Surgical Antimicrobial Prophylaxis Clinical Guideline

Policy Classification: Public-I1-A2 Policy No.: CG269

Surgical Antimicrobial Prophylaxis

Clinical Guideline Version No: 2.0

Approval date: 2 November 2017

INFORMAL COPY WHEN PRINTED Surgical Antimicrobial Prophylaxis Clinical Guideline v2.0

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Contents

1. Guideline Statement .......................................................................................................................... 4

2. Roles and Responsibility ................................................................................................................. 4

2.1. Local Health Network (LHN) Chief Executive Officers will ........................................................... 4

2.2. LHN AMS Committees are responsible for ..................................................................................... 4

2.3. Prescribers (including contracted staff) are responsible for ....................................................... 4

2.4. Pharmacists (including contracted staff) are responsible for ...................................................... 5

2.5. Nurses are responsible for ............................................................................................................... 5

3. Policy Requirements ......................................................................................................................... 5

3.1. Background ....................................................................................................................................... 5

3.2. Recommendations ............................................................................................................................ 5

3.2.1. Practice Points .................................................................................................................................. 5

3.2.2. Drug administration .......................................................................................................................... 6

3.2.3. MRSA risk........................................................................................................................................... 6

3.2.4. Vancomycin administration ............................................................................................................. 6

3.2.5. Clindamycin administration ............................................................................................................. 6

3.2.6. Gentamicin administration ............................................................................................................... 6

3.2.7. Repeat doses ..................................................................................................................................... 6

3.2.8. Obese patients ................................................................................................................................... 6

4. Implementation and Monitoring ....................................................................................................... 6

5. National Safety and Quality Health Service Standards ................................................................. 7

6. Definitions .......................................................................................................................................... 7

7. Associated Directives / Guidelines & Resources .......................................................................... 8

7.1. SA Policies and guidelines ............................................................................................................... 8

7.2. References ......................................................................................................................................... 8

7.3. Appendices ........................................................................................................................................ 8

Appendix 1 Breast procedures / Endocrine procedures / Abdominal procedures (including

Splenectomy) / Herniorrhaphy/ Insertion of infusaport / Clean excision procedures

Appendix 2 Cardiac Surgery

Appendix 3 CVIU / Cardiology Procedures

Appendix 4 Prevention of Endocarditis

Appendix 5 Endoscopic Gastrointestinal Surgery

Appendix 6 Gastrointestinal Surgery

Appendix 7 Head and Neck Surgery Prophylaxis

Appendix 8 Maxillofacial Surgery

Appendix 9 Neurosurgery Prophylaxis


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Appendix 10 Obstetrics and Gynaecology Surgery

Appendix 11 Ophthalmology

Appendix 12 Orthopaedic Surgery (Joint Replacement)

Appendix 13 Orthopaedic Surgery (Not Joint Replacement)

Appendix 14 Plastic and Reconstructive Surgery

Appendix 15 Thoracic Surgery

Appendix 16 Urology

Appendix 17 Vascular Surgery

8. Document Ownership & History ...................................................................................................... 9


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Surgical Antimicrobial Prophylaxis Clinical Guideline

1. Guideline Statement

Surgical antimicrobial prophylaxis has become an accepted part of surgical practice to prevent

infections at the surgical site and optimise postoperative recovery. This Surgical Antimicrobial

Prophylaxis Guideline has been developed by SAAGAR to assist clinicians with recommendations

on appropriate antimicrobial dosage and administration, risks and contraindications, and

postoperative care for a range of surgical procedures.

The recommendations within this guideline are based on those published in the Australian

Therapeutic Guidelines, and are intended to allow for some variations for South Australian patient

demographics and resistance patterns.

2. Roles and Responsibility

The Surgical Antimicrobial Prophylaxis Clinical Guideline applies to surgery performed in all South Australian public hospitals.

2.1. Local Health Network (LHN) Chief Executive Officers will:

> ensure clinicians have access to this guideline in electronic format

> ensure adequate resources and training are available for the implementation of this

guideline throughout the LHN

> maintain an effective mechanism for review of implementation of this guideline within the

LHN

> ensure the LHN meets standards for accreditation in relation to surgical antimicrobial

prophylaxis.

2.2. LHN AMS Committees are responsible for:

> providing governance over the use of prophylactic antimicrobial agents in surgery

> providing leadership for addressing requirements of the LHN relating to meeting the

surgical prophylaxis national standards for accreditation

> working collaboratively with departments of surgery, anesthesiology, or other relevant

hospital committees regarding development and implementation of surgical guidelines

> coordinating actions in response to results of audits of antimicrobial use in surgical

prophylaxis

> providing leadership for the training of clinical staff throughout the LHN in relation to AMS.

2.3. Prescribers (including contracted staff) are responsible for:

> safe and appropriate prescribing according to the general principles of antimicrobial surgical

prophylaxis

> ensuring antimicrobials are ordered so that they are administered within appropriate time

frames as specified in individual surgical prophylaxis guidelines

> prescribing according to the appropriate surgical prophylaxis guideline (see appendices) or

using the latest version of Therapeutic Guidelines: Antibiotic as part of their practice (1).

> where prescribing is not compliant with guidelines, documenting the reason on the

medication chart or case notes


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> provision of information to patients and their carers regarding their antimicrobial therapy

prior to surgery.

2.4. Pharmacists (including contracted staff) are responsible for:

> timely and accountable supply of antimicrobials used in surgical prophylaxis in accordance

with systems introduced by the LHN AMS Program, including mechanisms to control

access to restricted antimicrobials where restrictions exist

> safe, appropriate and timely advice to prescribers and nurses with regard to the selection,

dose, route, duration and monitoring of antimicrobials used in surgical prophylaxis

> where it is within their scope of practice, participation in providing evidence of monitoring

antimicrobial use in relation to surgical prophylaxis through auditing processes

> provision of information to patients and their carers regarding their antimicrobial therapy

prior to surgery.

2.5. Nurses are responsible for:

> being aware of the existence of surgical prophylaxis guidelines for a range of surgical

specialties, and able to assist prescribers to access electronic guidelines

> where it is within their scope of practice, ensuring safe and timely administration of

prescribed antimicrobials used in surgical prophylaxis

> where it is within their scope of practice, participation in providing evidence of monitoring

antimicrobial use in relation to surgical prophylaxis through auditing processes

> assisting patients and carers to obtain information and understanding of their antimicrobial

therapy.

3. Policy Requirements

3.1. Background

Prevention of surgical site infection accounts for between one-third and one-half of all

antimicrobial use in Australian hospitals. AURA 2016: First Australian report on antimicrobial

use and resistance in human health found that surgical prophylaxis was the most common

reason for antimicrobial use in hospitals in 2014 (2) . Of this use, 40% was deemed

inappropriate due to long duration, incorrect dose, or frequency (3). This guideline aims to

standardise the prescribing of surgical antimicrobial prophylaxis across the state.

3.2. Recommendations

Antimicrobial prophylaxis should be considered where there is a clear indication, a risk of

postoperative infection, or if postoperative infection will have serious consequences.

The recommended antimicrobial prophylaxis regimens for specific surgical procedures, along

with alternatives for patients with a high risk of penicillin/cephalosporin allergy, are available in

appendices 1 to 17.

3.2.1. Practice Points

Consider individual risk factors for every patient – need for prophylaxis, drug choice or dose

may alter (e.g. immune suppression, presence of prostheses, allergies, obesity, malnutrition,

diabetes, infection at another site, available pathology or malignancy).

Pre-existing infections at surgical site (known or suspected) – if present, use appropriate

treatment regimen instead of prophylactic regimen for procedure. Doses should be scheduled

to allow for re-dosing just prior to skin incision.

