Galway Antimicrobial Prescribing Policy / Guidelines (GAPP)

Principles of Antibiotic Prophylaxis in Surgery
Nephrology
Note Regarding Risk Factors for MRSA
Classification of Surgical Procedures
Breast Surgery
Cardiothoracic Surgery
Ear, Nose and Throat (ENT) Surgery
Gastrointestinal Surgery
Head and Neck Surgery
Maxillofacial Surgery
Obstetric and Gynaecological Surgery
Ophthalmic Surgery
Orthopaedic and Trauma Surgery
Plastic Surgery
Urological Surgery
Vascular Surgery and Limb Amputation
Interventional Radiological Procedures
References

Antibiotic Prophylaxis in Surgery

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Principles of Antibiotic Prophylaxis in Surgery

Principles of Antibiotic Prophylaxis in Surgery

Antibiotic prophylaxis in surgery is the use of antibiotics to prevent post-operative infection.

Are prophylactic antibiotics needed?

Prophylaxis is recommended for patients undergoing:

  • Clean-contaminated and contaminated/dirty surgical procedures (see also note below regarding post-operative infection).
  • Clean surgical procedures with increased infection risk/devastating consequences of infection such as lower limb vascular surgery, insertion of prosthetic material or on immunocompromised patients.

Choice of antibiotic​

  • The choice of agent will be determined by the procedure and the likely potential pathogens . These guidelines generally apply to procedures in patients admitted from the community.
  • Erythromycin should be avoided - it is not a suitable agent for prophylaxis for a number of reasons including poor tissue penetration.

Timing of administration​

  • The aim of prophylaxis is to have maximum tissue antibiotic levels at the time of first incision.
  • Therefore prophylaxis should be administered within 60 minutes before incision/procedure and is usually given in theatre at induction of anaesthesia.
  • Note that fluoroquinolones (e.g. ciprofloxacin) require a longer time for infusion (60 minutes for 400mg IV). Therefore ciprofloxacin infusion should commence within 120 minutes before the surgical incision.

Duration of prophylaxis

  • In most situations there is no value in continued prophylaxis after wound closure and prophylaxis is usually given as a single dose unless otherwise specified below.
  • As per the HSE National Clinical Programme in Surgery (NCPS) Surgical Antibiotic Prophylaxis Duration Position Paper
    • A duration of antibiotic prophylaxis of longer than 48 hours cannot be reasonably justified for any surgical procedure on the basis of current evidence or by consensus of expert opinion. (Note exception: management of open fractures)
    • Antibiotic prophylaxis should not be continued beyond the time frames outlined on the basis that drains remain in place.

Procedures requiring prophylaxis for >1 dose

Procedure

Duration

Breast: Reconstructive Breast Surgery

Up to 24 hours

Cardiothoracic: CABG, Prosthetic Valve Surgery, Electronic Device Placement, Pulmonary Resection

24 hours

ENT: Complex septo-rhinoplasty including grafts

24 hours

Head & Neck

Up to 24 hours, unless extensive head & neck flap reconstruction

Maxillofacial:

Open reduction and internal fixation of compound mandibular fractures, orthognathic surgery,

intraoral bone grafting procedures.

Facial plastic surgery with implant (consider prophylaxis).

Up to 24 hours

Orthopaedic:

Orthopaedic implant surgery, ORIF closed fractures , Spinal surgery

Open fracture intervention/acute trauma

Debridement chronic bone infection

24 hours

3 to 5 days, maximum 24 hours post final wound closure

Discuss with Microbiology or Infectious Diseases

Plastic Surgery

Discuss with Microbiology or Infectious Diseases

Urology: Transrectal Prostate Biopsy

2 doses ciprofloxacin (24 hours)

Vascular Surgery & Limb Amputation

24 hours

​

Additional intra-operative doses

Additional intra-operative doses of prophylactic antibiotic may be necessary in the following situations:

  • Prolonged surgical procedures. Some antibiotics such as cephalosporins (e.g. CefUROXime) are short-acting and therefore an additional dose may be needed during surgery in procedures lasting longer than four hours. Re-dosing is not recommended for antibiotics such as gentamicin, vancomycin or teicoplanin.
  • Blood loss/fluid replacement: In the event of major intra-operative blood loss (>1.5Litres) additional doses of prophylactic antibiotic should be considered after fluid replacement . Caution is needed in patients with renal impairment.

