Prophylaxis to Prevent

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Approved by:

Pharmacy and Therapeutic Committee

Infection Control Committee

Infection Control and Environmental Health Unit

Infection Control & Environmental Health Unit, 2012

.

Recommended Indications for Surgical Antibiotic

Prophylaxis to Prevent

Surgical Site Infections (SSI).

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Operations Antibiotic prophylaxis Antibiotic Head and Neck Intracranial

Craniotomy Recommended Cefazolin¹ 1–2 g IV preoperatively

and q 8 h for 2 doses or Vancomycin² 1g IV.

Cerebrospinal fluid (CSF)shunt Recommended

Spinal surgery Recommended

Head and neck surgery (clean, benign)

Not Recommended Head and neck surgery

(clean, malignant; neck dissection)

Should be Considered Cefazolin¹ 1–2 g IV preoperatively and q 8 h for 2 doses or

Vancomycin² 1g IV.

Head and neck surgery (contaminated/clean contaminated)

Recommended

Ophthalmic

Cataract surgery Highly Recommended Multiple drops topically over 2 to 24 hours.

Gentamicin, Tobramycin, Ciprofloxacin, Gatifloxacin Levofloxacin, Moxifloxacin, Ofloxacin or Neomycin-gramicidin- polymyxin B. or Cefazolin Glaucoma or corneal grafts Recommended

Lacrimal surgery Recommended

Penetrating eye injury Recommended

Facial

Open reduction and internal fixation of compound mandibular fractures

Recommended

Cefazolin¹ 1–2 g IV preoperatively and q 8 h for 2 doses or

Vancomycin² 1g IV. or Intraoral bone grafting

Procedures

Recommended Orthognathic surgery Recommended, Broad

spectrum antibiotics appropriate to oral flora should be given.

Clindamycin³ 600–900 mg IV ± Gentamicin 1.5 mg/kg IV

preoperatively and q 8 h for 2 doses Facial surgery (clean) Not Recommended

Facial plastic surgery (with implant)

Should be Considered Cefazolin¹ 1–2 g IV preoperatively and q 8 h for 2 doses or

Vancomycin² 1g IV. or Clindamycin³ 600–900 mg IV ± gentamicin 1.5 mg/kg IV

preoperatively and q 8 h for 2 doses Ear, nose and throat - benign

Ear surgery

(clean/clean-contaminated

Not Recommended Routine nose, sinus and

endoscopic sinus surgery

Not Recommended

1 .

Recommended Indications for Surgical Antibiotic Prophylaxis to Prevent Surgical Site Infections (SSI).

1- 2gm of Cefazolin is recommended for patients weight > 80kg.

Dosing Cefazolin for renal impairment: Clcr 35-54 mL/minute: Administer full dose in intervals of ≥8 hours , Clcr 11-34 mL/minute: Administer 1/2 usual dose every 12 hours , Clcr ≤10 mL/minute: Administer 1/2 usual dose every 18-24 hours Intermittent hemodialysis (IHD) (administer after hemodialysis on dialysis days): Dialyzable (20% to 50%): 0.5-1 g every 24 hours or use 1-2 g every 48-72 hours (Heintz, 2009); Note: Dosing dependent on the assumption of 3 times/week, complete IHD sessions. Alternatively, may administer 15-20 mg/kg (maximum dose: 2 g) after dialysis without regularly scheduled dosing (Ahern, 2003; Sowinski, 2001). Peritoneal dialysis (PD): 0.5 g every 12 hours, Continuous renal replacement therapy (CRRT) (Heintz, 2009; Trotman, 2005): Drug clearance is highly dependent on the method of renal replacement, filter type, and flow rate. Appropriate dosing requires close monitoring of pharmacologic response, signs of adverse reactions due to drug accumulation, as well as drug concentrations in relation to target trough (if appropriate). The following are general recommendations only (based on dialysate flow/ultrafiltration rates of 1-2 L/hour and minimal residual renal function) and should not supersede clinical judgment: CVVH: Loading dose of 2 g followed by 1-2 g every 12 hours,CVVHD/CVVHDF: Loading dose of 2 g followed by either 1 g every 8 hours or 2 g every 12

2-Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; Diphenhydramine (Benadryl and others) may be used to treat this adverse effect. Vancomycin levels should be monitored in patients with any renal impairment:

Renal impairment Clcr >50 mL/minute: Start with 15-20 mg/kg/dose (usual: 750-1500 mg) every 8-12 hours , Clcr 20-49 mL/minute: Start with 15-20 mg/kg/dose (usual: 750-1500 mg) every 24 hours , Clcr <20 mL/minute: Will need longer intervals; determine by serum concentration monitoring

3- No dosage adjustment required for renal impairment when using Clindamycin.

