Antibiotic Prophylaxis in Surgery
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.
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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.
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Procedures requiring prophylaxis for >1 dose |
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Procedure |
Duration |
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Breast: Reconstructive Breast Surgery |
Up to 24 hours |
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Cardiothoracic: CABG, Prosthetic Valve Surgery, Electronic Device Placement, Pulmonary Resection |
24 hours |
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ENT: Complex septo-rhinoplasty including grafts |
24 hours |
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Head & Neck |
Up to 24 hours, unless extensive head & neck flap reconstruction |
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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 |
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Orthopaedic: |
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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 |
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Plastic Surgery |
Discuss with Microbiology or Infectious Diseases |
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Urology: Transrectal Prostate Biopsy |
2 doses ciprofloxacin (24 hours) |
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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.
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Antibiotics requiring additional intra-operative doses |
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During procedures lasting over 4 hours or if major blood loss (>1.5L) |
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Antibiotic |
Dose |
Recommended redosing interval (from initiation of pre-op dose) in hrs * |
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Amoxicillin |
1g |
2 hrs |
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Cefuroxime |
1.5g |
4 hrs |
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Co-amoxiclav |
1.2g |
4 hrs (max 4 doses in 24 hrs) |
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Flucloxacillin |
1g |
4 hrs |
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* The re-dosing interval may vary depending upon the half-life of the drug in question, and the patients underlying renal and hepatic function. |
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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
- For patients requiring specific surgical prophylaxis against MRSA see Note Regarding Risk Factors for 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
Nephrology
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Antibiotics for Nephrology |
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Type of surgery |
Procedure
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1 st Line Antibiotic
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Penicillin allergy: immediate or severe delayed reaction |
Number & Timing of Doses |
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Peritoneal dialysis catheter insertion prophylaxis
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CefUROXime IV 1.5g (one dose only)
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Teicoplanin IV 10mg/kg* (Max 800mg) (one dose only)
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* 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
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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 .
Classification of Surgical Procedures
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Classification of Surgical Procedures |
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Clean |
Clean-contaminated |
Contaminated/Dirty |
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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. |
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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. |
Breast Surgery
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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 |
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See penicillin hypersensitivity section for further information |
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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 |
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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. |
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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. |
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| * Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy | |||||
Cardiothoracic Surgery
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Antibiotics for Cardiothoracic Surgery |
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Type of Surgery |
Procedure |
1 st Line Antibiotic |
In penicillin allergy |
Number & Timing of Doses |
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See penicillin hypersensitivity section for further information |
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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.
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| ** 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 | ||||
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Prosthetic valve surgery |
As for CABG |
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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
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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:
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1 st dose within 60 minutes before incision & continued for 24 hours. |
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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. |
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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. |
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| * Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy | ||||
Ear, Nose and Throat (ENT) Surgery
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Antibiotics for Ear, Nose and Throat (ENT) Surgery |
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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 |
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See penicillin hypersensitivity section for further information |
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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
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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. |
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| 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 | |||||||||
Gastrointestinal Surgery
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Antibiotics for Gastrointestinal Surgery |
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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 |
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See penicillin hypersensitivity section for further information |
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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 |
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Lower GIT (colon, rectum, appendix 1 ) |
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Gall–bladder surgery (open) Gall-bladder surgery (laparoscopic)-prophylaxis recommended for high-risk 3 patients only Pancreatic surgery |
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Percutaneous endoscopic gastrostomy (PEG) |
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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. |
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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 |
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Diagnostic laparoscopy |
Prophylaxis NOT recommended |
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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
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Antibiotics for Head and Neck Surgery |
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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 |
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See penicillin hypersensitivity section for further information |
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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. |
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Clean head and neck surgery with no mucosal breach (e.g. parotid or thyroid surgery) |
Surgical prophylaxis not routinely required
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| *Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy | |||||
Maxillofacial Surgery
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Antibiotics for Maxillofacial Surgery |
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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 |
