Antibiotic prophylaxis in surgery (ADULTS) Type of Surgery Antibiotic of Choice Alternative in true Penicillin Allergy or MRSA carriage

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1 These guidelines have been amended to reduce the incidence of Clostridium difficile associated diarrhoea and includes recommendations from the most recent guidance 1-8 NB. If patient is a VRE carrier or has had a recent VRE infection, please contact a Microbiologist for advice as standard antibiotics will be ineffective. Important notes: Refer to British National Formulary for further details of cautions, contra-indications, side effects and dosages 1. The pre-operative antimicrobial dose should be administered within 30 minutes before skin incision. However, give prophylaxis earlier for operations in which a tourniquet is used 2. An additional dose of antibiotic prophylaxis may be given during operations 1,2 a. lasting more than 4 hours b. in the event of major intra-operative blood loss (>1500ml). additional dosage of prophylactic antibiotics should be consider after fluid replacement 3. Antibiotic prophylaxis should be confined to the perioperative period only Postoperative doses should not be given, unless stated in the guidance or agreed with Microbiology 4. When severe renal impairment known or suspected please contact Pharmacy or Microbiology department for advice 5. If history of life threatening allergy to penicillin (e.g. anaphylaxis, angioedema, facial/throat swelling), consult microbiology/pharmacy for advice 6. Avoid cephalosporins (cefuroxime) in all patients 7. Alternative antibiotics should only be given if the patient has a penicillin allergy or is colonised or infected with MRSA 8. Where prophylaxis is not given when recommended, should be clearly recorded in the case records 9. With gentamicin, the risk of ototoxicity may be increased by other ototoxic drugs, e.g. furosemide. The risk of nephrotoxicity is increased by other drugs e.g. NSAIDs, cephalosporins, vancomycin and amphotericin. 7 Gentamicin key points 10. Gentamicin doses over 240 mg should be given as a 30 to 60 min infusion 11. Gentamicin Intravenous bolus injection should be given over 3 minutes Gentamicin- Maximum dose of 500mg OD 13. Gentamicin may interact with neuromuscular blocking agents e.g. suxamethonium used during anaesthesia, and can enhance the potential neuromuscular blockade 7 Orthopaedic surgery Total hip replacement Prosthetic knee joint Replacement (regardless of use of antibiotic cement) Hip fracture repair Spinal surgery Insertion of prosthetic Device Revision arthroplasty Major trauma/open fractures Co-amoxiclav 1.2 g IV at, followed by a second dose 8 hours later, and a final dose 8 hours later (total of 3 doses in 24 hours) Single dose Co-amoxiclav 1.2 g IV at Can be used for the following: Platings, metalwork insertion, metalwork removal, joint injections Antibiotics should NOT be given until samples have been taken Single dose Teicoplanin 10mg/kg IV (to nearest 100mg, maximum 800mg) stat after sampling + Meropenem 500mg IV stat bolus after sampling If sepsis syndrome followed by: Teicoplanin 10mg/kg IV (to nearest 100mg, maximum 800mg) 12 hourly for 3 doses then OD + Meropenem 500mg TDS IV Stop meropenem after 48 hours if no Gramnegatives on cultures and continue with teicoplanin until final cultures available, then seek advice from Microbiology Co-amoxiclav 1.2 g IV at, followed by a second dose 8 hours later, and a final dose 8 hours later (total of 3 doses in 24 hours) If Grossly contaminated add in: Metronidazole 500mg IV 8 hourly (2 doses) + Gentamicin 1.5mg/kg IV stat bolus at Consider extending treatment until definitive surgical procedure performed 800mg) stat at + Gentamicin 1.5mg/kg IV stat bolus at 800mg) 12 hours after first dose (two doses in total) Antibiotics should NOT be given until samples have been taken Single dose 800mg) stat after sampling + Gentamicin 1.5mg/kg IV stat bolus at If sepsis syndrome followed by: 800mg) 12 hourly for 3 doses then OD + Gentamicin 5mg/kg* IV as 30 to 60min infusion OD from day 2 onwards Gentamicin and Teicoplanin levels ARE required 800mg) stat at + Gentamicin 1.5mg/kg IV stat bolus at + Metronidazole 500mg IV stat at 800mg) 12 hours after first dose (two doses in total) + Metronidazole 500mg IV 8 hourly (2 doses) Consider extending treatment until definitive surgical procedure performed (additional gentamicin from day 2 onwards required. Gentamicin levels ARE required) Orthopaedic surgery without prosthetic device (elective) * Patients with impaired renal function CrCl < 60 ml/min (Cockcroft-Gault) use a reduced dose of 3mg/kg Obese dosing weight= IBW (ABW-IBW). ; 1 of 6

