Urological Surgery

Antimicrobial prescribing: NHS Lothian
NHS Lothian

General Principles of Prescribing Antibiotics for Surgical Prophylaxis

  1. Timing. Antibiotics should be administered or infusion completed within 60 minutes before the procedure or skin incision.
  2. Document doses in the “once only” section of the paper drug administration chart (the kardex) or as STAT orders on HEPMA.
  3. A single dose of antibiotic is recommended. Exceptions are outlined in individual protocols.
  4. No dose adjustment in renal or hepatic impairment is required unless indicated
  5. Repeat dosing may be required if the operation is prolonged (see table below for re-dosing guidance for individual antibiotics):
      1. The repeat dose is given at the recommended interval from the time the initial dose was administered.
      2. Intra-operative blood loss >1.5L. Re-dose following fluid replacement/blood transfusion.
  6. Discuss patients with consultant microbiologist at pre-op assessment for complex issues including:
    1. Carriage of, or previous infection with resistant organisms other than MRSA, e.g. gentamicin resistant coliforms.
    2. Where eGFR is <20ml/min for alternatives to gentamicin.
    3. Patients already being treated with antibiotics for urological infection
    4. Gentamicin toxicity is associated with cumulative use; discuss possible need for alternatives in patients with previous gentamicin courses and procedures recommending more than a single dose
  7. MRSA. See intranet for MRSA infection control policy on decolonisation prior to surgery.

Prostate

Procedure

Recommended

Penicillin allergy or MRSA

Transrectal prostate biopsy (TRUS)

Ciprofloxacin 500mg oral;
1 hour prior to procedure and 12hrs post
(2 doses total)

If known quinolone/ciprofloxacin resistant organisms:

Gentamicin IV (dose as per table)

MRSA

Ciprofloxacin 500mg oral;
1 hour prior to procedure and 12hrs post
(2 doses total)

AND

Teicoplanin IV 400mg

If known quinolone/ciprofloxacin resistant organisms:

Gentamicin IV (dose as per table)

AND

Teicoplanin IV 400mg

Transperineal prostate biopsy

Cefalexin oral 500mg 1hr before procedure

 

PENICILLIN ALLERGY

Co-trimoxazole 960mg oral; 1 hour before procedure

MRSA

ADD

Teicoplanin 400mg IV

Lap/robotic radical prostatectomy

Gentamicin IV (dose as per table)

MRSA

Gentamicin IV (dose as per table)

AND

Teicoplanin 400mg IV

Transurethral resection of prostate (TURP)/
green light laser/bladder neck incision (BNI)

NON-CATHETERISED

Gentamicin IV (dose as per table)

NON-CATHETERISED

Gentamicin IV (dose as per table)

MRSA

Gentamicin IV (dose as per table)

AND 

Teicoplanin 400mg IV

 

CATHETERISED PRE-OP

Gentamicin IV (dose as per table)
AND

Amoxicillin 1g IV

CATHETERISED PRE-OP

Gentamicin IV (dose as per table)

AND

Teicoplanin 400mg IV

Bladder

Procedure

Recommended

Penicillin allergy or MRSA

Trans urethral removal of bladder tumour (TURBT)/biopsy

Gentamicin IV (dose as per table)

MRSA

Gentamicin IV (dose as per table)
AND
Teicoplanin IV 400mg

Radical cystectomy and bladder augmentation/reconstruction/conduit

Gentamicin IV (dose as per table)
AND
Amoxicillin 1g IV
AND
Metronidazole 500mg IV

Gentamicin IV (dose as per table)
AND
Teicoplanin 400mg IV
AND
Metronidazole 500mg IV

Sacral nerve stimulation (SNS)

Teicoplanin 400mg IV on induction (or if local anaesthetic Teicoplanin 400mg IM 60 minutes prior to implantation)

Teicoplanin 400mg IV on induction (or if local anaesthetic Teicoplanin 400mg IM 60 minutes prior to implantation)

Andrology

Procedure

Recommended

Penicillin allergy or MRSA

Radical penectomy and perineal urostomy

Gentamicin IV (dose as per table)
AND
Co-amoxiclav 1.2g IV

 

Teicoplanin 400mg IV
AND
Gentamicin IV (dose as per table
AND
Metronidazole 500mg IV