Antibiotics requiring additional intra-operative doses

During procedures lasting over 4 hours or if major blood loss (>1.5L)

Antibiotic

Dose

Recommended redosing interval (from initiation of pre-op dose) in hrs *

Amoxicillin

1g

2 hrs

Cefuroxime

1.5g

4 hrs

Co-amoxiclav

1.2g

4 hrs (max 4 doses in 24 hrs)

Flucloxacillin

1g

4 hrs

* The re-dosing interval may vary depending upon the half-life of the drug in question, and the patients underlying renal and hepatic function.

Obesity

The pharmacokinetics of drugs may be altered in obese patients, so dosage adjustment based on body weight may be warranted. Discuss with Pharmacy / Microbiology / Infectious Diseases if necessary.

Documenting antibiotic use

  • Prophylactic antibiotics should be prescribed in the appropriate section of the patient’s drug chart.
  • Patients should ideally be informed prior to surgery, wherever possible, if they will need antibiotic prophylaxis, and afterwards if they have been given antibiotics during their operation.

Post-operative infection​

  • If infection is suspected during surgery or post-operatively within 24 hours, appropriate microbiological samples should be sent. An agent that is appropriate for prophylaxis may not be the optimal agent for treatment of established infection and treatment guidelines should be consulted.

Complex prophylaxis issues​

  • For patients with complex clinical situations e.g. those with resistant organisms, renal failure, immunocompromised or allergy to agents listed, please obtain advice from Microbiology or Infectious Diseases if necessary.
  • Patients at risk for development of endocarditis may require modification of standard antimicrobial prophylaxis regimens. See Prophylaxis of Infective Endocarditis . Please discuss with Microbiology or Infectious Diseases if necessary.

MRSA

Multi-drug Resistant Organisms (MDRO) other than MRSA

  • For patients colonised with an MDRO other than MRSA, discuss with Microbiology or Infectious Diseases. See note on MDRO

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Nephrology

Antibiotics for Nephrology

Type of surgery

Procedure

1 st Line Antibiotic

Penicillin allergy:

immediate or severe delayed reaction

Number &

Timing of Doses

Peritoneal dialysis catheter insertion prophylaxis

CefUROXime IV 1.5g (one dose only)

Teicoplanin IV 10mg/kg* (Max 800mg) (one dose only)

* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy

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Note Regarding Risk Factors for MRSA

Note Regarding Risk Factors for MRSA

  • Teicoplanin IV 10mg/kg (e.g. rounded up to 800mg for an average 70kg patient) should be ADDED to the recommended regimens (except those containing flucloxacillin, where teicoplanin should replace flucloxacillin), unless teicoplanin or vancomycin are already included, if the patient:
    • Is known to be colonised with MRSA
    • Was recently colonised with MRSA
    • Was an inpatient for more than 72 hours before the procedure and has not had a recent confirmed negative MRSA screen result
    • Was admitted from another hospital or nursing home and has not had a recent confirmed negative MRSA screen result
    • Is at high risk for colonisation with MRSA for other reasons and has not had a recent confirmed negative MRSA screen result
  • In the case of patients known to be colonised with MRSA who are undergoing cardiac, major orthopaedic implant or other complex surgery, it may be advisable to discuss an MRSA eradication protocol with Microbiology or Infectious Diseases in advance of the surgery.
  • The recommended dose of teicoplanin is 10mg/kg to ensure adequate tissue levels. The calculated dose is 700mg for an average 70kg patient - the dose is rounded to 800mg (2 x 400mg vials) for a patient with an average weight of 70kg for practical reasons.
  • Teicoplanin is used in surgical prophylaxis in preference to vancomycin in most cases, due to ease of administration, as doses up to 800mg can be given by slow intravenous injection over 3 to 5 minutes.
  • Doses over 800mg should be given by infusion (in 50ml NaCl 0.9% or Glucose 5%) over 30 minutes.
  • If continued antibiotic treatment is necessary post surgery, switch to vancomycin .

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Classification of Surgical Procedures

Classification of Surgical Procedures

Clean

Clean-contaminated

Contaminated/Dirty

No breach of respiratory, alimentary or genito-urinary tracts

Non-traumatic

No inflammation

No break in aseptic technique

Non-traumatic but with break in aseptic technique or breach of respiratory, alimentary or genito-urinary tract

No significant spillage

Contaminated: Major break in aseptic technique; acute inflammation (without pus); operations where there is visible contamination of wound e.g. gross spillage from a hollow viscus during surgery or fresh (less than 4 hours) traumatic wound from relatively clean source.