For patients with cardiac conditions that increase their risk of endocarditis following surgery,

refer to Antibiotic Prophylaxis Guidelines for Prevention of Endocarditis for further information

https://www.sahealth.sa.gov.au/wps/wcm/connect/a39de780436f24c2b95cbff2cadc00ab/Surg-Ab-Prophylaxis-guideline-Appendix4%2BEndocarditis_v2.0-ics-cdcb-20171120.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-a39de780436f24c2b95cbff2cadc00ab-n5jrljk


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3.2.2. Drug administration

> IV bolus – should be timed ≤ 60 minutes before skin incision (optimal 15-30 minutes).

Administration after skin incision or > 60 minutes before incision reduces effectiveness

> IV infusion – should be commenced 30-60 minutes prior to skin incision (e.g.

metronidazole). See below for vancomycin administration.

3.2.3. MRSA risk

Defined as history of MRSA colonisation or infection, OR inpatient of high risk hospital or unit

(where MRSA is endemic) for more than the last 5 days; add vancomycin (see vancomycin

administration below).

3.2.4. Vancomycin administration

Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion started 30-120

minutes before surgical incision and given at a recommended rate of 1g per hour (1.5g over 90

minutes). Note: infusion can be completed after skin incision.

3.2.5. Clindamycin administration

Give clindamycin 600mg (child: 15mg/kg up to 600mg) by IV infusion over at least 20 minutes

just before procedure. Repeat 4 hourly intra-operatively for prolonged procedures.

3.2.6. Gentamicin administration

Dosing should be based on ideal body weight, provided ideal body weight is less than actual

body weight. (See Aminoglycosides: Recommendations for use, dosing and monitoring clinical

guideline)

3.2.7. Repeat doses

A single pre-operative dose is sufficient for most procedures; however, repeat intra-operative

doses are advisable:

> for prolonged surgery (> 4 hours from the time of the first pre-operative dose) when a short-

acting agent is used (e.g. cefazolin); or

> if major blood loss occurs, following fluid resuscitation.

3.2.8. Obese patients

Consider increased dose of cefazolin if patient is obese (>120kg). Consult ID for advice.

4. Implementation and Monitoring

Where they exist, LHN AMS committees coordinate actions in response to results of audits of

antimicrobial use in surgical prophylaxis. The results of annual audits or KPI assessments should

be reported to LHN Chief Executive Officers and LHN Safety and Quality committees, together with

a plan for continuous (PDSA) improvement.

http://www.sahealth.sa.gov.au/wps/wcm/connect/e4c8cb004877c5c3a295f67675638bd8/Aminoglycosides_01062017.pdf?MOD=AJPERES&CACHEID=e4c8cb004877c5c3a295f67675638bd8

http://www.sahealth.sa.gov.au/wps/wcm/connect/e4c8cb004877c5c3a295f67675638bd8/Aminoglycosides_01062017.pdf?MOD=AJPERES&CACHEID=e4c8cb004877c5c3a295f67675638bd8


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5. National Safety and Quality Health Service Standards

National Standard 1

Governance for Safety

and Quality in Health

Care

National Standard 2

Partnering with

Consumers

National Standard 3

Preventing &

Controlling Healthcare associated infections

National Standard 4

Medication Safety

National Standard 5

Patient Identification & Procedure

Matching

National Standard 6

Clinical Handover

National Standard 7

Blood and Blood

Products

National Standard 8

Preventing &

Managing Pressure Injuries

National Standard 9

Recognising & Responding to

Clinical Deterioration

National Standard 10

Preventing Falls &

Harm from Falls

☐ ☐ ☒ ☒ ☐ ☐ ☐ ☐ ☐ ☐

The following National Safety and Quality Health Service Standard (NSQHSS) standards apply:

Standard 3 – Preventing & Controlling Healthcare Associated Infections

> Criterion 3.14 – Developing, implementing and regularly reviewing the effectiveness of the

antimicrobial stewardship system.

Standard 4 – Medication Safety

> Criterion 4.1 – Developing and implementing governance arrangements and organisational

policies, procedures and/or protocols for medication safety, which are consistent with national

and jurisdictional legislative requirements, policies and guidelines.

6. Definitions

In the context of this document:

> KPI Key Performance Indicators

> IBW Ideal Body Weight

> ID Infectious Disease Physician

> IV Intravenous

> MRSA Methicillin-resistant Staphylococcus aureus

> PDSA Plan-Do-Study-Act

> PO Per oral

> SAAGAR South Australian expert Advisory Group on Antimicrobial Resistance (SAAGAR)

> SSI Surgical site infection

http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/NSQHS-Standards-Fact-Sheet-Standard-1.pdf





























































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7. Associated Directives / Guidelines & Resources

7.1. SA Policies and guidelines

Antimicrobial Stewardship Policy Directive

Antimicrobial Prescribing Clinical Guideline

Peripartum Prophylactic Antibiotics Clinical Guideline

7.2. References 1. Antibiotic Expert Writing Group. Therapeutic Guidelines: Antibiotic (version 15). Melbourne;

2014. 2. Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2016: first

Australian report on antimicrobial use and resistance in human health. . Sydney; 2016. 3. National Centre for Antimicrobial Stewardship, Australian Commission on Safety and Quality

in Health Care. Antimicrobial prescribing practice in Australian hospitals: Results of the 2015 National Antimicrobial Prescribing Survey. Sydney; 2016.

7.3. Appendices

Appendix 1 Breast procedures / Endocrine procedures / Abdominal procedures (including

Splenectomy) / Herniorrhaphy / Insertion of infusaport / Clean excision

procedures

Appendix 2 Cardiac Surgery

Appendix 3 CVIU / Cardiology Procedures

Appendix 4 Prevention of Endocarditis

Appendix 5 Endoscopic Gastrointestinal Surgery

Appendix 6 Gastrointestinal Surgery

Appendix 7 Head and Neck Surgery Prophylaxis

Appendix 8 Maxillofacial Surgery

Appendix 9 Neurosurgery Prophylaxis

Appendix 10 Obstetrics and Gynaecology Surgery

Appendix 11 Ophthalmology

Appendix 12 Orthopaedic Surgery (Joint Replacement)

Appendix 13 Orthopaedic Surgery (Not Joint Replacement)

Appendix 14 Plastic and Reconstructive Surgery Appendix

15 Thoracic Surgery

Appendix 16 Urology

Appendix 17 Vascular Surgery

https://www.sahealth.sa.gov.au/wps/wcm/connect/b7adf38046bc387fbf85bf2195233e2a/Directive_Antimicrobial+Stewardship_03082017.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-b7adf38046bc387fbf85bf2195233e2a-n5ihZyS

https://www.sahealth.sa.gov.au/wps/wcm/connect/b7adf38046bc387fbf85bf2195233e2a/Directive_Antimicrobial+Stewardship_03082017.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-b7adf38046bc387fbf85bf2195233e2a-n5ihZyS

https://www.sahealth.sa.gov.au/wps/wcm/connect/b8a4bc0046a9c844bc14feb0ec6dccc9/Guideline_Antimicrobial_Prescribing_V1.1_22.11.2018.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-b8a4bc0046a9c844bc14feb0ec6dccc9-n5i8zv.

https://www.sahealth.sa.gov.au/wps/wcm/connect/b8a4bc0046a9c844bc14feb0ec6dccc9/Guideline_Antimicrobial_Prescribing_V1.1_22.11.2018.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-b8a4bc0046a9c844bc14feb0ec6dccc9-n5i8zv.

http://www.sahealth.sa.gov.au/wps/wcm/connect/84d20f804ee559c1a8baadd150ce4f37/Peripartum%2Bprophylactic%2Bantibiotics_June2014.pdf?MOD=AJPERES&CACHEID=84d20f804ee559c1a8baadd150ce4f37


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8. Document Ownership & History

Document developed by: South Australian expert Advisory Group on Antimicrobial

Resistance (SAAGAR

File / Objective No.: 2011-10137 | eA988353

Next review due:

Policy history:

2/11/2022

Is this a new policy (V1)? N

Does this guideline amend or update and existing policy? Y

If so, which version? Version 1.1

Does this guideline replace another policy with a different title? N

If so, which guideline (title)?

