Prophylaxis risk assessment

In a retrospective audit of 105 patients (38 men and 67 women, over 18 years of age) in a tertiary care center in India, 56 % had at least one documented intervention related to osteoporosis prevention (calcium, vitamin D, bisphosphonates, or a bone mineral density study) [17. Only three patients received bisphosphonates for osteoporosis prophylaxis. There was poor pretherapeutic risk assessment, absence of instructions regarding preventive measures, inappropriate investigation for the presence of osteoporosis, and unacceptable failure to use bone protective agents. 

Assess the risk for variceal bleeding and begin pharmacologic prophylaxis where indicated, reserving endoscopic therapy for high-risk patients or acute bleeding episodes. 

When a child has febrile convulsions the decision to embark on continuous prophylaxis is serious for the child, and depends on an assessment of risk factors, e.g. age, nature and duration of the fits. Most children who have febrile convulsions do not develop epilepsy. Prolonged drug therapy, e.g. with phenytoin or phenobarbitone, has been shown to interfere with cognitive development, the effect persisting for months after the drug is withdrawn. Parents may be supplied with a specially formulated solution of diazepam for rectal administration (absorption from a suppository is too slow) for easy and early administration, and advised on managing fever, e.g. use paracetamol at the first hint of fever, and tepid sponging. 

Inununosuppressed radiation victims with positive serology for herpes simplex viruses are at risk for reactivation of HSV infection, with resulting clinical picture that mimics radiation stomatitis. These patients should receive prophylaxis with acyclovir or one of its congeners. If serology results are not available, patients with a history of oral or genital herpes infection should receive acyclovir prophylaxis. Patients who develop severe mucositis require assessment for HSV reactivation (2). 

Immunosuppressed radiation victims may also be at risk for reactivation of cytomegalovirus (CMV) and Pneumocystis carinii pneumonia. In a limited casualty situation, if resources are available, clinicians should obtain CMV serology. In addition, patients should have a sensitive assay (antigen assessment or polymerase chain reaction test) every 2 weeks for 30 days postexposure, while those with documented previous CMV exposure should have the assay repeated until 100 days postexposure (2). Patients developing lymphopenia should have a CD4 cell count considered at 30 days postexposure. Those with a CD4 count below 0.2000 x 10 cells L" are at risk for Pneumocystis carinii pneumonia. Physicians should withhold trimethoprim-suha prophylaxis until the leukocyte count is above 3.0 x 10 cells L" or until the absolute neutrophil count is above 1.5 x 10 cells L . Atovaquone, dap-sone and aerosohzed pentamidine are alternative prophylactic agents. Patients should continue prophylactic treatment until the CD4 count reaches or exceeds 0.2000 X 10 cells L, which may occur over several months (2). 

Following each occupational exposure, proper assessment of the risk for HIV transmission should be performed by qualified personnel. If at all possible, the source patient should be evaluated for HIV, HBV, and HCV status to help mle out viral infection.Information pertaining to intravenous drug use and other source risk factors relevant for consideration of post-exposure prophylaxis should be sought. If this information is unavailable, the source person should be notified of the incident and consent sought to facilitate testing for serologic evidence for viral infection. If the source is sero-... 

Subcutaneous (SC) heparin use for prophylaxis of venous thromboembolism, typically 5000 units every 12 hours, has been used extensively and is not a contraindication for neuraxial techniques. Withholding heparin until the block is placed and assessing platelet count in patients who have received heparin for more than 4 days may reduce the risk of complications. 

The effect of low-molecular-weight heparin on bone mineral density has been assessed in a multicenter multinational randomized study in pregnant women with thrombophilia [118 ]. There was no significant difference in mean bone mineral density between those who were given low-molecular-weight heparin prophylaxis and those who were given no prophylaxis, but the study was not adequately powered to detect differences in the absolute risk of fractmes. 

The decision to provide post-exposure prophylaxis will involve a thorough assessment of risk regarding the potential extent and type of exposure encountered. 

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