Antibiotics - Surgical Prophylaxis

Principles of Surgical Prophylaxis

  1. Prophylaxis should be started ideally within one hour prior to incision. Please note that certain antibiotics (e.g. vancomycin, erythromycin, Clarithromycin*, clindamycin and metronidazole) cannot be given as bolus injections. It is important that the infusions are completed within one hour PRIOR to incision to ensure adequate plasma levels during surgery.
  2. Prophylaxis should be confined to the peri-operative period (i.e. immediately before and during procedure). The administration of additional doses of antibiotic after the end of procedure provides little or no additional prophylactic benefit. The use of antibiotics post-procedure is strongly discouraged in most cases.
  3. Post operative doses of antibiotics will further disturb normal microbiological flora and increase the risk of Clostridium difficile. Only use post-operative antibiotics if specifically advised in the guideline or the patient requires treatment of infection (e.g. peritonitis post- perforated appendicitis). Antibiotic usage in this scenario is therapeutic rather than prophylactic.
  4. An additional peri-operative prophylactic dose should be considered by the surgeon for procedures lasting > 4 hours, or if there is blood loss >1500ml or haemodilution >15ml/kg
  5. Always check previous microbiology cultures and sensitivities (MC&S) to guide choice of antibiotic for surgical prophylaxis. If recent history of MRSA colonisation, a glycopeptide antibiotic should be given as part of surgical prophylaxis. Consult microbiologist.
  6. Clean surgery is associated with a low risk of infection and there is usually no indication for surgical antibiotic prophylaxis.
  7. NB: Vancomycin infusion must be run ONE HOUR PRIOR TO INCISION to ensure that adequate serum levels are achieved by time of incision

Prophylaxis Neurosurgery

Procedure

Neurosurgery Craniotomy CSF shunt
Empiric treatment

Cefuroxime 1.5g iv single dose.
In penicillin allergy

Severe penicillin allergy / risk of MRSA:

Vancomycin 15mg/kg iv infusion pre-incision.
Duration Single dose.
Comments

* Clarithromycin can cause significant increases in INR. For patients on Warfarin and Clarithromycin, INR must be monitored very closely and appropriate Warfarin dose adjustments made as necessary.

Prophylaxis ENT Head & Neck surgery

Procedure

ENT. Head and neck
Empiric treatment

Co-amoxiclav 1.2g iv single dose.
In penicillin allergy

Clindamycin 900mg iv infusion
plus
Gentamicin 5mg/kg (max. 480mg) iv infusion single dose pre-incision.
Duration
Comments

Only for clean-contaminated / contaminated surgery. Single dose. Gentamicin dosing.

Prophylaxis Cardiothoracic surgery

Procedure

Cardiothoracic. CABG, Thoracotomy, Lobectomy, Pneumonectomy, Lung resection, VATS, Pacemaker / other cardiac device insertion
Empiric treatment

Cefuroxime 1.5g iv pre-incision
plus
two additional doses of Cefuroxime 1.5g iv eight and sixteen hours after first dose.
In penicillin allergy

Pencillin allergy / risk of MRSA: Gentamicin 5mg/kg (max 480mg) iv infusion single dose
plus
Vancomycin 15mg/kg iv infusion pre-incision
plus
one additional dose of vancomycin 15mg/kg iv infusion 12 hours after first dose.
Duration For 24 hrs.
Comments

Vancomycin dosing.

Gentamicin dosing.

Prophylaxis Prosthetic valve surgery

Procedure

Prosthetic valve surgery
Empiric treatment

Gentamicin 5mg/kg (max. 480mg) iv infusion single dose (see below)
plus
Vancomycin 15mg/kg iv infusion pre-incision,
plus
one additional dose of vancomycin 15mg/kg iv infusion 12 hours after first dose.
In penicillin allergy

As above
Duration

24 hours.
Comments

Vancomycin dosing.
Gentamicin dosing.

Prophylaxis Pacemaker insertion

Procedure

Pacemaker insertion
Empiric treatment

Flucloxacillin1g iv stat.
In penicillin allergy

Penicillin allergy / risk of MRSA: Vancomycin 1g iv stat.
Duration
Comments

Single dose.Vancomycin dosing.

Prophylaxis General surgery

Procedure

General surgery, Appendectomy, Biliary surgery, Gastro-duodenal surgery, Gastrostomy, Small bowel surgery, Oesophageal surgery, Colorectal surgery
Empiric treatment

Co-amoxiclav 1.2g iv single dose.
In penicillin allergy

Gentamicin 5mg/kg (max 480mg) iv infusion
plus
Metronidazole 500mg iv infusion pre-incision.
Duration
Comments

Prophylaxis not indicated for laparoscopic cholecystectomy or laparoscopic hernia repair without mesh.Use of antibiotics post surgery only if clinical evidence of infection, at the discretion of the surgeon.Gentamicin dosing.

Prophylaxis Breast surgery

Procedure

Breast
Empiric treatment

Co-amoxiclav 1.2g iv single dose.
In penicillin allergy

Penicillin allergy (minor):

Cefuroxime 1.5g iv single dose pre-incision.

Penicillin allergy (severe) / Risk of MRSA:

Vancomycin 15mg/kg iv infusion pre-incision.
Duration
Comments

Single dose.Vancomycin dosing.