Approval Date

Version Who approved New/Revised Version

Reason for Change

2/11/2017 V2 Safety & Quality Strategic Governance Committee

Formally reviewed in line with 1-5 year scheduled timeline for review.

12/08/14 V1.1 Safety & Quality Strategic Governance Committee

Minor amendments to reflect current practice.

12/02/13 V1 Safety & Quality Strategic Governance Committee

Original approved version.

Surgical Antibiotic Prophylaxis Guidelines Breastprocedures/Endocrineprocedures/Abdominalprocedures(includingSplenectomy)/

Herniorrhaphy/Insertionofinfusaport/Cleanexcisionprocedures

Pre-Operative Considerations

Consider individual risk factors for every patient – need for prophylaxis, drug choice or dose may alter (e.g. immune suppression, presence of

prostheses, allergies, obesity, malnutrition, diabetes, infection at another site, available pathology or malignancy).

Pre-existing infections (known or suspected) – if present, use appropriate treatment regimen instead of prophylactic regimen for procedure. Doses

should be scheduled to allow for re-dosing just prior to skin incision.

*For patients with cardiac conditions refer to Antibiotic Prophylaxis Guidelines for Prevention of Endocarditis for further information.

Practice Points

Drug administration

> IV bolus – should be timed 60 minutes before skin incision (optimal 30 minutes). Administration after skin incision or > 60 minutes before incision reduces effectiveness

> IV infusion – should be commenced 30-60 minutes prior to skin incision for metronidazole. See below for vancomycin administration.

MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of metropolitan or other high risk hospital for more than the last 5 days)

> Add vancomycin to cefazolin

Vancomycin administration

> Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion started 30-120 minutes before surgical incision and given at

a recommended rate of 1g per hour (1.5g over 90 minutes). Note: infusion can be completed after skin incision.

Repeat doses

A single pre-operative dose is sufficient for most procedures, however repeat intra-operative doses are advisable:

> for delayed or prolonged surgery (> 4 hours from the time of first preoperative dose) when a short-acting agent is used (e.g. amoxicillin, cefazolin), OR


Obese patients

> Consider increased dose of cefazolin (3g) if patient is obese (>120kg) .Consult ID for advice.

Recommended Prophylaxis

Recommended Prophylaxis *High risk

penicillin/cephalosporin allergy

Breast

Clean contaminated procedures

(microdochectomy, mastectomy,

reconstruction (incl. implants),

reduction, sentinel node biopsy,

re-operative surgery <6wks prior.

cefazolin 2g IV (child: 30mg/kg up to 2g)

High risk of MRSA infection:

ADD vancomycin 1g IV infusion (1.5g for patients > 80kg actual body weight)

vancomycin 1g IV infusion (1.5g for patients > 80kg

actual body weight)

Uncomplicated clean procedures

(wound revision, excision scar tissue,

local excision, lumpectomy).

Prophylaxis NOT recommended

Endocrine

Thyroidectomy (or similar)


Abdominal

Procedures involving viscera

(e.g. appendicectomy, division of

adhesions, resection)

metronidazole 500mg IV infusion (child:

12.5mg/kg),

PLUS either


OR

gentamicin 2mg/kg IV


ADD vancomycin 1g IV infusion (1.5g for

patients > 80kg actual body weight)

metronidazole 500mg IV infusion (child: 12.5mg/kg),

PLUS



ADD vancomycin 1g IV infusion (1.5g for patients

> 80kg actual body weight)

Procedures not involving viscera

(e.g. abdominoplasty)






actual body weight)

Splenectomy

(Vaccination and post-splenectomy

antibiotic prophylaxis required in all

cases)






actual body weight)

SA Health Clinical Guideline for Vaccination and Antimicrobial Prophylaxis for Adult Asplenic (Splenectomy) and Hyposplenic Patients available here.


https://www.sahealth.sa.gov.au/wps/wcm/connect/7d9c4800412ad856b9d6bfe8f09fe17d/Clinical_Guideline_Splenectomy_Vaccination+%26+Antimicrobial_Prophylaxis_v1.2_01.08.2019.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-7d9c4800412ad856b9d6bfe8f09fe17d-n5iLOmn




Herniorrhaphy

> with mesh insert





vancomycin 1g IV infusion (1.5g for patients >80kg

actual body weight)

> without mesh insert Prophylaxis NOT recommended

Other

Insertion of infusaport/other devices






actual body weight)

Clean excision procedures Prophylaxis NOT recommended

Post-Operative Care

Except where included above, post-operative antibiotics are NOT indicated unless infection is confirmed or suspected, regardless of the presence of

surgical drains.

If infection is suspected, consider modification of antibiotic regimen according to clinical condition and microbiology results.

Definitions / Acronyms

DRESS Drug rash with eosinophilia and systemic symptoms

ID Infectious Diseases

IV Intravenous

MRSA Methicillin-resistant Staphylococcus aureus

SJS / TEN Stevens-Johnson syndrome / Toxic epidermal necrolysis

* High Risk penicillin/cephalosporin allergy: History suggestive of high risk (eg. anaphylaxis, angioedema, bronchospasm, urticaria,

DRESS/SJS/TEN)

References

Antibiotic Expert Groups (2014). Therapeutic Guidelines: Antibiotic. Version 15. Melbourne, Therapeutic Guidelines Limited.

Bratzler, D, et al (2013). "Clinical practice guidelines for antimicrobial prophylaxis in surgery." Am J Health Syst Pharm 70 (3): 195-283.

Berrios-Torres, S., et al. (2017). "Centres for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection " JAMA Surgery May 3. doi: 10.1001/jamasurg.2017.0904. [Epub ahead of print].

Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) March 2012, Last reviewed and amended August 2017

SAAGAR has endeavored to ensure that the information in this publication is accurate; however it makes no representation or warranty to this effect.

You rely on this publication at your own risk. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or incurred

as a result of reliance on this publication. As the information in this publication is subject to review, please contact a medical or health professional

before using this publication.

October 2017

© Department for Health and Ageing, Government of South Australia.

All rights reserved.

Public – I1-A2

Surgical Antibiotic Prophylaxis Guidelines

Cardiac Surgery (adult)


prostheses, allergies, obesity, diabetes, remote infection, available pathology or malignancy).



Local epidemiology - modify prophylaxis if there is a high local incidence of specific infections.

Drug administration

> IV bolus – should be timed ≤ 60 minutes before skin incision (optimal 15 to 30 minutes). Commencing administration of any antibiotic after skin incision or completing administration of antibiotics > 60 minutes before incision reduces effectiveness.

> IV infusion – should be commenced 30-60 minutes prior to incision (e.g. gentamicin). See below for vancomycin administration.

MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of metropolitan or other high risk hospital for more than the last

five days)

> Add vancomycin to cefazolin (see vancomycin administration below).


> Give vancomycin 1g (1.5g for patients > 80kg actual body weight) started 30 to 120 minutes before surgical incision and given at a recommended rate of 1g per hour (1.5g over 90 minutes).

Gentamicin administration

Dosing should be based on ideal body weight, provided ideal body weight is less than actual body weight.

Repeat doses

A single pre-operative dose is sufficient for most procedures however repeat intra-operative doses (2g cefazolin) are advisable:

> for delayed or prolonged surgery (> 4 hours from the time of first preoperative dose) when a short-acting agent is used (e.g. cefazolin); OR

> if major blood loss occurs requiring fluid resuscitation.

Obese patients

> Consider increased dose of cefazolin (3g) if patient is obese (>120kg). Consult ID for advice.




