Antimicrobial Guideline - Waterford: Antimicrobial Guidelines

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Introduction

South East Acute Hospitals Surgical Prophylaxis Guidelines

Document Reference Number: ASG003 (Full document available on HCI Knowledge Portal)

Revision No : 7

Document Developed/Revised By : SE Acute Hospitals Antimicrobial Stewardship Group (ASG)

Approval Date: March 2024

Next Revision Date: March 2027

Introduction

Surgical site infections represent one of the most common hospital acquired infections. In a May 2017 prevalence survey, surgical site infections constituted 18.1% of all healthcare acquired infection with a prevalence of 1.2% of inpatients. ¹

Antibiotic prophylaxis in surgery refers to the planned administration of antibiotics to a patient, who does not have confirmed or suspected infection, for the purpose of reducing the risk that the patient develops infection at the surgical site post-operatively. ² In order to achieve this, appropriate antibiotics must be given at the correct time and for the appropriate duration.

Increasing the recommended duration of antimicrobial prophylaxis does not lead to an additional reduction in surgical site infection but it is associated with higher odds of acute kidney injury and C. difficile infection. ³ Furthermore, inappropriate use of antibiotics increases both the cost and the selective pressure that favours the emergence of resistant bacteria.

This guideline is adapted from Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery ⁴ and the joint position statement on surgical antibiotic prophylaxis duration 2021 by HSE Antimicrobial Resistance and Infection Control Team (AMRIC), the HSE Antimicrobial Stewardship Advisory Group & the National Clinical Programme for Surgery (NCPS). ²

This guidance is based on the best available evidence but its application must be modified by professional judgment. The final risk assessment for administration of antibiotic prophylaxis must be undertaken by the patients’ doctor.

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Principles of Surgical Antibiotic Prophylaxis

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Indication for Prophylaxis

Indication for prophylaxis ⁵

Do not use antibiotic prophylaxis routinely for clean surgery that does not involve a prosthesis.

Give antibiotic prophylaxis to patients before:

Clean surgery involving the placement of a prosthesis or implant
Clean-contaminated
Contaminated
Dirty of infected surgical procedures (antibiotic treatment course in addition to prophylaxis)

Class	Definition
Clean	An incision in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary or genitourinary tracts are not entered.
Clean-contaminated	An incision through which the respiratory, alimentary, or genitourinary tract is entered under controlled conditions but with no contamination encountered.
Contaminated	An incision undertaken during an operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than 12 to 24 hours old also fall into this category.
Dirty or infected	An incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered (for example, emergency surgery for faecal peritonitis), and for traumatic wounds if treatment is delayed, there is faecal contamination, or devitalised tissue is present

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Choice of Prophylactic Agent

Choice of Prophylactic Agent

Choice of antimicrobial agent is governed by the procedure and likely implicated pathogens at that site. Also, history must be carefully reviewed for both drug allergy (see Appendix 3) and colonisation with MRSA or multi-drug resistant organisms (MDRO).

A glycopeptide (e.g. Vancomycin) should be considered for antibiotic prophylaxis in patients undergoing high risk surgery who are colonised with MRSA.
For patients colonised with MDRO or CPE, consult local microbiologist for advice on prophylaxis.

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How to Document Surgical Prophylaxis

How to Document Surgical Prophylaxis

Prescribe in the patients’ medication chart in the Surgical Antimicrobial Prophylaxis section or “ONCE ONLY PRESCRIPTIONS” section. The antibiotic used, dose and time of administration may also be recorded on the anaesthetic record sheet.

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Timing of Prophylaxis

Timing of Prophylaxis

The antimicrobial agent should be administered within 60 minutes before surgical incision. ^2,4,6
Some agents such as ciprofloxacin and vancomycin require longer administration time and should begin within 120 minutes before surgical incision. ⁶
The aim of prophylaxis is to have maximum tissue antibiotic levels at the time of first incision. A single preoperative dose of antibiotic is as effective for majority of procedures. ^2,5,6
Additional intra-operative dose may be required for:
- a procedure longer than 4 hours or
- Intra-operative major blood loss > 1.5 litres (Re-dose following fluid replacement).
Patients who have suspected or documented infection at the time of surgery or within 48 hours post-operatively requires treatment course and not prophylaxis.