4- renal adjustment is recommended when using Cefoxitin: Clcr 30-50 mL/minute: Administer 1-2 g every 8-12 hours ,Clcr 10-29 mL/minute: Administer 1-2 g every 12-24 hours , Clcr 5-9 mL/minute: Administer 0.5-1 g every 12-24 hours, Clcr <5 mL/minute: Administer 0.5-1 g every 24-48 hours, Hemodialysis: Moderately dialyzable (20% to 50%); administer a loading dose of 1-2 g after each hemodialysis; maintenance dose as noted above based on Clcr. Continuous arteriovenous or venovenous hemodiafiltration effects: Dose as for Clcr 10-50 mL/minute

- Intravenous dose of an antimicrobial should start within 60 minutes before the initial skin incision. If Vancomycin or a fluoroquinolone is used, the infusion should begin 60-120 minutes before the incision to minimize the risk of antibiotic- associated reactions around the time of anesthesia induction and to ensure adequate tissue levels of the drug at the time of the initial incision.

References

Scottish Intercollegiate Guidelines Network, Antibiotic prophylaxis in surgery, July 2008.

Merck Manual Antibiotic Prophylaxis Guideline, June, 2010.

Treatment Guidelines from The Medical Letter, June 2009; Vol. 7 (82):47

6 .

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Operations Antibiotic prophylaxis Antibiotic Complex septorhinoplasty

(including grafts)

Recommended Cefazolin¹ 1–2 g IV preoperatively and q 8 h for 2 doses or Vancomycin² 1g IV. Or Clindamycin³600–900 mg IV ± gentamicin 1.5 mg/kg IV preoperatively and q 8 h for 2 doses

Tonsillectomy Not Recommended

Adenoidectomy (by curettage) Not Recommended Grommet insertion Single dose of topical

antibiotic is recommended

Cefazolin¹ 1–2 g IV preoperatively and q 8 h for 2 doses or Vancomycin² 1g IV. Or Clindamycin³600–900 mg IV ± Gentamicin 1.5 mg/kg IV preoperatively and q 8 h for 2 doses

Cleft lip and palate Recommended

Thorax

Breast cancer surgery Should be Considered Cefazolin¹1–2 g IV

preoperatively and q 6 h for 24 h Or Vancomycin² 1 g IV preoperatively Breast reshaping procedures Should be Considered

Breast surgery with implant (reconstructive or aesthetic)

Recommended Cardiac pacemaker insertion Recommended Open heart surgery Recommended Pulmonary resection Recommended Upper Gastrointestinal

Oesophageal surgery Recommended Cefazolin¹1–2 g IV

preoperatively

Or Clindamycin³600 mg plus Gentamicin 120 mg IV preoperatively Stomach and duodenal Surgery Recommended

Gastric bypass surgery Recommended Small intestine surgery Recommended Hepatobiliary

Bile duct surgery Recommended Cefazolin¹1–2 g IV

preoperatively or

Clindamycin³600 mg plus Gentamicin 120 mg IV preoperatively

Pancreatic surgery Recommended

Liver surgery Recommended

Gall bladder surgery (open) Recommended Gall bladder surgery

(laparoscopic)

Not Recommended, should be considered in high risk patients:

High risk: intraoperative cholangiogram, bile spillage, conversion to laparotomy, acute

cholecystitis/pancreatitis, jaundice, pregnancy, immunosuppression, insertion of prosthetic devices.

2 .

Recommended Indications for Surgical Antibiotic Prophylaxis to Prevent Surgical Site Infections (SSI).

Operations Antibiotic prophylaxis Antibiotic

Pyeloplasty Recommended Cefazolin¹1 g IV preoperatively

Surgery for vesicoureteric reflux (endoscopic or open)

Recommended Penile prosthesis insertion Recommended Orthopedic

Arthroplasty Highly Recommended

Antibiotic-loaded cement is recommended in addition to intravenous antibiotics

Cefazolin¹1–2 g IV preoperatively and q 6 h for 3 doses or Vancomycin² 1 g IV preoperatively

Open fracture Highly Recommended

Open surgery for closed fracture

Highly Recommended

Hip fracture Highly Recommended

Lower limb amputation Recommended Cefoxitin 2 g IV preoperatively and q 6 h for 4 doses

Vascular surgery(abdominal and lower limb arterial reconstruction)

Recommended Cefazolin¹1–2 g IV preoperatively and q 6 h for 24 h or Vancomycin² 1 g IV

preoperatively and 12 h after the procedure

Soft tissue surgery of the hand Should be Considered Non-Operative Interventions

Intravascular catheter insertion:

Non-tunnelled central venous catheter (CVC)

Not Recommended

Tunnelled central venous catheter (CVC)

Not Recommended General

Clean-contaminated

procedures –where no specific evidence is available

Recommended Cefazolin¹1–2 g IV preoperatively and q 6 h for 24 h

Or Vancomycin ² 1 g IV preoperatively and 12 h after the procedure

Insertion of a prosthetic device or implant –where no specific evidence is available

Recommended

5 .

