Adult Surgical (and Other Interventional) Prophylaxis Guidelines

Summary of changes in this version compared to previous version

  • Advice regarding modifications with documented carriage of resistant gram negatives.
  • Introduction of height based criteria for gentamicin dosing in surgical prophylaxis.
  • Introduction of streptococcal and enterococcal cover in GI and gynaecological surgery prophylaxis.
  • Switch to cefuroxime as prophylaxis for arthroplasty procedures other than total joint replacement.
  • Change in dosage recommendation for teicoplanin in orthopaedic prophylaxis.

The goal of surgical prophylaxis is to reduce the incidence of surgical site infection (SSI), while reducing the risk of adverse effects from the antibiotics used.

All IV doses should be given within 60 minutes prior to skin incision and as close to time of incision as practically possible.

Single preoperative doses only to be prescribed unless otherwise stated.

Aim to give indicated prophylaxis before pre-operative urinary catheterisation where this is performed.

Further intraoperative doses are required in prolonged procedures or with blood loss as below

Blood loss > 1500 ml

Re-dose following fluid replacement giving same dose for all agents except

  • Gentamicin* – give half initial prophylactic dose
  • teicoplanin – give half original dose if ≥1.5L blood loss within first hour of operation
  • clindamycin – give half original dose

Prolonged operation

  • 4 hours - re-dose amoxicillin, cefuroxime, clindamycin, co-amoxiclav, flucloxacillin
  • 8 hours – re-dose amoxicillin, cefuroxime, clarithromycin, clindamycin, co-amoxiclav, flucloxacillin, metronidazole and, if eGFR > 60 ml/min gentamicin* (at full prophylactic dose)

*For complex patients, discuss with microbiology in advance to ensure re-dosing is safe and appropriate

Contaminated or dirty, infected wounds require treatment courses not prophylaxis

Pregnant patients: Gentamicin should be avoided in pregnancy. Cefuroxime is suitable alternative.

 

Modifications related to carriage/colonisation with resistant bacteria

MRSA carriage

  • Consider preoperative or perioperative decolonisation
  • If prophylaxis indicated add Teicoplanin IV (400mg or  800mg/600mg for orthopaedic procedures) if not already included in regimen

Gentamicin resistant gram negatives

  • Review microbiology results for available susceptibility information and discuss with microbiologist when feasible
  • When prophylaxis is indicated and susceptibility information is unavailable consider use of meropenem as prophylactic agent.

Modifications related to allergy or other contra-indication to prophylactic antibiotics

Alternatives are generally provided for patients with penicillin allergy. For other circumstances when recommended agents cannot be given please contact microbiology or pharmacy for advice. Omitting agents will affect the cover offered.

Gentamicin dosing in surgical prophylaxis (based on GGC guideline)

Prophylactic gentamicin dosing is based on patient height and approximates to 3mg/kg ideal body weight capped at 300mg. This allows bolus administration in the anaesthetic room, as detailed in the table below.

Gentamicin surgical prophylaxis dosing table

Avoid gentamicin if eGFR <20 or renal transplant : seek advice on alternative from microbiology

Height ranges

(Feet and inches)

Height ranges

(cm)

Gentamicin dose (mg)

 

 

Males

Females

4’ 8” – 4’ 10”

142 - 147

160

140

> 4’ 10 – 5’ 3”

> 147 – 160

180

160

> 5’ 3” – 5’ 10”

> 160 - 178

240

200

> 5’ 10” – 6’ 2”

>178 - 188

300

260

> 6’ 2”

> 188

300

300

 

General Surgery

 

Appendectomy

 

Amoxicillin 1g IV  (or teicoplainin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV(see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

Colorectal surgery

 Amoxicillin 1g IV  (or teicoplainin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

Upper GI Surgery

 Amoxicillin 1g IV  (or teicoplainin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

Open cholecystectomy

Amoxicillin 1g IV  (or teicoplainin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

Laparoscopic cholecystectomy

Prophylaxis not recommended unless high risk

intraoperative cholangiogram, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, immunosuppression, insertion of

prosthetic devices, pregnancy (if pregnant use cefuroxime prophylaxis)

 Amoxicillin 1g IV  (or teicoplainin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

Endoscopic retrograde

Cholangiopancreatography (ERCP)

 

Prophylaxis not recommended unless high risk

pancreatic pseudocyst, immunosuprression, incomplete biliary drainage

Ciprofloxacin 500mg orally prior to procedure  or if not given Gentamicin according to gentamicin surgical prophylaxis table above

Breast surgery

Prophylaxis should be considered for procedures for breast cancer especially if extending towards the axilla.