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Duration of Antibiotic Prophylaxis

Duration of Antibiotic Prophylaxis ²

Surgical procedure	Recommended maximal duration of antibiotic prophylaxis (National Position Statement)*
Gastrointestinal (GI) surgery (including endoscopic GI surgery Obstetrics & gynaecology surgery (including caesarean section)	Single dose
Orthopaedic surgery Vascular surgery Neurosurgery Thoracic surgery Ear-nose and throat surgery Urology Plastic and reconstructive surgery Cardiology – percutaneous procedures	≤24 hours
Maxillofacial surgery Cardiac surgery Head and neck surgery	≤48 hours

*HSE Antimicrobial Resistance and Infection Control Team (AMRIC), the HSE Antimicrobial Stewardship Advisory Group & the National Clinical Programme for Surgery (NCPS) . A joint position statement on surgical antibiotic prophylaxis duration 2021

Antibiotic prophylaxis should not be continued beyond the time frames identified above on the basis that drains remain in-situ.
Surgical prophylaxis should be distinguished from pre-emptive use of antibiotics to treat early infection e.g. perforated appendix. If infection is suspected or confirmed, the model of antibiotic prophylaxis is no longer applicable.
An agent appropriate for surgical prophylaxis may not be optimal therapy for an established infection. Therefore, continuation of an agent as treatment may represent sub-optimal therapy. Treatment agent & duration should be as per antimicrobial prescribing guidelines or infection specialist advice.

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Dosage and Administration by Type of Surgical Procedures

Dosage and Administration by Type of Surgical Procedures

Drug :	*Adult prophylaxis dose (IV):**	2 ^nd intra-operative doses for procedures lasting > 4 hours	2nd intra-operative doses if >1.5L major blood loss (after fluid replacement)
Amoxicillin	1g	Repeat original dose	Repeat original dose
Cefuroxime	1.5g	Repeat original dose	Repeat original dose
Clindamycin	900mg	Repeat original dose	Repeat original dose
Co-amoxiclav	1.2g	Repeat original dose	Repeat original dose
Gentamicin	3-5mg/kg (Maximum dose 480mg - see gentamicin dosing guideline for adjustments for renal impairment and obesity where necessary)	Not required	Give half original dose
Metronidazole	500mg	Re-dose after 8 hours of prolonged surgery.	Repeat original dose
Vancomycin	15mg/kg (Maximum dose 2g - see vancomycin dosing guideline for adjustments for renal impairment and obesity where necessary) Administer at a maximum rate of 10mg/min	No	Give half original dose if 1,500 mL or more blood loss within first hour of operation

*Please refer to local guidelines on Intravenous (IV) Medication Administration Information for Adults. Dose adjustment may be required in renal/hepatic impairment and according to weight.

Adapted from SAPG Good practice recommendations for redosing antibiotics for surgical prophylaxis in adults. ⁷

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Breast

Breast

BREAST SURGERY
Type of surgery	Is surgical prophylaxis required? ⁴	Prophylactic Antibiotic of choice	Penicillin allergy (NOT severe hypersensitivity reaction/anaphylaxis)	Severe hypersensitivity reaction/anaphylaxis to penicillins	Max duration of prophylaxis ^2,8
Excision of benign lump without axillary procedure	Not recommended
Breast cancer surgery	Should be considered	Co-amoxiclav	Cefuroxime	Clindamycin	≤24 hours
Breast reshaping procedures	Should be considered
Breast surgery with implant (reconstructive or aesthetic)	Recommended
Consider addition of Vancomycin if MRSA high risk/known colonisation