Coronary Artery Bypass Surgery

(CABG)

cefazolin 2g IV before skin incision

THEN (post-operative)

cefazolin 2g IV 8-hourly for a further 2 doses

High risk of MRSA




actual body weight)

PLUS

gentamicin 5mg/kg IV (based on ideal body

weight)


vancomycin 1g IV infusion (1.5g for patients >

80kg actual body weight) 12 hours after first dose

Routine Cardiac Valve Surgery cefazolin 2g IV before skin incision

PLUS

vancomycin 1 g IV infusion (1.5g for patients >

80kg actual body weight)


cefazolin 2g IV 8-hourly for a further 2 doses


actual body weight)

PLUS


weight)



actual body weight) 12 hours after first dose

Practice Points





High Risk Cardiac Valve Surgery

Trans-catheter Aortic Valve

Implantation (TAVI)

cefazolin 2g IV before skin incision

PLUS depending on local epidemiology

consider additional

gentamicin 5mg/kg IV (based on ideal

body weight)

PLUS vancomycin 1 g IV infusion (1.5g for



cefazolin 2g IV 8-hourly for 3 further doses

(24 hours post-operatively)

vancomycin 1g IV infusion (1.5g for patients

> 80kg actual body weight) 12 hours after

first dose


actual body weight)

PLUS


weight)


vancomycin 1g IV infusion (1.5g for patients > 80kg actual body weight) 12 hours after first dose

Post-operative antibiotics (> 48 hours from first dose) are NOT indicated unless infection is confirmed or suspected, regardless of the presence of

surgical drains.


CABG Coronary Artery Bypass Graft



IV Intravenous



TAVI Trans-catheter Aortic Valve Implantation

* High Risk penicillin/cephalosporin allergy: History suggestive of high risk (e.g. anaphylaxis, angioedema, bronchospasm, urticaria,

DRESS/SJS/TEN)


Australian Injectable Drugs Handbook (2017) 7th

ed. Collingwood, VIC. (online)

Australian Medicines Handbook (2017). Adelaide, SA. (online)

Bratzler, D., E. P. Dellinger, K. M. Olsen, T. M. et al (2013). "Clinical practice guidelines for antimicrobial prophylaxis in surgery." Am J Health Syst

Pharm 70: 195-283.

Edwards, F., R. Engelman, P. Houck, D. Shahian and C. Bridges (2006). "The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic Prophylaxis in Cardiac Surgery, Part 1: Duration." Ann Thorac Surg 81: 397-404.

Engelman, R. M., D. Shahian, R. Shemin, T. S. Guy, D. Bratzler, F. H. Edwards, M. Jacobs, H. Fernando and C. Bridges (2007). "The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic Prophylaxis in Cardiac Surgery, Part 2: Antibiotic Choice." Ann Thorac Surg 83: 1569-1576.

Garcia, M. P. O., E. Marti-Bonmarti, J. G. Serrano and I. G. Gomez (2003). "Alteration of vancomycin pharmacokinetics during cardiopulmonary bypass in patients undergoing cardiac surgery." Am J Health Syst Pharm 60(Feb 1): 260-265.

Garey, K. W., T. Dao, H. Chen, P. Amritkar, N. Kumar, M. Reiter and L. O. Gentry (2006). "Timing of vancomycin prophylaxis for cardiac surgery patients and the risk of surgical site infections." Journal of Antimicrobial Chemotherapy 58: 645-650.

Haydon, TP., Presneill, JJ, Robertson, MS. (2010). "Antibiotic prophylaxis for cardiac surgery in Australia". Medical Journal of Australia 192 (3): 141-3

Frank, UK, Schmidt-Eisenlohr E, Mlangeni D, et al (1997). "Penetration of teicoplanin into heart valves and subcutaneous and muscle tissues of patients undergoing open-heart surgery". Antimicrobial Agents and Chemotherapy 41 (11): 2559-61.

Lador, A., Nasir, H, Mansur, N, Sharoni, E, Biderman, P, Leibovici, L, Paul, M. (2012). "Antibiotic prophylaxis in cardiac surgery: systematic review and meta-analysis. J Antimicrob Chemother 67: 541-50

Endorsed by South Australian expert Advisory Group on Antimicrobial Resistance (SAAGAR) March 2012, Last reviewed and amended August 2017. SAAGAR has endeavoured to ensure that the information in this publication is accurate; however it makes no representation or warranty to this effect. You rely on this publication at your own risk. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or incurred as a result of reliance on this publication. As the information in this publication is subject to review, please contact a medical or health professional before using this publication

October 2017

© Department for Health and Ageing, Government of South Australia.


Public – I1-A2

References


Post-Operative Care


CVIU / Cardiology Procedures






Practice Points

Drug administration


> IV infusion – should be commenced 30-120 minutes prior to incision (e.g.vancomycin). See vancomycin administration below.

MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of high risk hospital or unit (where MRSA is endemic) for more than the last 5 days)

> Add vancomycin to cefazolin (see vancomycin administration below)


> Give vancomycin 1g (1.5g for patients > 80kg actual body weight) starting the infusion 30 to 120 minutes before surgical incision and given at a recommended rate of 1g per hour (1.5g over 90 minutes)



Repeat doses

A single pre-operative dose is sufficient for most procedures; however, repeat intra-operative doses (2 g cefazolin) are advisable:

> for prolonged surgery (> 4 hours from the time of first preoperative dose) when a short-acting agent is used (e.g. cefazolin), OR

> if major blood loss occurs, following fluid resuscitation

Obese patients

Consider higher doses of cefazolin (3g) if patient morbidly obese (>120kg). Consult ID for advice.




Permanent pacemaker/defibrillator

insertion


PLUS

In patients with high MRSA risk, repeat

procedures, poor skin integrity, anticipated

difficult procedure, or recent (within last 3

months) antibiotic treatment:

ADD




actual body weight)

PLUS


Routine angioplasty, stent insertion


Valvuloplasty, septal occlusion for high risk patients only (e.g. femoral catheter > 6hrs, prosthetic valves, past history of endocarditis, atrial septal defect closure device insertion)

cefazolin 2g IV, then 8 hourly for up to 2 further

doses

PLUS




actual body weight)

PLUS


Post-Operative Care


surgical drains.


October 2017

© Department for Health and Ageing, Government of South Australia. All rights reserved.

Public – I1-A2


CVIU Cardiovascular investigational unit



IV Intravenous



* High Risk penicillin/cephalosporin allergy: History suggestive of high risk (eg. anaphylaxis, angioedema, bronchospasm, urticaria, DRESS/SJS/TEN)

References

Antibiotic Expert Group. Therapeutic Guidelines: Antibiotic, Version 15. Melbourne: Therapeutic Guidelines Limited; 2014

Baddour, LM et al. (2010). “AHA Scientific Statement: Update on Cardiovascular Implantable Electronic Device Infections and Their Management.” Circulation. 121:458-477.

Bratzler, D., E. P. Dellinger, K. M. Olsen, T. M. Perl, P. G. Auwaerter, M. K. Bolon, et al (2013). "Clinical practice guidelines for antimicrobial prophylaxis in surgery." Am J Health Syst Pharm 70: 195-283.

Darouiche, R., Mosier, M, Voigt, J. (2012). “Antibiotics and antiseptics to prevent infection in cardiac rhythm management device implantation surgery”. Pacing Clin Electrophysiol 35: 1348-60.

Karchmer, AW (2017). “Infections involving cardiac implantable electronic devices”..In: Calderwood, SB., and Ganz, LI (Eds), UpToDate, Waltham, MA. [www.uptodate.com]. Accessed Aug 2017

Korantzopoulos, P., Sideris, S, Dilaveris, P, Gatzoulis, K, Goudevenos, JA. (2016). “Infection control in implantation of cardiac implantable electronic devices: current evidence, controversial points, and unresolved issues”. Europace 18: 473-8.

Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) March 2012, Last reviewed and amended August 2017.

SAAGAR has endeavored to ensure that the information in this publication is accurate; however it makes no representation or warranty to this effect.