Recommended Indications for Surgical Antibiotic Prophylaxis to Prevent Surgical

Site Infections (SSI).

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Operations Antibiotic prophylaxis Antibiotic Lower Gastrointestinal

Appendicectomy Highly Recommended Cefoxitin⁴ 1–2 g IV preoperatively, q 6 h for 3 doses or Metronidazole 500 IV mg plus Gentamicin 1.5 mg/kg IV preoperatively.

Colorectal surgery Highly Recommended Neomycin 1 g plus erythromycin base 1 g po at 1, 2, and 11 pm on the day before surgery ± Cefoxitin⁴, 1–2 g IV.

For emergency: Cefoxitin⁴ 1–2 g IV Abdomen

Hernia repair-groin (inguinal/femoral with or without mesh)

Not Recommended

Hernia repair-groin

(laparoscopic or incisional with or without mesh

Not Recommended

Open/laparoscopic surgery with mesh (eg gastric band or rectoplexy)

Not Recommended:

Antibiotic prophylaxis should be considered in high risk patients.

ASA score >3

Cefazolin¹1–2 g IV preoperatively or Clindamycin³ 600 mg plus

Gentamicin 120 mg IV preoperatively

Diagnostic endoscopic procedures

Not Recommended Therapeutic endoscopic

procedures(endoscopic retrograde

cholangiopancreatography and percutaneous endoscopic gastrostomy

Antibiotic prophylaxis should be considered in high Risk patients:

High risk: pancreatic pseudocyst,

immunosupression, incomplete biliary drainage (eg primary sclerosing cholangitis or cholangiocarcinoma)

Spleen

Splenectomy Not Recommended,

Antibiotic prophylaxis should be considered in high Risk patients:

High risk:

immunosuppression -vaccination against capsulated organisms is highly recommended).

3 .

Recommended Indications for Surgical A ntibiotic Prophylaxis to Prevent Surgical Site Infections (SSI).

Operations Antibiotic prophylaxis Antibiotic

Obstetrics and Gynecology

Abdominal hysterectomy Recommended Cefazolin¹1 g IV preoperatively and q 6 h for 2 doses. or Clindamycin³600 mg Vaginal hysterectomy Recommended

Caesarean section Highly Recommended Cefazolin¹1 g IV after clamping cord and q 6 h for 2 doses or Clindamycin³600 mg Assisted delivery Not Recommended

Perineal tear Recommended for

third/fourth degree perineal tears involving the anal sphincter/rectal mucosa

Cefazolin¹1 g IV preoperatively

Manual removal of the placenta Should be Considered Antibiotic prophylaxis is recommended for patients with proven chlamydia or gonorrhoea

Penicillin G 1–2 million units IV preoperatively and 3 h later or Doxycycline 100 mg po before the procedure and 200 mg 1/2 h afterward

Induced abortion Highly Recommended Cefazolin¹1 g IV preoperatively and q 6 h for 2 doses

Evacuation of incomplete miscarriage

NOT Recommended Intrauterine contraceptive device

(IUCD) insertion

NOT Recommended Urogenital

Circumcision (routine elective) NOT Recommended Hydrocoeles/hernia repair NOT Recommended Transrectal prostate biopsy Recommended

Cefazolin¹1 g IV preoperatively.

+ Ciprofloxacin 500 mg PO or 400 mg IV in case of bacteriuria.

Shock wave lithotripsy Recommended Percutaneous nephrolithotomy Antibiotic prophylaxis is

recommended for patients with stone ≥ 20 mm or with pelvicalyceal dilation Urosepsis, Oral quinolone for one week preoperatively is recommended.

Endoscopic ureteric stone fragmentation/removal

Recommended Transurethral resection of the

prostate

Highly Recommended Transurethral resection of bladder

tumours

NOT Recommended

Radical cystectomy Recommended Cefazolin¹1 g IV preoperatively

Cystoscopy Antibiotic prophylaxis is

NOT recommended, should be considered if there is a high risk of UTI

Cefazolin¹1 g IV preoperatively only if high risk of UTI.

Nephrectomy NOT Recommended 4