Partial penectomy without graft

Co-amoxiclav 1.2g IV

Teicoplanin 400mg IV
AND
Gentamicin IV (dose as per table)
AND
Metronidazole 500mg IV

Partial penectomy and skin graft

Co-amoxiclav 1.2g IV every 8 hours for 3 doses

ORAL STEP DOWN

Co-amoxiclav 625mg oral every 8 hours for 4 days

 

Teicoplanin 400mg IV every 12 hours for two doses
AND
Gentamicin IV (dose as per table) single dose only
AND
Metronidazole 500mg IV every 8 hours for 3 doses

ORAL STEP DOWN

PENICILLIN ALLERGY

Co-trimoxazole oral 960mg every 12 hours (reduce dose if eGFR<30ml/min) for 4 days
AND
Metronidazole 400mg oral every 8 hours for 4 days

 

MRSA

Discuss with microbiology

Lymphadenectomy

Procedure

Recommended

Penicillin allergy or MRSA

Dynamic sentinel lymph node biopsy(DSLNB)

No prophylaxis

No prophylaxis

Radical lymphadenectomy

Co-amoxiclav 1.2g IV
Continue orally post-op until drains removed

Teicoplanin 400mg IV
AND
Gentamicin IV (dose as per table)
AND
Metronidazole 500mg IV

Discuss oral options with microbiology

Penile implant

Piperacillin-tazobactam 4.5g IV every 8 hours for three doses
AND
Gentamicin IV (dose as per table)
single dose only

ORAL STEP DOWN

Co-amoxiclav 625mg oral every 8 hours for 7 days

Teicoplanin 400mg IV every 12 hours for two doses
AND
Gentamicin IV (dose as per table) single dose only
AND
Metronidazole 500mg IV every 8 hours for 3 doses

ORAL STEP DOWN

PENICILLIN ALLERGY

Co-trimoxazole 960mg oral every 12 hours for 7 days (reduce dose if eGFR<30ml/min)

MRSA

Discuss oral options with microbiology

Orchidectomy with prosthesis

Co-amoxiclav 1.2g IV

Teicoplanin 400mg IV
AND
Gentamicin IV (dose as per table)
AND
Metronidazole 500mg IV

Surgery with skin grafts

Co-amoxiclav 1.2g IV every 8 hours for 3 doses

ORAL STEP DOWN

Co-amoxiclav 625mg oral every 8 hours for 4 days

Teicoplanin 400mg IV every 12 hours for two doses 
AND
Gentamicin IV (dose as per table)single dose only
AND
Metronidazole 500mg IV every 8 hours for 3 doses

ORAL STEP DOWN

PENICILLIN ALLERGY

Co-trimoxazole 960mg oral every 12 hours (reduce dose if eGFR<30ml/min) for 4 days

AND 

Metronidazole 400mg oral every 8 hours for 4 days

 

Oral step down MRSA

Discuss with microbiology

Kidney

 

Procedure

Recommended

Penicillin allergy or MRSA

Lap/robotic radical or partial nephrectomy

No prophylaxis.

If collecting system breached:
Gentamicin IV (dose as per table)
AND
Amoxicillin 1g IV

No prophylaxis.

If collecting system breached:
Gentamicin IV (dose as per table)

AND
Teicoplanin 400mg IV

Open radical/partial nephrectomy or nephroureterectomy

Gentamicin IV (dose as per table)
AND
Amoxicillin 1g IV

Gentamicin IV (dose as per table)
AND
Teicoplanin 400mg IV

Urethra

Procedure

Recommended

Penicillin allergy or MRSA

Optical urethrotomy/dilation

Gentamicin IV (dose as per table)

MRSA

Gentamicin IV (dose as per table)
AND
Teicoplanin IV 400mg

Urethroplasty

Gentamicin IV (dose as per table)
AND
Co-amoxiclav 1.2g IV single dose

ORAL STEP DOWN

Co-amoxiclav 625mg oral every 8 hours for 2 days

Gentamicin IV (dose as per table)
AND
Teicoplanin 400mg IV

If oral mucosal graft:
ADD Metronidazole 500mg IV

ORAL STEP DOWN

PENICILLIN ALLERGY

Co-trimoxazole 960mg oral every 12 hours for 48 hours (reduce dose if eGFR<30ml/min)

If oral mucosal graft:

ADD Metronidazole 400mg oral every 8 hours for 48 hours to above

MRSA:

Discuss oral treatment with microbiology

Artificial urinary sphincter

Gentamicin IV (dose as per table)
AND
Co-amoxiclav 1.2g IV single dose

ORAL STEP DOWN

Co-amoxiclav 625mg oral every 8 hours for 2 days

MRSA: See intranet for MRSA infection control policy on decolonization.