You rely on this publication at your own risk. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or incurred as a result of reliance on this publication. As the information in this publication is subject to review, please contact a medical or health professional before using this publication

http://www.uptodate.com/


NO


Prevention of Endocarditis or Infection of Prosthetic Implants or Grafts


Antibiotic prophylaxis to prevent endocarditis is ONLY recommended for patients with cardiac conditions associated with the HIGHEST RISK of

adverse outcomes from endocarditis (See Box 1) and only for certain conditions (See Box 2).

Box 1: Cardiac conditions for which antibiotic prophylaxis to prevent endocarditis is recommended.

> Prosthetic cardiac valve or prosthetic material used for cardiac valve repair

> Previous infective endocarditis

> Cardiac transplantation with the subsequent development of cardiac valvulopathy

> Rheumatic heart disease in Indigenous Australians and individuals at significant socioeconomic disadvantage

> Congenital heart disease, only if it involves:

i) unrepaired cyanotic defects, including palliative shunts and conduits;

ii) completely repaired defects with prosthetic material or devices, whether placed by surgery or catheter intervention, during the first six

months after the procedure (after which the prosthetic material is likely to have endothelialised);

OR

iii) repaired defects with residual defects at, or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation).

Box 2 Procedures where antibiotic prophylaxis for endocarditis may or may not be required

Prophylaxis ALWAYS REQUIRED CONSIDER prophylaxis Prophylaxis IS NOT REQUIRED

DENTAL PROCEDURES:

> extractions > periodontal procedures including surgery,

subgingival scaling and root planning > replanting avulsed teeth > other surgical procedures (e.g. implant

placement, apicoectomy).

RESPIRATORY PROCEDURES:

Any invasive procedure involving incision or biopsy of respiratory mucosa, for example:

> tonsillectomy/ adenoidectomy > surgery involving bronchial, sinus, nasal or

middle ear mucosa, including tympanostomy tube insertion.

GENITOURINARY AND GASTROINTESTINAL

PROCEDURES: Any procedure where antibiotic

prophylaxis is indicated for surgical reasons

> lithotripsy

> any genitourinary procedure in the presence

of a genitourinary infection unless already treating enterococci (for elective cystoscopy or urinary tract manipulations, obtain a urine culture and treat any bacteruria beforehand)

> any gastrointestinal procedure in the presence of an intra- abdominal infection unless already treating enterococci

> sclerotherapy for oesophageal varices.

OTHER PROCEDURES:

> Incision and drainage of local abscess: brain, boils and carbuncles, dacryocystitis, epidural, lung, orbital, perirectal, pyogenic liver, tooth, surgical procedures through infected skin.

> Percutaneous endoscopic gastrostomy

DENTAL PROCEDURES:

consider prophylaxis for

the following procedures if multiple procedures are being conducted, the procedure is prolonged, or periodontal disease is present:

> full periodontal probing for patients with periodontitis

> intraligamentary and intraosseous local and anaesthetic injection

> supragingival calculus removal or cleaning

> rubber dam placement with clamps (where risk of damaging gingiva)

> restorative matrix band/ > strip placement > endodontics beyond the apical

foramen > placement of orthodontic

bands or interdental wedges > subgingival placement of

retraction cords, antibiotic fibres or antibiotic strips

DENTAL PROCEDURES:

> oral examination > infiltration and block local

anaesthetic injection > restorative dentistry > supragingival rubber dam clamping

and placement of rubber dam > intracanal endodontic procedures

> removal of sutures > impressions and construction of

dentures > orthodontic bracket placement and

adjustment of fixed appliances > application of gels > intraoral radiographs > supragingival plaque removal

RESPIRATORY PROCEDURES:

> endotracheal intubation > rigid or flexible bronchoscopy with or

without incision or biopsy

GENITOURINARY AND

GASTROINTESTINAL PROCEDURES:

> urethral catheterisation, uterine dilatation and curettage, sterilization procedures, insertion or removal of intrauterine contraceptive device

> obstetric procedures > transoesophageal echocardiography > endoscopy (with or without

gastrointestinal biopsy including colonoscopy)

Antibiotic prophylaxis for

endocarditis NOT required.

Does the patient have any of the conditions listed in Box 1? YES

Antibiotic prophylaxis for endocarditis

MAY be required. See Box 2.

October 2017


Public – I1-A2

Practice Points

Clindamycin administration

> IV infusion – should be commenced 30-60 minutes prior to the procedure. Administer doses of 600mg over at least 20 minutes (maximum rate is 30mg/min)


> Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion started 30-120 minutes before the procedure at a recommended rate of 1g per hour (1.5g over 90 minutes).




Dental procedures amoxicillin 2g PO 1 hour prior to procedure clindamycin 600mg PO 1 hour prior to procedure

All other procedures amoxicillin 2g IV prior to procedure clindamycin 600mg by IV infusion

OR

vancomycin 1g IV infusion (1.5g > actual body

weight 80kg)



IV Intravenous

PO Per oral


* High Risk penicillin/cephalosporin allergy: History suggestive of high risk (e.g. anaphylaxis, angioedema, bronchospasm, urticaria,

DRESS/SJS/TEN)

References


Australian Injectable Drugs Handbook (2017) 7th

ed. Collingwood, VIC (online).


Glenny AM, Oliver R, Roberts GJ,et al (2013). "Antibiotics for the prophylaxis of bacterial endocarditis in dentistry". Cochrane Database of Systematic

Reviews, Issue 10. Art. No.: CD003813. DOI: 10.1002/14651858.CD003813.pub4.

Habib G., Lancelotti P, Antunes MJ, et al (2015). "ESC Guidelines for the management of infective endocarditis: The Task Force for the Management

of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the

European Association of Nuclear Medicine (EANM)". Eur Heart J. 36:3075-128

Nishimura, RA., Otto CM, Bonow RO, et al (2017). " AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With

Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am

Coll Cardiol 70 (2): 252-89.

Sexton DJ., Chu VH (2017). "Antimicrobial prophylaxis for bacterial endocarditis". In: Otto, C (ed), UpToDate, Waltham, WA. [www.uptodate.com] Accessed Nov 2015

Wilson, W., Taubert KA, Gewitz M, et al (2007). " Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group". Circulation 116 (15): 1736-54.


SAAGAR has endeavoured to ensure that the information in this publication is accurate; however, it makes no representation or warranty to this effect.

You rely on this publication at your own risk. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or incurred

as a result of reliance on this publication. As the information in this publication is subject to review, please contact a medical or health professional

before using this publication.



Endoscopic Gastrointestinal Procedures





For patients with cardiac conditions refer to Antibiotic Prophylaxis Guidelines for Prevention of Endocarditis for further information.

Drug administration


> IV infusion – should be commenced 30-60 minutes prior to incision (e.g. metronidazole). See below for vancomycin administration.

MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of metropolitan or other high risk hospital for more than the last five days)



> Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion started 30-120 minutes before surgical incision and given at a recommended rate of 1g per hour (1.5g over 90 minutes). Note: infusion can be completed after skin incision.


> Dosing should be based on ideal body weight, provided ideal body weight is less than actual body weight.

Repeat doses

A single pre-operative dose is sufficient for most procedures; however, repeat intra-operative doses (2g cefazolin) are advisable:



Obese patients

> Consider increased dose (3g) of cefazolin if patient is obese (>120kg). Consult ID for advice




Percutaneous Endoscopic

Gastrostomy/Jejunostomy

(PEG/PEJ) insertion/revision


High risk of MRSA :





Endoscopic Retrograde

Cholangiopancreatography (ERCP)

(For patients with a high risk of

infection, e.g. known or suspected

biliary obstruction, biliary sepsis,

pancreatic pseudocyst)


OR


PLUS consider adding


12.5mg/kg up to 500mg)

High risk of MRSA :




PLUS consider adding



High risk of MRSA :

ADD vancomycin 1g IV infusion (1.5g for patients >


Endoscopic ultrasound-guided

fine-needle aspiration



PLUS


High risk of MRSA :





PLUS


High risk of MRSA :

ADD vancomycin 1g IV infusion (1.5g for patients


All other procedures

(with or without biopsy), e.g.