Dirty: operations in the presence of pus e.g. where there is a previously perforated hollow viscus or compound/open injuries that are old (more than 4 hours) or from a dirty source.

Prophylaxis NOT usually recommended UNLESS clinical setting indicates an increased infection risk e.g. lower-extremity vascular procedures, or where infection may have devastating consequences e.g. orthopaedic implant surgery or placement of other prosthetic devices) , or if the patient is immunocompromised e.g. neutropenic, receiving immunosuppressive agents, malnourished.

Prophylaxis indicated (see individual speciality)

Prophylaxis indicated (see individual speciality).

Treatment course may be required (usually 5 to 7 days - duration will depend on clinical response). Discuss with Microbiology or Infectious Diseases if necessary.

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Breast Surgery

Antibiotics for Breast Surgery

Type of Surgery

Procedure

1 st Line Antibiotic

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Number &

Timing of Doses

See penicillin hypersensitivity section for further information

Prophylaxis in Breast Surgery

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms (MDRO)

Surgery for benign breast lump where no axillary procedure performed

Surgical prophylaxis generally not indicated

Breast surgery (including mastectomy, wide local excision, axillary clearance, breast reduction, duct excision)

Flucloxacillin IV 1g (one dose only)

If risk factors for or colonised with MRSA Replace Flucloxacillin with Teicoplanin IV 10mg/kg * (Max 800mg) (one dose only)

CefUROXime IV 1.5g (one dose only)

If risk factors for or colonised with MRSA Replace CefUROXime with Teicoplanin IV 10mg/kg*(Max 800mg) (one dose only)

Teicoplanin IV 10mg/kg *(Max 800mg) (one dose only)

One dose within 60 minutes before incision.

Reconstructive breast surgery with or without tissue expander

Co-amoxiclav IV

1.2g every 8 hours (up to maximum 3 doses)

CefUROXime IV

1.5g every 8 hours (up to maximum 3 doses)

Teicoplanin IV 10mg/kg * (Max 800mg) every 12 hours (up to maximum 2 doses)

+ Gentamicin IV one dose only, dose per GAPP App calculator

1 st dose within 60 minutes before incision.

Maximum 24 hours duration.

* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy

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Cardiothoracic Surgery

Antibiotics for Cardiothoracic Surgery

Type of Surgery

Procedure

1 st Line Antibiotic

In penicillin allergy

Number & Timing of  Doses

See penicillin hypersensitivity section for further information

Prophylaxis in Cardiothoracic Surgery

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms (MDRO)

Coronary artery bypass graft (CABG)

CefUROXime** IV 1.5g every 8 hours for a total of 3 doses 1 (24 hour cover)

+

If risk factors for or colonised with MRSA Add Teicoplanin IV 10mg/kg * (Max 800mg) every 12 hours for a total of 2 doses (24 hour cover)

Immediate or severe delayed reaction only:

Teicoplanin IV 10mg/kg* (Max 800mg) every 12 hours for a total of 2 doses (24 hour cover)

+

Gentamicin IV

ONE dose only, dose per GAPP App calculator (24 hour cover)

1 st dose within 60 minutes before incision & continued for 24 hours.

** Additional intra-operative dose of cefUROXime IV 1.5g required if duration of procedure > 4 hours or  >1.5L intra-operative blood loss - See Antibiotics requiring additional intra-operative doses

Prosthetic valve surgery

As for CABG

Transcatheter aortic valve implantation (TAVI)

Co-amoxiclav IV 1.2g every 8 hours for a total of 3 doses (24 hour cover).

Teicoplanin IV 10mg/kg* (Max 800mg) every 12 hours for a total of 2 doses (24 hour cover)

+

Gentamicin IV

ONE dose only, dose per GAPP App calculator (24 hour cover)

1st dose within 60 minutes before incision & continued for 24 hours

Cardiovascular Implantable Electronic Device placement (including permanent pacemakers and Implantable cardioverter-defibrillator (ICD))

Flucloxacillin IV 1g one dose; continue 1g PO every 6 hours for another 3 doses (24 hour cover)

If risk factors for or colonised with MRSA Replace Flucloxacillin with Teicoplanin IV 10mg/kg * (Max 800mg) every 12 hours for a total of 2 doses (24 hour cover)

Any history of penicillin allergy:
Teicoplanin IV 10mg/kg* (Max 800mg) every 12 hours for a total of 2 doses (24 hour cover)

1 st dose within 60 minutes before incision & continued for 24 hours.

