Adult Surgical (and Other Interventional) Prophylaxis Guidelines

Adult Surgical (and Other Interventional) Prophylaxis Guidelines

Summary of changes in this version compared to previous version

Introduction of new gentamicin dosing table
Introduction of new re-dosing table
Updated guidance regarding prophylaxis with ERCP
Updated guidance for Caesarean section prophylaxis
Updated guidance for termination of pregnancy

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.

Contaminated or dirty, infected wounds require treatment courses not prophylaxis

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

Single preoperative doses only to be prescribed unless otherwise stated.

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

Intra-operative re-dosing of surgical prophylaxis

For procedures lasting more than 4 hours, redosing (where indicated) after 4 or 8 hours promotes safe and effective surgical prophylaxis. Decisions around redosing should be made on an individual patient basis taking account of the risks and benefits of repeat dosing. Patients with complex management requirements should be discussed with microbiology colleagues in advance to ensure redosing is safe and appropriate. These recommendations include redosing advice where there is intraoperative blood loss of 1,500 mL or more. It is not recommended to give a repeat dose of antibiotics after every subsequent 1,500 mL blood loss and specialist advice is needed where blood loss exceeds 3,000 mL

Further Intraoperative doses in prolonged procedures of more than 4 hours and/or blood loss >1500ml

Antibiotic	Procedure Duration		Blood loss >1500ml
	Over 4 hours	Over 8 hours	After giving fluid replacement
Amoxicillin IV	Repeat original dose	Repeat original dose (again)	Repeat original dose
Cefuroxime IV	Repeat original dose	Repeat original dose (again)	Repeat original dose
Clindamycin IV	Repeat original dose	Repeat original dose (again)	Repeat original dose
Co-amoxiclav IV	Repeat original dose	Repeat original dose (again)	Repeat original dose
Flucloxacillin IV	Repeat original dose	Repeat original dose (again)	Repeat original dose
Gentamicin IV	Not required	Not required	Co-amoxiclav 1.2g IV Or, in penicillin allergy, Ciprofloxacin 400mg IV
Metronidazole IV	Not required	Repeat original dose	Repeat original dose
Teicoplanin IV	Not required	Not required	Give half original dose if ≥1500ml blood loss within first hour of operation

Ref. SAPG Good practice recommendations for redosing antibiotics for surgical prophylaxis in adults.https://www.sapg.scot/media/7247/20221121-gprs-for-redosing-antibiotics-for-surgical-prophylaxis.pdf

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

(based on Lothian gentamicin surgical prophylaxis dosing in urology)

Height is used to estimate ideal body weight, dosing equates to approximately 5mg/kg capped at 400mg.

*When height <5 foot use actual body weight to calculate gentamicin dose to maximum of 240 mg (females) or 280mg (males)

Administered as IV bolus over 3 – 5 minutes

Avoid gentamicin if eGFR <20mls/min, seek advice on an alternative from microbiology

Female
Height (feet/inches)	Height (cm)	Gentamicin dose
< 5’	<152	5mg/kg* (max 240mg)
5’ – 5’1”	152 – 155	240mg
>5’1” – 5’6”	>155 – 168	280mg
5’6” – 5’10”	>168 – 178	320mg
>5’10” – 6’2”	>178 – 188	360mg
> 6’2”	>188 cm	400mg

Male
Height (feet/inches)	Height (cm)	Gentamicin dose
<5’	<152	5mg/kg* (max 280mg)
5’ – 5’4”	152 – 163	280mg
>5’4” – 5’8”	>163 – 173	320mg
>5’8” – 6’1”	>173 – 185	360mg
>6’1”	>185	400mg

General Surgery

Appendectomy

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

plus

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)

plus

Metronidazole 500mg IV

ERCP

Ongoing cholangitis – continue established therapy otherwise ciprofloxacin single dose 750 mg orally 60-90mins pre procedure

Biliary obstruction / CBD stones / stent change where biliary decompression is not achieved – commence and complete course of treatment with procedure

Where complete biliary drainage unlikely to be achieved e.g. PSC, hilar cholangiocarcinoma. Communicating pancreatic cyst or pseudocyst – ciprofloxacin single dose 750 mg orally 60-90mins pre procedure

Biliary complications following liver transplant ciprofloxacin single dose 750 mg orally 60-90mins pre procedure plus vancomycin dosed by guideline

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 and at 12 hours post procedure
Transurethral resection of prostate	Gentamicin Dose as per table above If long term catheter in place preoperatively add: Amoxicillin 1g IV (or teicoplainin 400mg IV if beta-lactam allergy)
TURBT (Local practice)	Gentamicin Dose as per table above If long term catheter in place preoperatively add Amoxicillin 1g IV (or teicoplainin 400mg IV if beta-lactam allergy)

Obstetrics and Gynaecology
Caesarean Section	Cefuroxime 1.5g IV as a single agent 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	Doxycycline 100 mg bd orally for 7 days Applicable groups: · Anyone under 20 years old · Those undergoing a surgical procedure · Previous Chlamydial infection · Two or more partners in last year (unless negative NAATS since last partner)

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

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 guideline) )

References

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

Bratzler DW,Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013;70:195–283.