> endoscopy > colonoscopy

> sigmoidoscopy > sclerotherapy

> oesophageal dilatation


Practice Points



Public – I1-A2


surgical drains

If infection is suspected, consider modification of antibiotic regimen accordingly to clinical condition and microbiological results.


ID Infectious diseases

IV Intravenous



* High Risk penicillin/cephalosporin allergy: History suggestive of high risk (eg. anaphylaxis, angioedema, bronchospasm, urticaria, DRESS/SJS/TEN)


ASGE Standards of Practice Committee, Khashab, MA, Chithadi, KV, et al (2015). “Antibiotic prophylaxis for GI endoscopy”. Gastrointestinal

Endoscopy 81(1): 81-9.

Bratzler, D., E. P. Dellinger, K. M. Olsen, T. M. Perl, P. G. Auwaerter, M. K. et al (2013). "Clinical practice guidelines for antimicrobial prophylaxis in

surgery." Am J Health Syst Pharm 70: 195-283.

Meyer GW. (2017). “Antibiotic prophylaxis for gastrointestinal endoscopic procedures”. In: Saltzman JR (Ed), UpToDate, Waltham, MA.

[www.uptodate.com]. Accessed Aug 2017.

Endorsed by South Australian expert Advisory Group on Antimicrobial Resistance (SAAGAR) March 2012, Last reviewed and amended August 2017.

SAAGAR has endeavoured to ensure that the information in this publication is accurate; however it makes no representation or warranty to this effect.

You rely on this publication at your own risk. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or incurred as a result of reliance on this publication. As the information in this publication is subject to review, please contact a medical or health professional before using this publication

October 2017


References


Post-Operative Care




Gastrointestinal Surgery

June 2020 Public - I4 - A2

© Department for Health and Wellbeing Government of South Australia.




prostheses, allergies, renal function, obesity, diabetes, remote infection, available pathology or malignancy).

Pre-existing infections (known or suspected) – if present, use appropriate treatment regimen instead of prophylactic regimen for procedure.

Doses should be scheduled to allow for re-dosing just prior to skin incision.

Practice Points

Drug administration

> IV bolus – should be administered no more than 60 minutes before skin incision (optimal 15 to 30 minutes). Commencing administration of any antibiotic after skin incision or completing administration of antibiotics more than 60 minutes before incision reduces effectiveness.

> IV infusion – should be commenced 30-60 minutes prior to incision (e.g. metronidazole). See below for vancomycin administration.

MRSA risk (defined as history of MRSA colonisation or infection OR frequent stays or a current prolonged stay in a hospital with a high prevalence of MRSA OR residence in an area or aged care facility with high prevalence of MRSA)

> Add vancomycin (see vancomycin administration below)


> For adult patients, give vancomycin 1g (1.5g for patients >80kg actual body weight) started 30 to 120 minutes before surgical incision and given at a recommended rate of 1g per hour (1.5g over 90 minutes). Note: infusion can be completed after skin incision.


> Dosing should be based on ideal body weight, provided ideal body weight is less than actual body weight. If the patient is obese (for adults, body mass index 30 kg/m

2 or more), use adjusted body weight to calculate the gentamicin dose.

Repeat doses


> for prolonged surgery (more than 4 hours from the time of first preoperative dose) when a short-acting agent is used (e.g. cefazolin), OR

> if major blood loss occurs (e.g.more than 1500mL in adults), following fluid resuscitation

Patients receiving antibiotic treatment for established infection prior to surgery

> It is not necessary to give additional antibiotic prophylaxis, provided the treatment regimen has activity against the organism(s) most likely to cause postoperative infection. However, adjust the timing of the treatment dose to achieve adequate plasma and tissue concentrations at the time of surgical incision and for the duration of the procedure—seek advice from ID or the AMS team if unsure.

Obese patients

> Consider increased dose of cefazolin (3g) if patient obese (more than 120kg). Consult ID/AMS team for advice.


Surgery Recommended Prophylaxis High Risk Penicillin /

Cephalosporin allergy*

Gastroduodenal and oesophageal

Non-endoscopic procedures that enter the GI

tract lumen or Non-endoscopic procedures that

do not enter the GI lumen but the patient has risk

factors for post-op infection (morbid obesity,

gastric outlet obstruction, reduced gastric

acidity/motility, GI bleeding, malignancy or

perforation) i.e. gastric bypass, resection, ulcer

oversew, oesophagectomy


High risk of MRSA :

ADD vancomycin 1g IV infusion (1.5g for patients more than 80kg actual body weight) (child: 30mg/kg up to 1.5g)


PLUS

vancomycin 1g IV infusion (1.5g for

patients more than 80kg actual body

weight)(child: 30mg/kg up to 1.5g)

Biliary (including laparoscopic procedures)

Open cholecystectomy or laparoscopic surgery where the patient has risk factors for postoperative infection (e.g. older than 70 years, diabetes, obstructive jaundice, common bile duct stones, acute cholecystitis, non-functioning gallbladder)


High risk of MRSA :


patients more than 80kg actual body weight)

(child: 30mg/kg up to 1.5g)


PLUS

vancomycin 1g IV infusion (1.5g for

patients more than 80kg actual body

weight) (child: 30mg/kg up to 1.5g)

Small intestinal

Nonendoscopic small intestinal procedures


If the small intestine is obstructed:

ADD metronidazole 500mg IV infusion (child:


High risk of MRSA :





PLUS



High risk of MRSA :


patients more than 80kg actual body wt)



Gastrointestinal Surgery

June 2020 Public - I4 - A2

© Department for Health and Wellbeing Government of South Australia.


Stoma cefazolin 2g IV (child: 30mg/kg up to 2g)

PLUS

metronidazole 500mg IV infusion (child: 12.5mg/kg up to 500mg)

High risk of MRSA :



PLUS



High risk of MRSA :

ADD vancomycin 1g IV infusion (1.5g for patients more than 80kg actual body wt) (child: 30mg/kg up to 1.5g)

Colorectal

Nonendoscopic colorectal procedures i.e. colon

resection, revision of anastomosis etc.

Pancreatic

Whipple’s procedure, pancreatic necrosectomy

Liver resection

Exploratory laparotomy/division of adhesions


PLUS


High risk of MRSA :



PLUS



High risk of MRSA :




Appendicectomy

All appendicectomy procedures, including

laparoscopic appendicectomy


PLUS



High risk of MRSA :





PLUS



High risk of MRSA :




Hernia repair with or without mesh insertion


If entry into the bowel lumen is expected:

ADD metronidazole 500mg IV infusion (child:


High risk of MRSA:


vancomycin 1g IV (1.5g for patients

more than 80kg actual body weight)


OR

If entry into the bowel lumen is expected

give INSTEAD:



PLUS


High risk of MRSA:




* High risk penicillin/cephalosporin allergy as suggested by history of anaphylaxis, angioedema, bronchospasm, urticaria, DRESS/SJS/TEN.

Post-Operative Care


surgical drains. If infection is suspected, consider modification of antibiotic regimen accordingly to clinical condition and microbiological results.



GI Gastrointestinal


IV Intravenous



References

Antibiotic Expert Group (2019). Therapeutic Guidelines: Antibiotic, Version 16. Melbourne: Therapeutic Guidelines Limited. Anderson DJ., Sexton DJ. (2017). “Control measures to prevent surgical site infection following gastrointestinal procedure in adults”. In: Harris A (Ed), UpToDate. Waltham, MA. [www.uptodate.com]. Accessed Aug 2017 Bratzler, D, et al (2013). "Clinical practice guidelines for antimicrobial prophylaxis in surgery." Am J Health Syst Pharm 70 (3): 195-283. Jafri, NS., Mahid, SS, Minor, KS, et al. (2007). “Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous endoscopic gastrostomy”. Aliment Pharmacol Ther 25 (6): 647. Tacconelli, E., et al. (2009). "Antibiotic usage and risk of colonisation and infection with antibiotic-resistant bacteria: A hospital population-based study." Antimicrob Agents Chemother 53(10): 4264-4269. Tosas, A., et al. (2018). "Frequent undetected ward-based methicillin-resistant Staphylococcus aureus transmission linked to patient sharing between hospitals." Clin Inf Dis 66(6): 840-848.