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Ear, Nose and Throat

Ear, Nose and Throat

EAR, NOSE & THROAT SURGERY
Type of surgery	Is surgical prophylaxis required? ⁴	Prophylactic Antibiotic of choice	Penicillin allergy (NOT severe hypersensitivity reaction/anaphylaxis)	Severe hypersensitivity reaction/anaphylaxis to penicillins	Max duration of prophylaxis ²
Ear Surgery	Not recommended
Routine nose, sinus and endoscopic sinus surgery	Not recommended
Tonsillectomy Adenoidectomy	Not recommended
Grommet insertion	A single dose of topical antibiotic is recommended
Complex septo-rhinoplasty including graft	Recommended	Co-amoxiclav	Cefuroxime	Clindamycin	≤24 hours
Consider addition of Vancomycin if MRSA high risk/known colonisation

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Gastrointestinal Tract

Gastrointestinal Tract

GASTROINTESTINAL TRACT (GIT)
Type of surgery	Is surgical prophylaxis required? ⁴	Prophylactic Antibiotic of choice	Penicillin allergy (NOT severe hypersensitivity reaction/anaphylaxis)	Severe hypersensitivity reaction/anaphylaxis to penicillins	Max duration of prophylaxis ²
Diagnostic endoscopic procedures	Not recommended
PEG Insertion Endoscopic retrograde cholangio-pancreatograhy (ERCP)	Should be considered in high risk ** patients	Co-amoxiclav	Cefuroxime + Metronidazole	Gentamicin + Metronidazole	Single dose
Hernia repair	Not recommended unless mesh insertion.	Co-amoxiclav	Cefuroxime + Metronidazole	Clindamycin	Single dose
Splenectomy*	Not recommended Should be considered in high risk (immunosuppresed) patients	Co-amoxiclav	Cefuroxime + Metronidazole	Clindamycin + Gentamicin	Single dose
Gall bladder surgery (laparoscopic)	Not recommended Should be considered in high risk*** patients	Co-amoxiclav	Cefuroxime + Metronidazole	Gentamicin + Metronidazole	Single dose
Gall bladder surgery (open)	Recommended	Co-amoxiclav	Cefuroxime + Metronidazole	Gentamicin + Metronidazole	Single dose
Upper GIT: Oesophageal, gastro-duodenal, gastric bypass, small bowel surgery	Recommended	Co-amoxiclav	Cefuroxime + Metronidazole	Gentamicin + Metronidazole	Single dose
Lower GIT^: Appendectomy, Colorectal surgery	Recommended	Co-amoxiclav	Cefuroxime + Metronidazole	Gentamicin + Metronidazole	Single dose
Consider addition of Vancomycin if MRSA high risk/known colonisation Please refer to Appendix 2 for post-splenectomy prophylaxis and vaccination recommendations. High risk: pancreatic pseudocyst, immunosupression, incomplete biliary drainage (e.g. primary sclerosing cholangitis or cholangiocarcinoma) **High risk: intraoperative cholangiogram, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, pregnancy, immunosuppression, insertion of prosthetic devices, extremes of age, diabetes, obesity, poor nutritional state, known co-existing bacterial colonization / infections at other sites. ^If appendix is perforated or associated with peritonitis, treatment course may be required.

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Head and Neck

Head and Neck

HEAD AND NECK SURGERY
Type of surgery	Is surgical prophylaxis required? ⁴	Prophylactic Antibiotic of choice	Penicillin allergy (NOT severe hypersensitivity reaction/anaphylaxis)	Severe hypersensitivity reaction/anaphylaxis to penicillins	Max duration of prophylaxis ²
Clean, benign; with no mucosal breach (e.g. Parotid or thyroid surgery	Not recommended
Clean, malignant; neck dissection	Should be considered	Co-amoxiclav	Cefuroxime + Metronidazole	Clindamycin	48-72 hours
Clean-contaminated/Contaminated	Recommended	Co-amoxiclav	Cefuroxime + Metronidazole	Clindamycin	48-72 hours
Consider addition of Vancomycin if MRSA high risk/known colonisation ² National position statement recommends a maximum duration of prophylaxis of 48 hours for Head & Neck surgeries.