Teicoplanin 400mg IV
AND
Gentamicin IV (dose as per table)
AND
Metronidazole 500mg IV

ORAL STEP DOWN

PENICILLIN ALLERGY

Co-trimoxazole 960mg oral every 12 hours for 48 hours (reduce dose if eGFR<30ml/min)

MRSA

Discuss oral treatment with microbiology.

Endourology

Procedure

Recommended

Penicillin allergy or MRSA

Extracorporeal shock wave lithotripsy (ESWL)

 

No prophylaxis. If recent UTI consider Gentamicin IV (dose as per table) if isolate susceptible.

Stent insertion/change

Gentamicin IV (dose as per table)

 

MRSA

Gentamicin IV (dose as per table)
AND
Teicoplanin IV 400mg

Ureteroscopy (URS) +/- biopsy +/- stone laser

Gentamicin IV (dose as per table)

 

MRSA

Gentamicin IV (dose as per table)
AND
Teicoplanin IV 400mg

Percutaneous nephrolithonomy (PCNL)

 

Gentamicin IV (dose as per table)

If evidence of urinary tract infection and stones treat with antibiotics post-op, based on cultures, for up to 7 days.

MRSA
Gentamicin IV (dose as per table)
AND
Teicoplanin IV 400mg

If evidence of urinary tract infection and stones treat with antibiotics post-op, based on cultures, for up to 7 days.

Gentamicin surgical prophylaxis dosing in urology

Gentamicin surgical prophylaxis dosing - 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.

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 400mg)

5' - 5'1''

152 - 155

240mg

>5'1'' - 5'6''

>155 - 168

280 mg

>5'6'' - 5'10''

>168 - 178

320 mg

>5'10'' - 6'2''

>178 - 188

360 mg

>6'2''

>188

400mg

MALE

Height (Feet/Inches)

Height (cm)

Gentamicin dose

<5'

<152

5mg/kg* (max 400mg)

5' - 5'4''

152 - 163

280mg

>5'4'' - 5'8''

>163 - 173

320 mg

>5'8'' - 6'1''

>173 - 185

360 mg

>6'1''

>185

400mg

IV antibiotic administration and re-dosing guidance

Urology iv antibiotic administration and re-dosing guidance

Antibiotic

Administration

Re-dosing advice: prolonged surgery

Re-dosing advice: >1.5L blood loss

Amoxicillin IV

Bolus over 3-5 minutes

Repeat original dose (every) 4 hours

Repeat original dose

Cefalexin oral

60 minutes prior to procedure

Repeat dose after 4 hours

Repeat dose

Ciprofloxacin oral

60 minutes prior to procedure

Not relevant

Not relevant

Ciprofloxacin IV

Infuse 400mg over 60 minutes

Not relevant

Not relevant

Co-amoxiclav IV

Bolus over 3-5 minutes

Repeat dose after 4 hours

Repeat dose

Co-trimoxazole oral

60 minutes prior to procedure

Re-dosing not required

Not relevant

Gentamicin IV

Bolus over 3-5 minutes

Where 5mg/kg dosing has been used, measure gentamicin level at 6 hours; if <2.0mg/L re-dose with half original dose after 8 hours

Where 5mg/kg dosing has been used, once bleeding controlled measure gentamicin level; if <2.0mg/L re-dose with half original dose

Metronidazole IV

Infuse over 20 minutes

Repeat dose after 8 hours

Repeat dose

Piperacillin-tazobactam IV

Infuse over 30 minutes

Repeat original dose after (every) 4 hours

Repeat original dose

Teicoplanin IV

Bolus over 3-5 minutes

Re-dosing not required

 200mg (50% original dose), if ≥ 1.5L blood loss within first hour of operation.