Thoracotomy, Pulmonary resection

CefUROXime** IV 1.5g every 8 hours for a total of 3 doses (24 hour cover)

Immediate or severe delayed reaction only:

Teicoplanin IV 10mg/kg *(Max 800mg) every 12 hours for a total of 2 doses (24 hour cover)

+

Gentamicin IV

ONE dose only, dose per GAPP App calculator (24 hour cover)

1 st dose within 60 minutes before incision & continued for 24 hours.

Video-assisted thoracoscopy (VATS)

CefUROXime** IV 1.5g (one dose only)

Immediate or severe delayed reaction only:

Teicoplanin IV 10mg/kg * (Max 800mg) (one dose only)

+

Gentamicin IV

ONE dose only, dose per GAPP App calculator

One dose within 60 minutes before incision.

* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy

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Ear, Nose and Throat (ENT) Surgery

Antibiotics for Ear, Nose and Throat (ENT) Surgery

Type of Surgery

Procedure

1st Line Antibiotic

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Number &

Timing of Doses

See penicillin hypersensitivity section for further information

Prophylaxis in

Ear, Nose, & Throat (ENT)

Surgery

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms (MDRO)

ENT: Complex septo-rhinoplasty including grafts

Co-amoxiclav IV

1.2g every 8 hours for a total of 3 doses (24 hour cover)

CefUROXime IV

1.5g every 8 hours for a total of 3 doses (24 hour cover)

+

Metronidazole IV 500mg every 8 hours for a total of 3 doses (24 hour cover)

Teicoplanin IV 10mg/kg* (Max 800mg) every 12 hours for a total of 2 doses (24 hour cover)

+

Gentamicin IV one dose only, dose per GAPP App calculator (24 hour cover)

+

Metronidazole  IV 500mg every 8 hours for a total of 3 doses (24 hour cover)

1 st dose within 60 minutes before incision & continued for 24 hours.

Routine nose, sinus, endoscopic sinus surgery, tonsillectomy ,adenoidectomy or placement of tympanostomy tubes (grommets). Surgical prophylaxis NOT recommended
* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy

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Gastrointestinal Surgery

Antibiotics for Gastrointestinal  Surgery

Type of Surgery

Procedure

1 st Line

Antibiotic

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Number & Timing of Doses

See penicillin hypersensitivity section for further information

Prophylaxis in Gastro-intestinal Surgery

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms (MDRO)

Upper GIT (including oesophageal, gastro-duodenal, small-intestinal, gastric bypass)

Co-amoxiclav IV 1.2g (one dose only)

CefUROXime IV 1.5g (one dose only)

+

Metronidazole IV 500mg (one dose only)

Ciprofloxacin IV 400mg (one dose only)

+

Metronidazole IV 500mg (one dose only)

One dose within 60 minutes before incision.

See note below re ciprofloxacin infusion 2

Lower GIT (colon, rectum, appendix 1 )

Gall–bladder surgery (open)

Gall-bladder surgery (laparoscopic)-prophylaxis recommended for high-risk 3 patients only

Pancreatic surgery

Percutaneous endoscopic gastrostomy (PEG)

Hernia repair: antibiotic prophylaxis NOT recommended unless mesh insertion

Splenectomy: NOT generally recommended for procedure unless immunocompromised. Post-splenectomy prophylaxis is discussed elsewhere in these guidelines.

ERCP-antibiotic prophylaxis NOT recommended unless high-risk 3 patient

Ciprofloxacin PO 750mg one dose 60 to 90 minutes prior to procedure OR Gentamicin IV one dose only, dose per GAPP App calculator, within 60 minutes before procedure.

One dose

Diagnostic  laparoscopy

Prophylaxis NOT recommended

1 If appendix perforated or associated with peritonitis, treatment course may be required.

2 Ciprofloxacin requires a longer time for infusion (60 minutes for 400mg IV). Therefore ciprofloxacin infusion should commence within 120 minutes before the surgical incision.