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Non-Operative Interventions

Non-Operative Interventions

NON-OPERATIVE INTERVENTIONS
Type of surgery	Is surgical prophylaxis required? ⁴	Prophylactic Antibiotic of choice	Penicillin allergy (NOT severe hypersensitivity reaction/anaphylaxis)	Severe hypersensitivity reaction/anaphylaxis to penicillins
Intravascular catheter insertion (Non-tunnelled & Tunnelled CVC)	Not recommended
Insertion of Pacemaker or ICD	Recommended	Cefuroxime	Cefuroxime	Vancomycin

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Obstetric and Gynaecological

Obstetric and Gynaecological

OBSTETRIC AND GYNAECOLOGICAL SURGERY
Type of surgery	Is surgical prophylaxis required? ⁴	Prophylactic Antibiotic of choice	Penicillin allergy (NOT severe hypersensitivity reaction/anaphylaxis)	Severe hypersensitivity reaction/anaphylaxis to penicillins	Max duration of prophylaxis ²
Abdominal/ Vaginal hysterectomy	Recommended	Co-amoxiclav	Cefuroxime + Metronidazole	Gentamicin + Metronidazole	Single dose
Caesarean section*	Highly recommended	Cefuroxime	Cefuroxime	Clindamycin	Single dose
Perineal tear**	Recommended for 3 ^rd /4 ^th degree perineal tears involving the anal sphincter/rectal mucosa	Co-amoxiclav	Cefuroxime + Metronidazole	Clindamycin + Gentamicin	Single dose
Manual removal of the placenta	Should be considered Recommended in proven chlamydia or gonorrhoea infection	Co-amoxiclav	Cefuroxime + Metronidazole	Clindamycin + Gentamicin	Single dose
Assisted delivery	Recommended (RCOG Green-top Guideline No. 26 2020)	Co-amoxiclav	Cefuroxime + Metronidazole	Clindamycin + Gentamicin	Single dose
Evacuation of incomplete miscarriage Intrauterine contraceptive device (IUCD) insertion	Not recommended
Consider addition of Vancomycin if MRSA high risk/known colonisation *NICE 2021: Offer women prophylactic antibiotics before skin incision for caesarean birth. Do not use co-amoxiclav when giving prophylactic antibiotics before skin incision for caesarean birth ¹¹

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Orthopaedics

Orthopaedics

Orthopaedics
Type of surgery	Is surgical prophylaxis required? ⁴	Prophylactic Antibiotic of choice	Penicillin allergy (NOT severe hypersensitivity reaction/anaphylaxis)	Severe hypersensitivity reaction/anaphylaxis to penicillins	Max duration of prophylaxis ²
Orthopaedic surgery without implant	Not recommended
Arthroplasty	Recommended	Cefuroxime	Cefuroxime	Vancomycin	≤24 hours
Open surgery for closed fracture	Recommended	Cefuroxime	Cefuroxime	Vancomycin	≤24 hours
Hip fracture	Recommended	Cefuroxime	Cefuroxime	Vancomycin + Gentamicin	≤24 hours
**Open fracture (See also Appendix 1: South East Orthopaedic Guideline -Antibiotic Prophylaxis for Open Fractures in the ED and Orthopaedic Departments)	Recommended	Phase 1: Cefuroxime + metronidazole ± Gentamicin Phase 2: Vancomycin + Gentamicin	Phase 1: Cefuroxime + Metronidazole ± Gentamicin Phase 2: Vancomycin + Gentamicin	Phase 1: Clindamycin + Gentamicin Phase 2: Vancomycin + Gentamicin	Phase 1 : ≤24 hours Phase 2: Single Dose
Phase 1: Within 1 hour of injury and continue until wound excision for 24 hours Phase 2: At the time of definitive skeletal stabilisation and definitive soft tissue coverage the patient should receive a single intravenous dose at induction of vancomycin plus gentamicin Consider addition of Vancomycin if MRSA high risk/known colonisation.

