Antimicrobial Prophylaxis for Patients on Prednisone

Introduction to Prophylaxis Guidelines

The American Gastroenterological Association recommends that HBsAg-positive patients receiving ≥20 mg prednisone daily for ≥4 weeks require anti-HBV prophylaxis with entecavir or tenofovir preferred over lamivudine due to lower resistance rates 2, 3
The American College of Gastroenterology suggests that patients with HBsAg-negative/anti-HBc-positive status on moderate-to-high dose prednisone (10-20 mg or >20 mg daily) for ≥4 weeks are at moderate risk for HBV reactivation and may require antiviral prophylaxis 2, 3

For patients receiving ≥20 mg prednisone daily for ≥4 weeks, the American College of Cardiology recommends PJP prophylaxis with trimethoprim-sulfamethoxazole, which provides 91% reduction in PJP occurrence and 83% reduction in PJP-related mortality 1
The Infectious Diseases Society of America recommends that patients with GVHD continue antifungal prophylaxis throughout the duration of corticosteroid equivalent >1 mg/kg/day for >2 weeks 4, 5

The American Thoracic Society suggests that trimethoprim-sulfamethoxazole is the preferred agent for PJP prophylaxis, providing protection against common bacterial infections, listeriosis, nocardiosis, and toxoplasmosis 1
The European Association for the Study of the Liver recommends that entecavir or tenofovir be preferred over lamivudine for HBV prophylaxis due to lamivudine's 20-30% resistance rate at 1-2 years 3

The Centers for Disease Control and Prevention recommend screening all patients for HBsAg, anti-HBs, and anti-HBc before initiating immunosuppressive prednisone therapy 2
The American Academy of Dermatology suggests monitoring HBcAb-positive/HBsAg-negative patients not on prophylaxis with ALT, HBsAg, and HBV DNA every 3-6 months 7

The American College of Rheumatology recommends that HBV prophylaxis must continue for at least 6 months after stopping prednisone (12 months for B-cell depleting agents) 2
The National Institutes of Health suggest that PJP prophylaxis should continue throughout the duration of immunosuppression 1
The European Society of Clinical Microbiology and Infectious Diseases recommends recognizing that doses >60-80 mg prednisone equivalent provide no additional therapeutic benefit but substantially increase infection risk 8