2 Obstetrics and Gynaecology Caesarean section Hysterectomy (abdominal or vaginal) Perineal tear third or fourth degree involving anal sphincter/rectal mucosa Manual removal of placenta Co-amoxiclav 1.2g i.v. stat at 9 During a caesarean section, prophylaxis could be delayed until the cord is clamped (at + Metronidazole 500mg i.v. stat Surgical termination of pregnancy Co-amoxiclav 1.2g i.v. stat at Plus Azithromycin 1gram PO if patient not screened for STDs prior to the procedure If PID suspected, please refer to the Trust Antibiotic Guidance or contact Microbiology or Sexual Health Medicine for further advice Assisted delivery Evacuation of complete mis Urology Transrectal prostate biopsy +/- Metronidazole 500mg i.v. stat at (at Hydrocoeles/hernia repair Transurethral resection of the prostate Transurethral resection of bladder tumours At surgeon s discretion may consider Nephrectomy +/- Metronidazole 500mg i.v. stat at (at At surgeon s discretion may consider Cystoscopy To be considered if high risk of UTI Ciprofloxacin 500 mg p.o. 1 hour before procedure (single dose) 8 If urine colonised with resistant organism: or contact Microbiology for targeted therapy To be considered if high risk of UTI Ciprofloxacin 500 mg p.o. 1 hour before procedure (single dose) 8 If urine colonised with resistant organism: or contact Microbiology for targeted therapy * Patients with impaired renal function CrCl < 60 ml/min (Cockcroft-Gault) use a reduced dose of 3mg/kg Dosing is based on actual body weight (ABW) unless patient is obese (20% over ideal body weight-(ibw)) Obese dosing weight= IBW+ 0.4 (ABW-IBW). 2 of 6

3 UPPER GASTROINTESTINAL Oesophageal surgery Stomach and duodenal surgery Gastric bypass surgery Small intestine surgery Endoscopic gastrostomy LOWER GASTROINTESTINAL Colorectal surgery 4-5 Appendicectomy Suspected or confirmed Ruptured viscus/ peritoneal contamination HEPATOBILIARY Gentamicin 5mg/kg* i.v. infusion over 30 min at +/- Amoxicillin 1g i.v. stat at (at If Treatment regimen required (post surgery) Piperacillin/Tazobactam 4.5g i.v. 8 hourly for 5 to 7 days +/- Amoxicillin 1g i.v. stat at (at Piperacillin/Tazobactam 4.5g i.v. at Piperacillin/Tazobactam 4.5g i.v. 8 hourly for 5 to 7 days 60min at +/- Teicoplanin 400mg i.v. stat (at surgeon s If Treatment regimen required (post surgery) Metronidazole 500mg i.v. 8 hourly + Teicoplanin 10mg/kg IV (to nearest 100mg: maximum 800mg) for 3 loading doses 12 hours apart then OD From day 2 add in: 60minutes OD Gentamicin and Teicoplanin levels ARE required +/- Teicoplanin 400mg i.v. stat (at surgeon s 60min at +/- Teicoplanin 400mg i.v. stat (at surgeon s If Treatment regimen required (post surgery) Metronidazole 500mg i.v. 8 hourly + Teicoplanin 10mg/kg IV (to nearest 100mg: maximum 800mg) for 3 loading doses 12 hours apart then OD From day 2 add in: 60minutes OD Gentamicin and Teicoplanin levels ARE required Biliary surgery (open) Pancreatic surgery Liver surgery Gall bladder surgery (open) +/- Amoxicillin 1g i.v. stat at (at Gall bladder surgery (laparoscopic) +/- Teicoplanin 400mg i.v. stat at (at Gentamicin and Teicoplanin levels NOT required * Patients with impaired renal function CrCl < 60 ml/min (Cockcroft-Gault) use a reduced dose of 3mg/kg Obese dosing weight= IBW+ 0.4 (ABW-IBW). 3 of 6