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Skin

Skin

SKIN
Type of surgery	Is surgical prophylaxis required? ⁴	Prophylactic Antibiotic of choice	Penicillin allergy (NOT severe hypersensitivity reaction/anaphylaxis)	Severe hypersensitivity reaction/anaphylaxis to penicillins	Max duration of prophylaxis ²
Skin grafting	Should be considered	Co-amoxiclav	Cefuroxime	Clindamycin	Single dose
Consider addition of Vancomycin if MRSA high risk/known colonisation

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Urogenital

Urogenital

UROGENITAL SURGERY
Type of surgery	Is surgical prophylaxis required? ^4,10	Prophylactic Antibiotic of choice	Penicillin allergy (NOT severe hypersensitivity reaction/anaphylaxis)	Severe hypersensitivity reaction/anaphylaxis to penicillins	Max duration of prophylaxis ^2,10
Transurethral resection of prostate (TURP)	Recommended	Gentamicin + Amoxicillin	Gentamicin	Gentamicin	Single dose
Transrectal ultrasound (TRUS)-guided prostate biopsy (Please see Appendix 4 for note regarding Multi-drug Resistant Organisms (MDRO))	Recommended	Ciprofloxacin ± Gentamicin	Ciprofloxacin ± Gentamicin	Ciprofloxacin ± Gentamicin	24 hours
Transperineal prostate biopsy	*May be considered in high risk patients	Co-amoxiclav	Cefuroxime	Gentamicin	Single dose
Cystourethroscopy with manipulation (includes transuretheral resection of bladder tumour-TURBT, any biopsy, resection, fulguration, foreign body removal, urethral dilatation, stent placement/removal, stone removal)	Recommended	Gentamicin	Gentamicin	Gentamicin	Single dose
Radical cystectomy (cystectomy and urinary diversion), Nephrectomy or nephroureterectomy Radical prostatectomy	Recommended	Co-amoxiclav± Gentamicin	Cefuroxime± Metronidazole (if bowel involvement)	Gentamicin + Vancomycin ± Metronidazole (if bowel involvement)	Single dose
Percutaneous nephrolithotomy (PCNL)	Recommended	Gentamicin	Gentamicin	Gentamicin	Single dose
Robotic surgery	Recommended	Co-amoxiclav	Cefuroxime	Gentamicin	Single dose
Cystoscopy Urethral catheterisation	*May be considered in high-risk patients	Gentamicin	Gentamicin	Gentamicin	Single dose
Circumcision, hydrocele, urodynamics, Extracorporeal shock wave lithotripsy (ESWL)	Not recommended
Patients at increased risk of infection include those with pre-existing UTI, immunodeficiency, advanced age, anatomical abnormality of the renal tract and on immunosuppressive therapy. Consider addition of Vancomycin if MRSA* high risk/known colonisation Tailor prophylaxis based on susceptibility report of pre-operative urine culture.

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Vascular and Limb

Vascular and Limb

VASCULAR & LIMB SURGERY
Type of surgery	Is surgical prophylaxis required? ⁴	Prophylactic Antibiotic of choice	Penicillin allergy (NOT severe hypersensitivity reaction/anaphylaxis)	Severe hypersensitivity reaction/anaphylaxis to penicillins	Max duration of prophylaxis ²
Lower limb amputation	Recommended	Co-amoxiclav	Cefuroxime + Metronidazole	Clindamycin + Gentamicin	≤24 hours
Vascular surgery (abdominal and lower limb arterial reconstruction) AAA repair, EVAR, carotid endarterectomy, lower limb revascularisation	Recommended	Co-amoxiclav	Cefuroxime + Metronidazole	Vancomycin + Gentamicin + Metronidazole	≤24 hours
Varicose veins	Not recommended A single dose could be considered in patients undergoing groin surgery*	Co-amoxiclav	Cefuroxime + Metronidazole	Vancomycin + Gentamicin + Metronidazole	Single dose
Soft tissue surgery of the hand	Should be considered	Co-amoxiclav	Cefuroxime + Metronidazole	Clindamycin	Single dose
* Single dose prophylaxis may be beneficial in patients undergoing groin surgery for varicose veins especially if patients are obese or current smokers ⁶ Consider addition of Vancomycin if MRSA high risk/known colonisation

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Appendices

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Appendix 1: South East Regional Orthopaedic Service Antibiotic Prophylaxis For Open Fractures

Appendix 1: South East Regional Orthopaedic Service Antibiotic Prophylaxis For Open Fractures

PHASE 1 : Within 1 hour of injury and continue until wound excision

Antibiotic Regimen should be administered as soon as possible after the injury:

