatient treatment of open wounds of the hand. J Hand Surg Am 1988;13:960-964.
9. Ribeiro N, Heath C, Kierath J, Rea S, Duncan-Smith M, Wood F. Burn wounds infected by contaminated water: Case reports, review of the literature and recommendation for treatment. Burns 2010;36:9-22.
10. Rodriguez L, Jung HS, Goulet JA, Cicalo A, Machado-Aranda DA, Napolitano LM. Evidence-based protocol for prophylactic antibiotics in open fractures: Improved antibiotic stewardship with no increase in infection rates. The Journal of Trauma and Acute Care Surgery 2014;77(3):400-408.
11. Templeman DC, Gulli B, Tsukayama DT Gustilo RB. Update on the management of open fractures of the tibial shaft. Clin Orthop 1998; 350: 18-25.
12. Zalavras CG, Patzakis MJ, Holtom PD, Sherman R. Management of open fractures. Infect Dis Clin North Am 2005;19:915-29.