4 ABDOMEN Pseudomyxoma peritonei Laparoscopic or nonlaparoscopic hernia repair with mesh Co-amoxiclav 1.2 g i.v. at, followed by a second dose 4 hours later And a final dose 8 hours later (total of 3 doses in 24 hours) followed by: Metronidazole 500mg i.v. 8 hourly (total of 3 doses in 24hours) Gentamicin 3mg/kg i.v. infusion over 30 to 60min at, +/- Teicoplanin 400 mg i.v. stat at Metronidazole 500mg i.v. 8 hourly (2 doses) + Teicoplanin 400 mg i.v. one additional dose at 12 hours Gentamicin and Teicoplanin levels NOT required Laparoscopic or nonlaparoscopic hernia repair without mesh THERAPEUTIC ENDOSCOPIC PROCEDURES ERCP Endoscopic gastrostomy (PEG) + Amoxicillin 1g i.v. stat at (at + Teicoplanin 400mg i.v. stat at Gentamicin and Teicoplanin levels NOT required BREAST SURGERY Breast cancer surgery Breast reshaping procedures Breast surgery with implant (reconstructive or aesthetic) Breast cancer surgery with implant Flucloxacillin 2g i.v. stat at +/- Metronidazole 500mg i.v. stat at (at Flucloxacillin 2g i.v. stat at +/- Metronidazole 500mg i.v. stat at Flucloxacillin 1g i.v. 6hourly +Metronidazole 500mg i.v. 8hourly Until drains are removed Switch to oral antibiotics can be considered at 48 hours Teicoplanin 400mg i.v. stat at +/- Metronidazole 500mg i.v. stat at(at Teicoplanin level NOT required Teicoplanin 400mg i.v. stat at +/- Metronidazole 500mg i.v. stat (at surgeon s Metronidazole 500mg i.v. 8hourly + Teicoplanin 10mg/kg IV (to nearest 100mg: maximum 800mg) for 3 loading doses 12 hours apart then OD Until drains are removed Switch to oral antibiotics should be discussed with Microbiology Teicoplanin levels ARE required * Patients with impaired renal function CrCl < 60 ml/min (Cockcroft-Gault) use a reduced dose of 3mg/kg Obese dosing weight= IBW (ABW-IBW). 4 of 6

5 VASCULAR SURGERY Lower limb amputation Vascular surgery (abdominal & lower limb) Cardiothoracic Flucloxacillin 1g i.v. stat at + Gentamicin 240mg* i.v. stat at At surgeon s discretion may give up to 2 further doses of Flucloxacillin 500mg i.v. 6hourly + Metronidazole 500mg i.v. 8hourly (No further gentamicin) Teicoplanin 400mg i.v. stat at + + Metronidazole 500mg i.v. at At surgeon s discretion may give up to 2 further doses of Metronidazole 500mg i.v. 8hourly + Teicoplanin 400 mg i.v. one additional dose at 12 hours (No further gentamicin) Cardiac pacemaker insertion Flucloxacillin 1g i.v. stat at Teicoplanin 400mg i.v. stat at Head and neck surgery Head and neck surgery (contaminated & clean contaminated) Complex septorhinoplasty with implant Flucloxacillin 1g i.v. stat at Flucloxacillin 1g iv 6hourly (3 doses) + Metronidazole 500mg i.v. 8hourly (2 doses) Flucloxacillin 1g i.v. stat at Flucloxacillin 1g iv 6hourly (3 doses) + Metronidazole 500mg i.v. 8hourly (2 doses) Flucloxacillin 500 mg p.o. 6hourly for 5 days Head and neck surgery (clean) Clindamycin 900mg i.v. 8hourly (3 doses) Clarithromycin 500 mg i.v. 12hourly (2 doses) + Metronidazole 500mg i.v. 8hourly (3 doses) Clarithromycin 250 mg p.o. 12hourly for 5 days Ear surgery (clean) Ear surgery with Prosthesis Revision surgery Co-Amoxiclav 1.2g i.v. 8hourly (3 doses) Amoxicillin 500 mg p.o. 8hourly for 5 days Nose or sinus surgery Clarithromycin 500 mg i.v. 12hourly (2 doses) + Metronidazole 500mg i.v. 8hourly (3 doses) Clarithromycin 250 mg p.o. 12hourly for 5 days Tonsillectomy Grommet insertion Single dose of topical ofloxacin Single dose of topical ofloxacin * Patients with impaired renal function CrCl < 60 ml/min (Cockcroft-Gault) use a reduced dose of 3mg/kg Obese dosing weight= IBW (ABW-IBW). 5 of 6

6 References: 1 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery - Principles, 2008 available online at: 2 National Institute for Health and Clinical excellence (NICE) Surgical Site Infection Prevention and treatment of surgical site infection, October 2008 available on line at: 3 Privitera G, Scarpellini P, Ortisi G, Nicastro G, Nicolin R, de Lalla F. Prospective study of Clostridium difficile intestinal colonisation and disease following single dose antibiotic prophylaxis in surgery. Antimicrob Agents Chemother1991; 35: Health Technology Assessment (HTA) Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomised controlled trials, 1998 available on line at: 5 Zelenitsky S, Ariano R, Godfrey K, et al. Antibiotic Pharmacodynamics in Surgical Prophylaxis: and association between intraoperative antibiotic concentrations and efficacy. Antimicrob Agenst Chemother 2002; 46: Summary of Product Characteristics. Cidomycin adult injectable 80mg/2ml. (accessed 27 January 2009) 7 Wright J, Gray A, Goodey V. Clinical Pharmacy. Pharmaceutical Press Wolf J. S., Bennett C, Dmochowski R, et al. Best practice Policy Statement on Urology Surgery Antimicrobial Prophylaxis. American Urological Association. J. juro 2008; 179: of 6