Endorsed by South Australian Medicines Advisory Committee, April 2020 The SA expert Advisory Group on Antimicrobial Resistance (SAAGAR) has endeavoured to ensure that the information in this publication is accurate; however, it makes no representation or warranty to this effect. You rely on this publication at your own risk. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or incurred as a result of reliance on this publication. As the information in this publication is subject to review, please contact a medical or health professional before using this publication.


Otorhinolaryngology / Head & Neck Surgery


Prophylaxis is not indicated for intra-oral procedures: dentoalveolar surgery (extractions, impactions, exposures); minor pathology (soft tissue,

cysts).





*For patients with cardiac conditions refer to Antibiotic Prophylaxis Guidelines for Prevention of Endocarditis for further information

Practice Points

Drug administration

> IV bolus – should be timed 60 minutes before skin incision (optimal 30 minutes) [1]. Administration after skin incision or > 60 minutes before incision reduces effectiveness.

> IV infusion – should be timed to end ≤ 30 minutes before skin incision (e.g. see clindamycin below)

MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of high risk hospital or unit (where MRSA is endemic) for more than the last five days)

> Add vancomycin to cefazolin (see vancomycin administration below).


> Give clindamycin 600mg (child: 15 mg/kg up to 600mg) by IV infusion over at least 20 minutes, timed to end just before procedure. Repeat 4 hourly intra-operatively for prolonged procedures.


> Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion started 30-120 minutes before surgical incision and given at a recommended rate of 1g per hour (1.5g over 90 minutes). Note: infusion can be completed after skin incision.

Repeat doses




Obese patients





No incision through mucosal (oral,

nasal, pharyngeal, oesophageal)

surface


High risk of MRSA :


clindamycin 600mg IV infusion (child: 15mg/kg up to

600mg)

High risk of MRSA :


With incision through mucosal (oral,

nasal, pharyngeal, oesophageal)

surface


PLUS



High risk of MRSA :


clindamycin 600mg IV infusion (child: 15mg/kg up

to 600mg

High risk of MRSA :


Other uncomplicated or minor clean

procedures (e.g. tonsillectomy,

adenoidectomy, typanostomy, nasal

septoplasty, endoscopic sinus

surgery, uncontaminated neck

dissection)


Post-Operative Care


surgical drains



October 2017


Public – I1-A2




IV Intravenous




DRESS/SJS/TEN)

References

Anderson DJ., Sexton DJ.(2017). “Antimicrobial prophylaxis for prevention of surgical site infection in adults”. In: Harris A (Ed), UpToDate,

Waltham, MA. [www.uptodate.com]. Accessed Aug 2017


Expert Group Antibiotics. Therapeutic Guidelines: Antibiotic (2014)

Ottoline, ACX., Tomita, S., et al. (2013). “Antibiotic prophylaxis in otolaryngologic surgery”. Otorhinolaryngol 17(1):85-91.


SAAGAR has endeavored to ensure that the information in this publication is accurate; however, it makes no representation or warranty to this

effect.

You rely on this publication at your own risk. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or

incurred as a result of reliance on this publication. As the information in this publication is subject to review, please contact a medical or health

professional before using this publication.



Oral and Maxillofacial Surgery


Prophylaxis is not indicated for intra-oral procedures: dentoalveolar surgery (extractions, impactions, exposures); minor pathology (soft tissue, cysts).






Practice Points

Drug administration


> IV infusion – should be commenced 30-60 minutes prior to skin incision (e.g. metronidazole, clindamycin). See below for vancomycin administration.


> Add vancomycin (see vancomycin administration below).


> Give vancomycin 1g (1.5g for patients > 80kg actual body weight) started 30 to 120 minutes before surgical incision and given at a recommended rate of 1g per hour (1.5g over 90 minutes). Note: Infusion can be completed after skin incision.


> Give clindamycin 600mg (child: 15 mg/kg up to 600mg) by IV infusion over at least 20 minutes just before procedure. Repeat 4 hourly intra- operatively for prolonged procedures.

Repeat doses




Obese patients





Orthognathic surgery benzylpenicillin 1.2g IV (child < 12 years:

30mg/kg up to 1.2g)

THEN (for procedures greater than 2 hours

duration)

Repeat dose 2-hourly intra-operatively

clindamycin 600mg IV infusion (child: 15mg/kg up to

600mg)

Skin approach procedures

(oral cavity not involved)

cefazolin 2g IV (child < 12 years: 30mg/kg up

to 2g)

clindamycin 600mg (child: 15mg/kg up to 600mg) by

IV infusion, then 8-hourly for 24 hours

Skin approach procedures

(with concurrent oral cavity

involvement)


to 2g)

PLUS

metronidazole 500mg IV infusion (child < 12

years:12.5mg/kg up to 500mg) before incision,

then 12-hourly for 24 hours



Implants (1st stage) benzylpenicillin 1.2g IV (child < 12 years:

30mg/kg up to 1.2g) before incision

THEN 2-hourly intra-operatively (for procedures

greater than 2 hours duration)

clindamycin 600mg (child: 15mg/kg up to 600mg) by IV infusion





Trauma

Intraoral compound operation

(injury of any age, compound to

nose/skin/sinuses)

benzylpenicillin 1.2g IV infusion (child < 12

years: 30mg/kg up to 1.2g) at presentation, then

4-hourly for 48 hours

PLUS


12.5mg/kg up to 500mg) at presentation, then

12-hourly for 48 hours

clindamycin 600mg (child: 15mg/kg up to 600mg) by IV infusion, then 8-hourly for 48 hours

Skin approach with concurrent

oral cavity involvement

(reconstructive surgery with ORIF

or bone graft placement)


to 1g), then 8-hourly for 24 hours

PLUS


12.5mg/kg up to 500mg), then 12-hourly for

24 hours



Post-Operative Care


surgical drains

If infection is suspected, consider modification of antibiotic regimen according to clinical condition and microbiological results.




IV Intravenous




DRESS/SJS/TEN)

References

Anderson, DJ., Sexton,DJ. (2017). "Antimicrobial prophylaxis for prevention of surgical site infection in adults." In: Harris, A (ed). UptoDate. Waltham,

MA.[www.uptodate.com]. Accessed Aug2017.

Antibiotic Expert Group. (2014). Therapeutic Guidelines: Antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited


Berrios-Torres, S., et al. (2017). "Centres for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection " JAMA Surgery

May 3. doi: 10.1001/jamasurg.2017.0904. [Epub ahead of print].



effect.






Neurosurgery







Practice Points

Wound irrigation

> Antibiotic solutions should NOT be used to irrigate the wound during surgery

Drug administration


> IV infusion – vancomycin infusion should be commenced 30-120 minutes prior to incision. See vancomycin administration below.




> Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion started 30-120 minutes before surgical incision and given at a recommended rate of 1g per hour (1.5g over 90 minutes). Note: Infusion can be completed after skin incision.

Repeat doses

A single pre-operative dose is sufficient for most procedures; however, repeat intra-operative doses are advisable:



Obese patients





Craniotomy procedures

Trans-sphenoidal procedures

Spinal procedures (laminectomy)

CSF shunt / drain procedures

External ventricular drain shunt

cefazolin 2g IV(child: 30mg/kg up to 2g)

High risk of MRSA :



actual body weight)

Other minor clean procedures Prophylaxis NOT recommended

Post-Operative Care


surgical drains



CSF Cerebrospinal fluid



IV Intravenous




DRESS/SJS/TEN)


October 2017


Public – I1-A2

References

Anderson, DJ., Sexton, DJ. (2017). “Antimicrobial prophylaxis for prevention of surgical site infection in adults”. In: Harris, A (ed). UptoDate. Waltham, MA.