Cefuroxime 1.5 g IV TDS plus Metronidazole 500 mg IV TDS until time of first debridement.
In case of IgE-mediated /severe penicillin allergy/anaphylaxis: Use Clindamycin 600mg-1.2g QDS IV plus Gentamicin 3mg/kg once daily IV. Patients with non-severe penicillin allergy (mild / rash only and no history of severe reaction / anaphylaxis / angioedema), a cephalosporin such as Cefuroxime is considered safe and is the agent of choice.
In the case of open fractures of the distal phalanx of the finger use Cefuroxime 1.5g TDS IV only – (in case of severe penicillin allergy/anaphylaxis use Clindamycin 600mg-1.2g QDS IV).
If history or high risk of MRSA colonisation / infection add Vancomycin 15mg/kg (max 2g) to the antibiotic regimens.
In the case of heavily contaminated wounds, e.g. farmyard injuries or injuries with vascular insufficiency or Gustilo Grade III fractures, add Gentamicin 3 mg/kg IV once daily to antibiotic regimen on initial presentation.At the time of first debridement and stabilisation, ensure prophylaxis of Cefuroxime 1.5 g IV and Metronidazole 500 mg IV is given; in addition give Gentamicin 3 mg/kg IV stat pre-operatively (unless Gentamicin has been given in the past 16 hours).
Antibiotics after wound excision should continue for 24 hours .

PHASE 2:

At the time of definitive skeletal stabilisation and definitive soft tissue coverage the patient should receive a single intravenous dose at induction of Vancomycin 15mg/kg (max 2g) (if it has been more than 12 hour since the last dose) plus Gentamicin 3 mg/ kg (if it has been more than 16 hours since the last dose).

Reference: Eccles S, et al. Standards for the management of open fractures. Oxford University Press; 2020.

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Appendix 2: Post-Splenectomy Prophylaxis in Adults

Appendix 2: Post-Splenectomy Prophylaxis in Adults

Note: These guidelines are intended for use in adult patients only. For immunisation schedule for children with splenectomy or hyposplenism seek expert advice and refer to National Immunisation Guidelines.

Individuals with an absent or dysfunctional spleen are at increased of fulminant infection especially from encapsulated bacteria such as Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae.
Patients should be encouraged to wear an alert bracelet or equivalent and carry a card with information about their condition. Patients should be educated about the risks of animal exposure including bites and potential risks of tick and mosquito-borne diseases when travelling.
It is essential to educate patients regarding the risk of infection, the importance of vaccines and antimicrobial prophylaxis, and prompt recognition and treatment of any infections that develop.

Vaccination

For those requiring splenectomy, vaccination should be completed at least 2 weeks and preferably 4 weeks or more before surgery.
In the case of emergency splenectomy, or if immunisation was not completed pre-operatively, vaccination can be commenced 2 weeks post operatively.
Advise general practitioner in discharge letter of requirement for these vaccines.
In immunocompromised patients, seek expert advice regarding timing of vaccination.

Additional vaccines for those with asplenia or hyposplenia
Neisseria meningitidis	MenACWY	2 doses 2 months apart; booster every 5 years
Neisseria meningitidis	MenB	If unvaccinated, 2 doses 1 month apart
Streptococcus pneumoniae*	PCV13*	1 dose ≥ 2 months after previous dose. If unvaccinated, 2 doses 2 months apart
Streptococcus pneumoniae*	PPV23*	1 - 3 doses 1st dose at least 2 months after PCV13 2nd dose 5 years later Final dose at >65 years
Haemophilus influenzae type b	Hib	1 dose ≥ 2 months after previous dose.
Influenza	Inactivated influenza	Annually

Adapted from National Immunisation Guidelines. Chapter 3 immunisation of Immunocompromised

* Please refer to National Immunisation Guidelines Chapter 16 Pneumococcal Infection . PCV13 should be given first, followed by PPV23 at least 2 months later.

Antimicrobial Prophylaxis

The increased risk of infection is life-long but is highest early after splenectomy. The risk is greatest in children up to the age of 16 years and in adults over 50 years.

