Aim

The aim of surgical prophylaxis is to reduce surgical site infections. SIGN 104 outlines which surgical procedures require prophylaxis with antimicrobials, when they should be administered and for how long. This guideline states which antibiotics should be used for surgical procedures within NHS Forth Valley, taking into account national guidance on reducing the incidence of C.difficle by restricting certain antibiotics.

Points of note

• These regimes may be unsuitable for patients who have infections with ESBL organisms
• If concerns re choice of prophylaxis for selected patients or their renal function, please discuss with microbiology for alternative options.
• If patient already on antibiotics prior to surgery ensure the suitability of these as prophylaxis, discuss with microbiology if needed
• If antibiotics to be continued post operatively ensure their suitability by checking the microbiology culture results
• Teicoplanin can affect renal function and bone marrow
• Co-amoxiclav and cefuroxime are associated with C.difficile infection

Principles of Therapy

1. Indication for prophylaxis should comply with national (SIGN104) and local guidelines.
2. Timing – Optimum timing is ≤30 minutes prior to skin incision. (Suboptimal if > 1 hour prior to skin incision or post-skin incision).
3. Prescribing / Recording of Administration – This should be recorded on HEPMA - this is preferable to recording on the anaesthetic chart.  Where prophylaxis is to continue beyond a single dose, the reason for this along with the duration should be recorded in the medical notes.
4. Choice of drug -
   • Avoid cephalosporins,clindamycin,co-amoxiclav and quinolones where possible due to C diff risk
   • Narrow spectrum agents should be used where possible
   • Consider alternatives if beta-lactam allergy or previous MRSA
5. Administration – frequency – Single  dose is sufficient except  in  the  following  circumstances:
• >1.5 litre intra-operative blood loss. Re-dose following fluid replacement – see below for dosing guidance or prolonged procedure - refer to Drug Dosage Table
• Arthroplasty – up to 24 hours prophylaxis can be considered.
6. De-colonisation therapy should be carried out prior to surgery when MRSA positive patients are identified where recommended in Infection Control Policies.
7. Complex individual prophylaxis issues should be discussed with Microbiology prior to surgery and recorded in medical notes.
8. Post operative infection. Management of empirical infections guidance should be used.