3 Consider antibiotic prophylaxis for high-risk patients : intra-operative cholangiogram, pancreatic pseudo-cyst, immunosuppression, incomplete biliary drainage, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, pregnancy (discuss choices with Microbiology or Infectious Diseases), insertion of prosthetic device e.g. T-tube, primary sclerosing cholangitis, age > 70 years, diabetes, likely prolonged procedure.

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Head and Neck Surgery

Antibiotics for Head and Neck Surgery

Type of Surgery

Procedure

1st Line Antibiotic

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Number &

Timing of Doses

See penicillin hypersensitivity section for further information

Prophylaxis in Head & Neck Surgery

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms (MDRO)

Head and neck surgery: clean-contaminated and contaminated (including radical neck dissection)

Co-amoxiclav IV

1.2g every 8 hours (up to maximum 3 doses)

CefUROXime IV

1.5g every 8 hours (up to maximum 3 doses)

+

Metronidazole  IV 500mg every 8 hours (up to maximum 3 doses)

Teicoplanin IV 10mg/kg* (Max 800mg) every 12 hours (up to maximum 2 doses)

+

Gentamicin IV one dose only, dose per GAPP App calculator

+

Metronidazole IV 500mg every 8 hours (up to maximum 3 doses)

1 st dose within 60 minutes before incision.

Duration no longer than 24 hours unless extensive head and neck flap reconstruction.

Clean head and neck surgery with no mucosal breach (e.g. parotid or thyroid surgery)

Surgical prophylaxis not routinely required

*Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy

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Maxillofacial Surgery

Antibiotics for Maxillofacial Surgery

Type of Surgery

Procedure 1

1 st Line Antibiotic

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Number &

Timing of Doses

See penicillin hypersensitivity section for further information

Prophylaxis in Maxillofacial Surgery

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms

(MDRO)

Open reduction and internal fixation of compound mandibular fractures, orthognathic surgery, intraoral bone grafting procedures 1

Facial plastic surgery with implant (consider prophylaxis).

Co-amoxiclav IV

1.2g every 8 hours (up to maximum 3 doses)

CefUROXime IV

1.5g every 8 hours (up to maximum 3 doses)

+

Metronidazole IV 500mg every 8 hours (up to maximum 3 doses)

Teicoplanin  IV

10mg/kg* (Max 800mg) every 12 hours (up to maximum 2 doses)

+

Gentamicin IV one dose only, dose per GAPP App calculator

+

Metronidazole IV 500mg every 8 hours (up to maximum 3 doses)

1 st dose within 60 minutes before incision.

Duration usually no longer than 24 hours.

1 List of procedures requiring prophylaxis is not exhaustive

* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy

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Obstetric and Gynaecological Surgery

Antibiotics for Obstetric and Gynaecological Surgery

Type of Surgery

Procedure

1 st Line

Antibiotic

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Number & Timing of Doses

See penicillin hypersensitivity section for further information

Prophylaxis in Obstetric & Gynaecological Surgery

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms (MDRO)

Hysterectomy:

Vaginal and total abdominal hysterectomy

Co-amoxiclav IV 1.2g (one dose only)

CefUROXime IV

1.5g (one dose only)

+

Metronidazole IV 500mg (one dose only)

Ciprofloxacin IV 400mg (one dose only)

+

Metronidazole IV 500mg (one dose only)

One dose within 60 minutes before incision.

See note below  re ciprofloxacin  infusion**

Caesarean section (elective and emergency)

Co-amoxiclav IV 1.2g (one dose only)

CefUROXime IV 1.5g (one dose only)

+

Metronidazole IV 500mg (one dose only)

Teicoplanin IV 10mg/kg* (Max 800mg) (Use booking weight)

+

Metronidazole IV 500mg (one dose only)

+

Gentamicin IV one dose only, dose per GAPP App calculator (Use booking weight)

One dose within 60 minutes before incision.

Operative vaginal delivery

prophylaxis should be offered to all women as soon as possible after delivery .

For detailed guideline see WAC GUH Q pulse document (CLN-LW-0067-update in progress)

Co-amoxiclav IV 1.2g (one dose only)

CefUROXime IV 1.5g (one dose only)

+

Metronidazole IV 500mg (one dose only)

Teicoplanin IV 10mg/kg* (max 800mg) (Use booking weight)

+

Metronidazole IV 500mg (one dose only)

+

Gentamicin IV one dose only, dose per GAPP App calculator (Use booking weight)

One dose as soon as possible after delivery

Manual removal of placenta

For full detailed guidelines see WAC Directorate guidelines for Manual Removal of the placenta (Q pulse CLN-LW-0029)

Repair of 3 rd and 4 th degree perineal tears involving the anal sphincter/rectal mucosa .