Lifelong prophylactic antibiotics should be offered to patients considered at continued high risk of pneumococcal infection:

age less than 16 years or greater than 50 years
inadequate serological response to pneumococcal vaccination
a history of previous invasive pneumococcal disease
splenectomy for underlying haematological malignancy particularly in the context of on-going immunosuppression

Antibiotic prophylaxis is recommended for a minimum of 1 to 2 years in low risk patients but these patients should be counselled regarding the risks and benefits of lifelong antibiotics and may choose to continue or discontinue prophylaxis.

Oral penicillin is the drug of choice

Penicllin V (Calvepen ^TM ) 666mg po q12h OR amoxicillin 250-500mg q12h po
In patients with confirmed penicillin allergy, clarithromycin 250 mg bd po is an alternative option.

Consider interactions with other drugs and consult with hospital pharmacist if necessary.

Note: Patients developing symptoms and/or signs of infection, despite the above measures, must be given systemic antibiotics and admitted urgently to hospital.

References:

National Immunisation Advisory Committee. The Immunisation Guidelines for Ireland: Chapter 3 Immunisation of Immunocompromised Persons March 2022– accessed at www.immunisation.ie
National Immunisation Advisory Committee. The Immunisation Guidelines for Ireland: Chapter 16 Pneumococcal infection– accessed at www.immunisation.ie
Davies, John M., et al. "Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: Prepared on behalf of the British Committee for Standards in Haematology by a Working Party of the Haemato-Oncology Task Force." British journal of haematology 155.3 (2011): 308-317.

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Appendix 3: Penicillin Allergy

Appendix 3: Penicillin Allergy

** It is important to document exactly what symptoms occurred before deciding if a patient is truly penicillin allergic. Check with Patient / Relatives / GP / Community Pharmacist to clarify the nature of allergic reaction.**

Many patients are misdiagnosed as being penicillin allergic.
An incorrect diagnosis of penicillin allergy leads to unnecessary avoidance of this relatively non-toxic class of drugs, exposes the patient to potentially more toxic drugs, increases health care costs and contributes to the development of antibiotic resistance.
Patients are often labelled as having a hypersensitivity reaction when in fact a patient may be experiencing a side effect of penicillin, such as gastrointestinal upset (e.g. nausea, diarrhea) or headache.
Other concomitant medicines can also be responsible for triggering a hypersensitivity reaction. Therefore, it is important to consider the timeframe over which the hypersensitivity reaction has developed relative to the initiation of different medications.
Patients who have previously presented with a less severe penicillin allergy (e.g mild-moderate rash not on the EM/SJS/TEN spectrum of rash and not requiring hospitalisation ) may be considered to be prescribed cephalosporins/carbapenems if the benefits outweigh the risks of cross reactivity. This is a clinical risk assessment. The potential for an allergic reaction should be monitored and resuscitation equipment available if required.
However, patients who are documented as having experienced a severe reaction (e.g. anaphylaxis) from a penicillin should not be prescribed cephalosporins, carbapenems and other beta-lactam containing antibiotics where acceptable alternatives available. A risk-benefit assessment may be needed in certain circumstances. Discuss individual case with senior clinician and clinical microbiology team if needed.

Please see HSE guidelines for Antibiotic Allergy with a special reference to Penicillin and Beta Lactam Allergy for further information

https://www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/drug-interactions/guidelines-for-antibiotic-allergy-with-special-reference-to-penicillin-and-beta-lactam-allergy.html

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Appendix 4: Prophylaxis Pre-TRUS Guided Prostate Biopsy

Appendix 4: Prophylaxis Pre-TRUS Guided Prostate Biopsy

Antimicrobial prophylaxis is recommended for ALL patients undergoing TRUS-guided prostate biopsy

The figures below outline the recommended approach.

Patients with a history of colonisation/infection or with risk factors for CRE/CPE (Carbapenem Resistant Enterobacterales/ Carbapenemase Producing Enterobacterales) should be screened in advance with a rectal swab for CRE/CPE carriage and not listed for TRUS-guided prostate biopsy pending CRE/CPE screening results.