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See penicillin hypersensitivity section for further information |
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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. |
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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
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Antibiotics for Obstetric and Gynaecological Surgery |
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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 |
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See penicillin hypersensitivity section for further information |
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Prophylaxis in Obstetric & Gynaecological Surgery See Note Regarding Risk Factors for MRSA See Note Regarding Multi-drug Resistant Organisms (MDRO)
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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** |
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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. |
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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 |
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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 |
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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 |
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* 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
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Antibiotics for Ophthalmic Surgery |
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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 |
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See penicillin hypersensitivity section for further information |
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Prophylaxis in Ophthalmic Surgery See Note Regarding Risk Factors for MRSA See Note Regarding Multi-drug Resistant Organisms (MDRO)
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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. |
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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. |
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Other ophthalmological procedures |
Discuss with Microbiology or Infectious Diseases |
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Orthopaedic and Trauma Surgery
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Antibiotics for Orthopaedic and Trauma Surgery |
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Type of Surgery |
Procedure |
1 st Line Antibiotic |
Penicillin allergy: immediate or severe delayed reaction |
Number & Timing of Doses |
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See penicillin hypersensitivity section for further information |
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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 |
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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. |
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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. |
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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 |
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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. |
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| * Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy | ||||
Plastic Surgery
|
Antibiotics for Plastic Surgery |
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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 |
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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) |
1 st dose within 60 minutes before incision |
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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 |
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*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
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Antibiotics for Urological Surgery |
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Type of Surgery
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Procedure
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1 st Line Antibiotic
|
Penicillin allergy: delayed onset non-severe reaction |
Penicillin allergy: immediate or severe delayed reaction |
Number & Timing of Doses |
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See penicillin hypersensitivity section for further information |
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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)
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Transrectal prostatic biopsy
See Note Regarding Multi-drug Resistant Organisms (MDRO)
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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. |
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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
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If indicated, use regimen above for transrectal prostatic biopsy |
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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.
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* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy |
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Procedure
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1 st Line Antibiotic
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Penicillin allergy: delayed onset non-severe reaction |
Penicillin allergy: immediate or severe delayed reaction |
Number & Timing of Doses |
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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 |
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Extracorporeal shock wave lithotripsy |
Gentamicin IV one dose only, dose per GAPP App calculator |
One dose within 60 minutes before incision. |
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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) |
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Urological procedures involving bowel e.g. radical cystectomy
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Co-amoxiclav IV 1.2g
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CefUROXime IV 1.5g (one dose only) + Metronidazole IV 500mg (one dose only)
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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.
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Cystoscopy |
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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. |
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* Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy |
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Vascular Surgery and Limb Amputation
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Antibiotics for Vascular Surgery and Limb Amputation |
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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 | ||||
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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 | |||||
Interventional Radiological Procedures
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Antibiotics for Interventional Radiological Procedures |
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Type of surgery |
Procedure |
1 st line antibiotic |
Penicillin allergy: immediate or severe delayed reaction |
Number & Timing of Doses |
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See penicillin hypersensitivity section for further information |
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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 | ||
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Renal tumour embolisation |
Gentamicin IV one dose only, dose per GAPP App calculator |
One dose within 60 minutes before incision. |
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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 |
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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. |
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| * Discuss dosing in obese patients with Microbiology, Infectious Diseases or Pharmacy | ||||
References
References
- Bratzler et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery Am J Health Syst Pharm.2013;70:195-283
- SIGN 104: Antibiotic Prophylaxis in Surgery July 2008, updated April 2014
- The Sanford Guide to Antimicrobial Therapy App accessed online February 2021
- Bennett and Brachman's "Hospital Infections" Lippincott, Williams and Wilkins 6 th edition 2013
- AMRIC Surgical Antibiotic Prophylaxis Duration Position Paper October 2021
- European Society Guidelines . ISPD Catheter-related Infection Recommendations: 2023 Update. Peritoneal Dialysis International. 2023. 1-19.