For detailed guideline see WAC Directorate document for the Management of 3 rd and 4 th Degree Tears (Q pulse CLN-LW-0022)

Co-amoxiclav IV 1.2g (one dose only)

CefUROXime IV 1.5g (one dose only)

+

Metronidazole  IV 500mg (one dose only)

Teicoplanin IV 10mg/kg* (Max 800mg) (use booking weight)

+

Metronidazole IV 500mg (one dose only)

+

Gentamicin IV one dose only, dose per GAPP App calculator (Use booking weight)

Single dose within 60 minutes before procedure

Laparoscopy (without breach of bowel, uterine, vaginal mucosa), Dilation and curettage (D&C), Intrauterine device insertion, Hysteroscopy, Endometrial ablation***

Surgical prophylaxis is NOT generally recommended

* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy

** Ciprofloxacin requires a longer time for infusion (60 minutes for 400mg IV). Therefore ciprofloxacin infusion should commence within 120 minutes before the surgical incision.

*** List of procedures NOT requiring prophylaxis is not exhaustive

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Ophthalmic Surgery

Antibiotics for Ophthalmic Surgery

Type of Surgery

Procedure

1 st Line Antibiotic

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Number &

Timing of Doses

See penicillin hypersensitivity section for further information

Prophylaxis in

Ophthalmic Surgery

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms (MDRO)

Ophthalmology: cataract surgery

Povidone Iodine 5% solution topically to lids, lashes and to irrigate conjunctival sac

Plus

Consider intracameral CefUROXime 1mg in 0.1mls sodium chloride 0.9% as per surgeon

Discuss with Microbiology or Infectious Diseases

Further management as per surgeon.

Open lacrimal surgery

Co-amoxiclav IV

1.2g (one dose only)

CefUROXime IV

1.5g (one dose only)

Discuss with Microbiology or Infectious Diseases

One dose within 60 minutes before incision.

Other ophthalmological  procedures

Discuss with Microbiology or Infectious Diseases

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Orthopaedic and Trauma Surgery

Antibiotics for Orthopaedic and Trauma Surgery

Type of Surgery

Procedure

1 st Line Antibiotic

Penicillin allergy: immediate or severe delayed reaction

Number & Timing of Doses

See penicillin hypersensitivity section for further information

Prophylaxis in Orthopaedic and Trauma Surgery

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms (MDRO)

Closed clean orthopaedic procedures without implant of foreign material (e.g. arthroscopy)

Antimicrobial prophylaxis NOT required

Minor metalwork insertion

(e.g. K-wires, screws, small orthopaedic plates)

CefUROXime IV 1.5g (one dose only)

Teicoplanin IV 10mg/kg* (Max 800mg) (one dose only)

One dose within 60 minutes before incision. Give antibiotic prophylaxis at least 15 minutes prior to tourniquet inflation.

Orthopaedic implant surgery (total joint replacement or revision)

Open reduction with internal fixation of closed fractures

Spinal surgery (with or without implant).

CefUROXime IV 1.5g every 8 hours for a total of 3 doses (24 hour cover)

If risk factors for or colonised with MRSA Add Teicoplanin IV 10mg/kg  * (Max 800mg) every 12 hours for a total of 2 doses (24 hour cover)

Teicoplanin IV 10mg/kg* (Max 800mg) every 12 hours for a total of 2 doses (24 hour cover)

+

Gentamicin IV one dose only, dose per GAPP App calculator

1 st dose within 60 minutes before incision & continued for 24 hours

Give antibiotic prophylaxis at least 15 minutes prior to tourniquet inflation.

Open fracture intervention +/- insertion of nail/screw (includes acute trauma with contaminated wounds)

CefUROXime IV 1.5g every 8 hours

+

Metronidazole IV 500mg every 8 hours

See comment re duration

Teicoplanin IV 10mg/kg* (Max 800mg) every 12 hours for 3 doses, then every 24 hours

+

Gentamicin IV dose per GAPP App calculator every 24 hours

+

Metronidazole IV

500mg every 8 hours

See comment re duration

1 st dose within 60 minutes before incision.

Duration usually 3 to 5 days – maximum 24 hours post final wound closure.