Risk factors may include but are not limited to:

History of fluoroquinolone use in the previous six months
Patient is a healthcare worker
Previous sepsis/infection following TRUS-guided prostate biopsy
History of antimicrobial resistant Enterobacterales colonisation/infection (e.g., ESBL, fluoroquinolone and/or aminoglycoside resistance)
Other risk factors as per local policy

If the results of CRE/CPE screening are positive, it is recommended that the multi-disciplinary team (MDT) discuss the optimal strategy for performing the prostate biopsy safely in this patient.

Thereafter there are two recommended options (2a and 2b in Figure 1):

Oral ciprofloxacin 750mg as a one drug antimicrobial prophylaxis regimen for patients without risk factors for colonisation with resistant Enterobacterales .

Patients with risk factors for antimicrobial resistant Enterobacterales (other than CRE/CPE) should be given a two drug antimicrobial prophylaxis regimen.

A combination of ciprofloxacin and an aminoglycoside is recommended (unless the patient has a history of previous microbiology results indicating resistance to fluoroquinolones and/or aminoglycosides, in which case the prophylaxis choice should be discussed with the local Clinical Microbiologist

Before prescribing antimicrobial prophylaxis, it is important to document if the patient has an antimicrobial allergy and calculate the Creatinine Clearance (CrCl) for adjustment of dosing/therapy in renal impairment.

Please note important safety information, cautions and contraindications if prescribing a quinolone including risk of tendon damage, seizures & prolonged QT interval. Please see European Medicines Agency review for further details

https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products

Figure 1

Adapted from: NCCP National Prostate Biopsy Infection Project Board

NCCP&HSE. National Policy on the Prevention and Management of Infection Post Trans Rectal Ultrasound (TRUS) Guided Prostate Biopsy 2014

Available from: https://www.hse.ie/eng/services/list/5/cancer/pubs/guidelines/nccp%20management%20of%20infection%20post%20trus%20biopsy%20policy%20document.pdf

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References

References

1. Health Protection Surveillance Centre. Point Prevalence Survey of Hospital Acquired Infections & Antimicrobial Use in European Acute Care Hospitals 2017 Available from: https://www.hpsc.ie/a-z/microbiologyantimicrobialresistance/infectioncontrolandhai/surveillance/hospitalpointprevalencesurveys/2017/nationalppsreports/PPS%202017%20National%20Report_FINAL_191218.pdf

2. HSE Antimicrobial Resistance and Infection Control Team (AMRIC), the HSE Antimicrobial Stewardship Advisory Group & the National Clinical Programme for Surgery (NCPS). A joint position statement on surgical antibiotic prophylaxis duration 2021 Available from: https://www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/hospital-related-guidelines/surgical-antibiotic-prophylaxis-duration-position-statement-october-2021-v1.pdf

3. Branch-Elliman W, O’Brien W, Strymish J, Itani K, Wyatt C, Gupta K. Association of Duration and Type of Surgical Prophylaxis With Antimicrobial-Associated Adverse Events. JAMA Surgery. 2019;154(7):590-8.

4. Scottish Intercollegiate Guidelines Network (SIGN). Antibiotic prophylaxis in surgery 2008 Available from: http://www.sign.ac.uk

5. National Institute for Health and Care Excellence (NICE). Surgical site infections: prevention and treatment2019. Available from: https://www.nice.org.uk/guidance/ng125/resources/surgical-site-infections-prevention-and-treatment-pdf-66141660564421

6. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surgical infections. 2013;14(1):73-156.

7. Healthcare Improvement Scotland. Scottish Antimicrobial Prescribing Group (SAGP). Good practice recommendations for redosing antibiotics for surgical prophylaxis in adults. 2022. Available from https://www.sapg.scot/media/7247/20221121-gprs-for-redosing-antibiotics-for-surgical-prophylaxis.pdf

8. Association of Breast Surgery. The Royal College of Surgeons of England. Guidelines on Antibiotic Prophylaxis in Breast Surgery. Available from: https://associationofbreastsurgery.org.uk/media/1430/guidelines-on-antibiotic-prophylaxis-in-breast-surgery.pdf

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