Prophylaxis ERCP

Procedure

ERCP
Empiric treatment

Ciprofloxacin 750mg po single dose one hour pre-op.
In penicillin allergy

Ciprofloxacin 750mg po single dose one hour pre-op.
Duration Single dose.
Comments

Prophylaxis Vascular surgery

Procedure

Vascular
Empiric treatment

Co-amoxiclav 1.2g iv pre-incision
plus
up to two additional doses of co-amoxiclav 8 and 16 hours after the first dose.

Penicillin allergy (minor):

Cefuroxime 1.5g iv pre-incision plus up to two additional doses of cefuroxime 1.5g iv eight and sixteen hours after first dose.

Pencillin allergy (severe) / risk of MRSA: Gentamicin* 5mg/kg (max. 480mg) iv infusion
plus
Vancomycin 15mg/kg iv infusion pre-incision plus one additional dose of Vancomycin 15mg/kg iv infusion twelve hours after first dose.
In penicillin allergy

Gentamicin 2mg/kg iv
plus
Vancomycin iv (q12h).
Duration Up to 24 hours only.
Comments

Vancomycin dosing

Gentamicin dosing.

Prophylaxis TURBx

Procedure

TURBx
Empiric treatment

No risk factors for resistant organisms:

Ciprofloxacin 750mg po pre op and one dose 12 hours later.

Risk factors for resistant organisms (other than CRE):

Ciprofloxacin 750mg po pre op and one dose 12 hours later plus Gentamicin 5mg/kg (max 480mg) iv infusion stat pre op.

ESBL colonisation:

Seek micro advice.
In penicillin allergy
Duration
Comments

Use previous MC&S to guide choice for antibiotic.

Prophylaxis recommended in guideline assumes the patient has NOT had a positive urine culture.

Seek advice from Microbiology for ESBL colonised or other complex patients.Gentamicin dosing.

Prophylaxis Shock-wave lithotripsy

Procedure

Shock-wave lithotripsy
Empiric treatment

Oral option: Ciprofloxacin 750mg po single dose one-hour before procedure.

IV option: Gentamicin 5mg/kg (max 480mg) iv infusion <30 minutes before procedure.
In penicillin allergy
Duration
Comments

Gentamicin dosing.

Prophylaxis Percutaneous nephrolithotomy

Procedure

Percutaneous nephrotithotomy
Empiric treatment

Only indicated if stone > 20mm or with pelvicalyceal dilatation: Ciprofloxacin 500mg q12h po for 7 days pre-procedure..
In penicillin allergy

As above.
Duration

As above.
Comments

Only if stone >20mm or with pelvicalyceal dilation.

Prophylaxis Endoscopic Ureteric stone removal

Procedure

Endoscopic ureteric stone fragmentation/ removal
Empiric treatment

Oral option: Ciprofloxacin 750mg oral single dose one-hour before procedure.

IV option: Gentamicin 5mg/kg (max 480mg) iv at induction only.
In penicillin allergy As above
Duration
Comments Gentamicin dosing.

Prophylaxis TURP

Procedure

TURP
Empiric treatment

Gentamicin 5mg/kg (max 480mg) iv at induction only.

If Gentamicin contraindicated: Co-amoxiclav 1.2g IV at induction only (repeat at 4 hours if operation ≥4 hours).
In penicillin allergy Seek advice from microbiology.
Duration
Comments

Gentamicin dosing.

Prophylaxis Radical Cystectomy Nephrectomy

Procedure

Radical cystectomy and nephrectomy
Empiric treatment

Co-amoxiclav 1.2g IV at induction only (repeat at 4 hours if operation ≥ hours).
In penicillin allergy

Gentamicin 5mg/kg (max 480mg) iv infusion
plus
Vancomycin 15mg/kg iv at induction only.
Duration

As above.
Comments

Gentamicin dosing.

Prophylaxis Orthopaedic surgery

Procedure

Orthopaedic Surgery
Empiric treatment

Cefuroxime 1.5g iv pre-op, then 750mg q8h iv for 2 doses.
In penicillin allergy

Severe penicillin allergy / risk of MRSA:

Gentamicin 5mg/kg (max 480mg) iv infusion stat
plus
Vancomycin 15mg/kg iv infusion pre-incision. One additional dose of vancomycin to be given 12 hours after first dose.

For dirty wounds: add Metronidazole 500mg iv infusion pre-incision to the above regimens.
Duration For up to 24 hours only.
Comments Prophylaxis not recommended for elective orthopaedic surgery where there is no insertion of prosthetic device.
MRSA positive patients: Teicoplanin 10mg/kg iv pre-op then one dose of 6mg/kg 12 hours after
plus
Gentamicin 160mg iv single dose pre-op.* Clarithromycin can cause significant increases in INR.
For patients on Warfarin and Clarithromycin, INR must be monitored very closely and appropriate Warfarin dose adjustments made as necessary.Gentamicin dosing.

Prophylaxis O & G surgery

Procedure

O&G
Empiric treatment

Co-amoxiclav 1.2g iv single dose.
In penicillin allergy

Clindamycin 600mg iv
plus
Gentamicin 160mg iv single dose.
Duration Single dose
Comments

Gentamicin dosing.

Content By Dr. Íomhar O' Sullivan 10/08/2010. Last review Dr. ÍOS 6/05/15.