It is vital that any patient with an open fracture be closely observed for signs of sepsis. Please discuss with Microbiology or Infectious Diseases if necessary and if treatment with gentamicin is extended beyond 3 days

Debridement surgery/patients with chronic bone infection

Prophylactic antibiotic depends on infecting organism(s).Check results of previous cultures if available. Discuss with Microbiology or Infectious Diseases if necessary.

* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy

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Plastic Surgery

Antibiotics for Plastic Surgery

Type of Surgery

Procedure

1 st Line Antibiotic*

Penicillin allergy: immediate or severe delayed reaction

Number & Timing of  Doses

See penicillin hypersensitivity section for further information

Prophylaxis in

Plastic Surgery

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms (MDRO)

Consider surgical prophylaxis for patients with risk factors for surgical site infection.

Co-amoxiclav* IV 1.2g (one dose only)

Clindamycin* IV 900mg (one dose only)

One dose within 60 minutes before incision

Leech therapy (Hirudotherapy) prophylaxis

Consider antimicrobial prophylaxis

Ciprofloxacin  PO 500mg every 12 hours

(See quinolone warning)

Ciprofloxacin PO 500mg every 12 hours

(See quinolone warning)

1 st dose to be given 60 mins before leech therapy, continued for the duration of therapy and for 24 hours after leech therapy

*Antibiotic choice should be guided by microbiological culture results, where an additional agent may be indicated. Discuss with Microbiology or Infectious Disease teams where necessary.

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Urological Surgery

Antibiotics for Urological Surgery

Type of Surgery

Procedure

1 st Line Antibiotic

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe

delayed reaction

Number &

Timing of Doses

See penicillin hypersensitivity section for further information

Prophylaxis in Urological Surgery Whenever possible submit a pre-operative/pre-catheter removal urine sample. If urine culture is positive, base prophylaxis on the susceptibility report

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms (MDRO)

Transrectal prostatic biopsy

See Note Regarding Multi-drug Resistant Organisms (MDRO)

Ciprofloxacin PO 750mg every 12 hours for a total of 2 doses

+

Gentamicin IV one dose only, dose per GAPP App calculator

Ciprofloxacin PO 2 doses: 1 st dose 60 minutes prior to procedure; 2 nd dose 12 hours post-biopsy

Gentamicin: One dose 30 minutes before biopsy.

Transperineal prostatic biopsy

Brachytherapy

Consider prophylaxis in patients at high risk of infection e.g. immunocompromised, poor general health, diabetes, immunosuppressive therapy

If indicated, use regimen above for transrectal prostatic biopsy

If indicated, use regimen above for transrectal prostatic biopsy

Transurethral resection of prostate (TURP), nephrectomy, percutaneous nephrolithotomy (PCNL), radical prostatectomy, changing of stents/nephrostomy change

Gentamicin IV one dose only, dose per GAPP App calculator

+

Amoxicillin IV 1g (one dose only)

Gentamicin IV one dose only, dose per GAPP App calculator

+

Teicoplanin IV 10mg/kg* (Max 800mg) (one dose only)

One dose within 60 minutes before incision.

* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy

Procedure

1 st Line Antibiotic

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Number &

Timing of Doses

Robotic prostatectomy

Cefuroxime  IV 1.5g

Gentamicin IV one dose only, dose as per GAPP App calculator

+

Teicoplanin IV 10 mg/Kg* (Max 800mg)  (one dose only)

One dose within 60 minutes of the procedure

Extracorporeal shock wave lithotripsy

Gentamicin IV one dose only, dose per GAPP App calculator

One dose within 60 minutes before incision.

Cystourethroscopy with manipulation (includes transuretheral resection of bladder tumour-TURBT, any biopsy, resection, fulguration, foreign body removal, urethral dilatation, ureteral instrumentation including catheterisation, stent placement/removal, stone removal)

Urological procedures involving bowel e.g. radical cystectomy

Co-amoxiclav IV 1.2g

CefUROXime IV 1.5g (one dose only)

+

Metronidazole IV 500mg (one dose only)

Teicoplanin IV

10mg/kg* (Max 800mg) (one dose only)

+

Gentamicin IV one dose only, dose per GAPP App calculator

+

Metronidazole IV 500mg (one dose only)

One dose within 60 minutes before incision.

