Cardiothoracic, including pacemaker insertion surgery

General Principles of Prescribing Antibiotics for Surgical Prophylaxis

Timing. Antibiotics should be administered, or infusion completed within 60 minutes before the procedure or skin incision.
Document doses in the “once only” section of the paper drug administration chart (the kardex) or as STAT orders on HEPMA.
A single dose of antibiotic is recommended. Exceptions are outlined in individual protocols.
No dose adjustment in renal or hepatic impairment is required unless indicated.
Repeat dosing may be required if the operation is prolonged (see table below for re-dosing guidance for individual antibiotics):
- The repeat dose is given at the recommended interval from the time the initial dose was administered.
- Intra-operative blood loss >1.5L. Re-dose following fluid replacement/blood transfusion.
Discuss patients with medical microbiology at pre-op assessment for complex issues including carriage of, or previous infection with resistant organisms other than MRSA. For patients with multidrug resistant pseudomonas please review antibiotic susceptibilities in microbiology report and discuss with medical microbiology, Ceftazidime 2g IV may be a suitable alternative.
MRSA – See intranet for MRSA infection control policy on de-colonisation prior to surgery.
Surgery for Aspergillus lung disease e.g. aspergilloma. These are complex patients some of whom have antifungal resistant strains. Please discuss antifungal prophylaxis on a case-by-case basis at the time the patient at pre-op assessment. Do not wait until day of operation.

Antimicrobial recommendations

Cardiac Surgery

Procedure	Recommended	Penicillin allergy or MRSA
CABG	Cefuroxime 1.5g IV	Teicoplanin 800mg IV (600mg if <60kg)
CABG (off pump)	Cefuroxime 1.5g IV	Teicoplanin 800mg IV (600mg if <60kg)
Prosthetic Valve Surgery	Cefuroxime 1.5g IV followed by 1.5g IV at 8 hour intervals (three doses in total)	Teicoplanin 800mg IV (600mg if <60kg)
TAVI	Cefuroxime 1.5g IV	Teicoplanin 800mg IV (600mg if <60kg)
Urgent re-opening	Teicoplanin 800mg IV (600mg if <60kg)	Teicoplanin 800mg IV (600mg if <60kg)

Thoracic Surgery

Procedure

Recommended

Penicillin allergy or MRSA

Pulmonary resection

Co-amoxiclav 1.2g IV followed by 1.2g at 6 hour intervals (two doses in total)

If high risk of pseudomonas infection (e.g., bronchiectasis)*

Use piperacillin/tazobactam 4.5g followed by 4.5g at 6 hour intervals (two doses in total)

Teicoplanin 800mg (600mg if <60kg)

If high risk of pseudomonas infection (e.g., bronchiectasis)*

ADD

Ciprofloxacin 750mg oral (60 mins prior to procedure)

Pacemaker/other device prophylaxis

Procedure	Recommended	Penicillin allergy or MRSA
Pacemaker implantation	Flucloxacillin 1g IV	Teicoplanin 400mg IV

IV antibiotic administration and re-dosing guidance

Antibiotic	Administration	Re-dosing advice: prolonged surgery	Re-dosing advice: >1.5L blood loss
IV Cefuroxime	Bolus over 3-5 minutes	Repeat original dose every 4 hours	Repeat original dose
IV Co-amoxiclav	Bolus over 3-5 minutes	Repeat original dose after 6 hours	Repeat original dose
IV Teicoplanin	Bolus over 3-5 minutes	Not required	Half original dose original dose if > 1.5L blood loss within first hour of operation
IV Flucloxacillin	Bolus over 3-5 minutes	Repeat original dose every 4 hours	Repeat original dose
Oral Ciprofloxacin	60 mins prior to procedure	Not required	Not required
IV Ceftazidime	Bolus over 3-5 minutes	Not required	Repeat original dose
IV Piperacillin /Tazobactam	IV infusion over 30 minutes	Repeat original dose after 6 hours	Repeat original dose