Prophylaxis should be considered for breast re-shaping procedures.

Prophylaxis is advised for breast surgery involving the insertion of implants.

 

Flucloxacillin 1g IV

or, if penicillin allergy,

Teicoplanin  400 mg IV

 

Hernia repair with or without mesh

Prophylaxis not routinely recommended

Consider in patients with mesh insertion if: obesity, diabetes, or other risk factors for SSI)

 

Teicoplanin 400 mg IV

plus

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

 

Haemorrhoidectomy, including stapled haemorrhoidopexy

Amoxicillin 1g IV  (or teicoplainin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

 

Urology

 

Transrectal prostate biopsy

Ciprofloxacin 500mg oral 60 minutes before procedure

Transurethral resection of prostate

Gentamicin 160mg IV

 

TURBT (Local practice)

Gentamicin 160mg IV

 

 

Obstetrics and Gynaecology

 

Caesarean Section

Cefuroxime 1.5g IV + metronidazole 500mg IV.

 

Or, in immediate (type 1) beta-lactam sensitivity

Clindamycin 900mg IV as a single agent

Gynaecology majors, including PFRs

Amoxicillin 1g IV  (or teicoplainin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

Termination of pregnancy

Metronidazole 1g oral or PR 2 hours before surgery followed by Azithromycin 1g oral single dose (unless pre-operative screening has ruled out chlamydial infection) with administration of Misoprostol

Transvaginal tapes

Amoxicillin 1g IV  (or teicoplainin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

 

 Orthopaedic Surgery

 

Total Joint Arthroplasty (antibiotic loaded cement is also recommended in addition to IV antibiotics)

 

Cefuroxime 1.5g IV at induction as a single agent, followed by 2 doses of 750mg IV at 8 hourly intervals

 

Or, in immediate (type 1) beta-lactam sensitivity

 

Teicoplanin  IV 800mg (600mg if weight ≤ 60kg) single dose

plus

Gentamicin IV according to gentamicin surgical prophylaxis table above) single dose

Other arthroplasty procedures

 

 

All intramedullary nails

 

Other internal fixations

 Cefuroxime 1.5g IV as a single agent

 

Or, in immediate (type 1) beta-lactam sensitivity

 

Teicoplanin  IV 800mg (600mg if weight ≤ 60kg) single dose

 

plus

Gentamicin IV according to gentamicin surgical prophylaxis table above, single dose

 

Oral Surgery

 

Wisdom teeth extraction

High risk patients (at discretion of oral surgeon)

Preferred choice: Co-amoxiclav 1.2g IV

Alternative: clindamycin 600mg IV

 

Gastrointestinal Endoscopy

 

PEG insertion

Co-amoxiclav 1.2g IV

 

Or, in penicillin allergy, teicoplanin 400mg IV

Variceal banding in presence of ascites

Ceftriaxone 2g as a single agent

or in immediate (type 1 ) beta-lactam sensitivity

Teicoplainin 6mg/kg

plus

gentamicin  IV (see gentamicin surgical prophylaxis dosing table above)

Variceal bleeding

Ceftriaxone 2g as a single agent daily for 5 days

or in immmediate (type 1 ) beta-lactam sensitivity

Teicoplainin 6mg/kg mg twice daily for 3 doses then 6 mg/kg  daily

plus

gentamicin  IV (divided dose regimen - see separate guidance)

 

Scottish Antimicrobial Prescribing Group. Good practice recommendations for surgical prophylaxis 2014.

 https://www.sapg.scot/media/4109/gprs-for-surgical-and-procedural-antibiotic-prophylaxis-in-adults-in-nhs-scotland.pdf

SAPG recommendations for re-dosing antibiotics for surgical prophylaxis

https://www.sapg.scot/media/4105/gprs-for-re-dosing-antibiotics-for-surgical-prophylaxis.pdf

British Society of Gastroenterology.Antibiotic prophylaxis in gastrointestinal endoscopy. Gut 2009; 58: 869-880.

https://gut.bmj.com/content/58/6/869

Antibiotic prophylaxis in surgery, general principles NHS GGC