Cystoscopy

  • Antibiotic prophylaxis generally NOT indicated for simple cystoscopy in the absence of risk factors.
  • Prophylaxis, where indicated, should be guided by the results of urine microbiological cultures.
  • Patients at increased risk of infection include those with pre-existing UTI, immunodeficiency, advanced age, anatomical abnormality of the renal tract, on immunosuppressive therapy and where additional procedures are performed during cystoscopy.

Routine prophylaxis is NOT recommended for urethral catheterisation or removal of urinary catheter . However, on removal of urinary catheter following recent urological surgery it may be appropriate to give gentamicin IV one dose only, dose per GAPP App calculator, infusion to be completed within one hour of catheter removal.

* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy

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Vascular Surgery and Limb Amputation

Antibiotics for Vascular Surgery and Limb Amputation

Type of Surgery

Procedure

1st Line Antibiotic

Penicillin allergy: delayed onset non-severe reaction

Penicillin allergy: immediate or severe delayed reaction Number & Timing of Doses
See penicillin hypersensitivity section for further information See penicillin hypersensitivity section for further information

Prophylaxis in Vascular Surgery & Limb Amputation

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms (MDRO)

Abdominal aortic aneurysm repair (including EVAR)

Carotid endarterectomy

Lower limb revascularisation (eg femoropopliteal by-pass)

Lower extremity amputation

Co-amoxiclav IV 1.2g every 8 hours for a total of 3 doses (24 hour cover)

If risk factors for or colonised with MRSA Add Teicoplanin IV 10mg/kg* (Max 800mg) every 12 hours for a total of 2 doses (24 hour cover)

CefUROXime IV 1.5g every 8 hours for a total of 3 doses (24 hour cover)

+

Metronidazole IV 500mg every 8 hours for a total of 3 doses (24 hour cover)

If risk factors for or colonised with MRSA Add Teicoplanin IV 10mg/kg* (Max 800mg) every 12 hours for a total of 2 doses (24 hour cover)

Teicoplanin IV 10mg/kg* (Max 800mg) every 12 hours for a total of 2 doses (24 hour cover)

+

Gentamicin IV one dose only, dose per GAPP App calculator

+

Metronidazole IV 500mg every 8 hours for a total of 3 doses (24 hour cover)

1 st dose within 60 minutes before incision and continued for 24 hours
* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy

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Interventional Radiological Procedures

Antibiotics for Interventional Radiological Procedures

Type of surgery

Procedure

1 st line antibiotic

Penicillin allergy: immediate or severe delayed reaction

Number & Timing of  Doses

See penicillin hypersensitivity section for further information

Interventional radiological procedures (not already mentioned above )

See Note Regarding Risk Factors for MRSA

See Note Regarding Multi-drug Resistant Organisms

(MDRO) 		Brachytherapy See urological surgery

Renal tumour embolisation

Gentamicin IV one dose only, dose per GAPP App calculator

One dose within 60 minutes before incision.

Uterine artery embolisation

CefUROXime IV 1.5g (one dose only)

Teicoplanin IV

10mg/kg* (Max 800mg) (one dose only)

+

Gentamicin IV one dose only, dose per GAPP App calculator

Liver tumour embolisation/ablation

CefUROXime IV 1.5g (one dose only)

+

Metronidazole IV 500mg (one dose only)

See comment re duration

Teicoplanin IV

10mg/kg* (Max 800mg) (one dose only)

+

Gentamicin IV one dose only, dose per GAPP App calculator

+

Metronidazole IV

500mg (one dose only)

See comment re duration

One dose within 60 minutes before incision.

Longer duration of antibiotic may be required in some cases e.g. chronic biliary bacterial colonisation or incompetent Sphincter of Oddi, which constitutes treatment rather than prophylaxis. Discuss with Microbiology or Infectious Diseases, if necessary.

* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy

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References

References

  1. Bratzler et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery Am J Health Syst Pharm.2013;70:195-283
  2. SIGN 104: Antibiotic Prophylaxis in Surgery July 2008, updated April 2014
  3. The Sanford Guide to Antimicrobial Therapy App accessed online February 2021
  4. Bennett and Brachman's "Hospital Infections" Lippincott, Williams and Wilkins 6 th edition 2013
  5. AMRIC Surgical Antibiotic Prophylaxis Duration Position Paper October 2021
  6. European Society Guidelines .  ISPD Catheter-related Infection Recommendations: 2023 Update. Peritoneal Dialysis International. 2023. 1-19.