Antibiotic Expert Group (2014). Therapeutic Guidelines: Antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited.

Bratzler, D., E. P. Dellinger, K. M. Olsen, T. M. Perl, P. G. Auwaerter, M. K. et al. “Clinical practice guidelines for antimicrobial prophylaxis in surgery”. Am J Health

Syst Pharm 2013; 70: 195-283.



effect.







Obstetrics / Gynaecology






Before hysterectomy – screening for and treating bacterial vaginosis (BV) reduces BV-associated cuff infection.

Before surgical termination of pregnancy – screening for and treating Chlamydia trachomatis and BV reduces infectious complications.

Practice Points

Drug administration


> IV infusion – should be commenced 30-60 minutes prior to skin incision (e.g. metronidazole, clindamycin). See below for vancomycin administration.




> Give clindamycin 600mg (child: 15mg/kg up to 600mg) by IV infusion over at least 20 minutes just before procedure. Repeat 4 hourly intra- operatively for prolonged procedures.





Repeat doses




Obese patients





Hysterectomy, laparotomy

procedures, vaginal repair

cefazolin 2g IV 15-30 mins prior to incision

PLUS either (for vaginal hysterectomy)

metronidazole 500mg IV infusion

OR

tinidazole 2g PO as a single dose (6-12hrs

prior to incision)

High risk of MRSA:

Add cefazolin with vancomycin 1g IV infusion (1.5g for patients > 80kg actual body weight)

clindamycin 600mg IV infusion

PLUS

gentamicin 2 mg/kg IV

High risk of MRSA:

Replace clindamycin with vancomycin 1g IV infusion (1.5g for patients > 80kg actual body weight)

Caesarean section cefazolin 2g IV 15-30 mins prior to incision

High risk of MRSA:

Add cefazolin with vancomycin 1g IV infusion (1.5g for patients > 80kg actual body weight)

clindamycin 600mg IV infusion

PLUS


High risk of MRSA:

Replace clindamycin with vancomycin 1g IV infusion (1.5g for patients > 80kg actual body weight)

Endoscopic procedures, IUD

insertion, early suction termination,

other minor procedures


October 2017


Public – I1-A2


Recommended Prophylaxis *High risk penicillin/cephalosporin

allergy

Surgical termination of

pregnancy

doxycycline 400mg PO as a single dose (1hr prior to procedure

OR

azithromycin 1g PO (1hr prior to procedure)

Later term termination As for hysterectomy (see on previous page)

Post-Operative Care


surgical drains


Additional notes

Caesarian section: Traditionally administration of antibiotics after the cord is clamped has been common practice to avoid exposing the neonate to

antibiotics. However, recent studies have shown lower surgical site infection rates, without compromising neonatal outcome, if prophylaxis is

administered before skin incision.




IV Intravenous




DRESS/SJS/TEN)

References

Antibiotic Expert Group. (2014). Therapeutic Guidelines: Antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited.

Berghella V. Cesarean delivery: Preoperative issues. In: Lockwood C (Ed), UpToDate, Waltham, MA. [www.uptodate.com] Accessed Nov 2015


The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2016). “Prophylactic antibiotics in obstetrics and gynaecology”

[https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG- MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical%20-

%20General/Prophylactic-antibiotics-in-obstetrics-and-gynaecology- (C-Gen-17)-Review-July-2016.pdf?ext=.pdf]

South Australian Perinatal Practice Guidelines Workgroup (2015). “South Australian Perinatal Practice Guidelines: Peripartum prophylactic

antibiotics”. Adelaide: SA Health. [Available at:

www.sahealth.sa.gov.au/wps/wcm/connect/84d20f804ee559c1a8baadd150ce4f37/Peripartum+prophylactic+antibiotics_June2014.pdf?MOD=AJPE

RES&CACHEID=84d20f804ee559c1a8baadd150ce4f37]. Accessed Aug2017.

Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) May 2017, Last reviewed and amended August 2017


effect.





http://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-





Ophthalmology






Practice Points

Drug administration

> IV bolus – should be timed 60 minutes before skin incision (optimal 30 minutes) [1]. Administration after skin incision or > 60 minutes before incision reduces effectiveness [2].

> IV infusion – should be timed to end ≤ 30 minutes before skin incision (e.g. see clindamycin below)


> See recommended prophylaxis


> Give clindamycin 600mg (child: 10mg/kg up to 450mg) single dose IV infusion at a rate ≤ 30mg/minute. The IV infusion should be timed to end ≤ 30 minutes before skin incision.

Obese patients

> Consider increased dose of cefazolin (3g) if patient is obese (>120kg) .




All procedures Pre-operatively: Immediately prior to surgical incision, apply sterile povidone-iodine 5% swab to

conjunctival cul de sac, lid margins and periorbital skin and dry at 2 minutes. In patients with a povidone

iodine (Betadine®) allergy, use a sterile product containing chlorhexidine acetate 0.05% for 5 minutes

[3].

Extra-ocular procedures

Clean procedures

> conjunctival procedures

> rectus / oblique muscle

procedures

> entropion / ectropion repair

There is no strong evidence that IV prophylactic antibiotics improve outcomes for clean extra-ocular

procedures in otherwise healthy individuals. If required, use:



REPLACE cefazolin with clindamycin 600mg IV

infusion

clindamycin 600mg IV infusion (child: 10mg/kg up

to 450mg)

Procedures where infection may

be present

(e.g. Dacryocystorhinostomy)

No strong evidence for IV prophylaxis (as above).

Chloramphenicol 0.5% eye drops four times a day post-operatively for 7 days. [4]

Intra-ocular procedures

Anterior procedures

> phacoemulsification / lens

implant

> keratoplasty

> trabeculectomy / tube implant

> corneal graft

cefazolin 1mg/0.1ml intracameral injection at

the end of the procedure

PLUS

chloramphenicol 0.5% eye drops four times

a day post-operatively for one week

OR, if chloramphenicol contraindicated then:

tobramycin 0.3% eye drops four times a day

post-operatively for one week

Seek ID advice:

Intracameral moxifloxacin 0.5% (available by SAS

only) may be considered as an alternative to

ceftazidime / cephazolin based on evidence

presented in a meta-analysis of non-randomised

studies [5, 6].

Intracameral vancomycin is not recommended due to

the risk of haemorrhagic occlusive retinal vasculitis

[7].

Vitreous procedures

> retinal detachment repair

> scleral buckle

> cryotherapy

ceftazidime 2.25 mg/0.1 mL subconjunctival

injection at the end of the procedure

PLUS

chloramphenicol 0.5% eye drops four times

a day post-operatively for one week

OR if chloramphenicol contraindicated then:

tobramycin 0.3% eye drops four times a day

post-operatively for one week

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Post-Operative Care

There is a lack of strong evidence to support the use of post-operative topical antibiotics [4]. Prolonged treatment with antibiotic ointment or drops is

not indicated unless there is confirmed or suspected infection. For patients who are treated with extended periods of topical steroids or who have

been treated with systemic steroids preoperatively, immunological defenses may be reduced and the risk of infection may be increased [9]. If post-

operative topical antibiotics are considered necessary due to higher risk of infection, chloramphenicol 0.5% eyedrops can be used four times daily

for 7 days [4]. Tobramycin eyedrops should only be used in patients hypersensitive to chloramphenicol due to an increased risk of resistance [4].




IV Intravenous




DRESS/SJS/TEN)

References

1. Bratzler, D., et al., Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm, 2013. 70(Feb 1): p. 195 -283.

2. Weber, W.P.M.D., et al., The Timing of Surgical Antimicrobial Prophylaxis. Annals of Surgery, 2008. 247(6): p. 918-926.

3. Merani, R., et al., Aqueous chlorhexidine for intravitreal injection antisepsis: a case series and review of the literature Ophthalmology 2016. 123: p. 2588-94.

4. Therapeutic Guidelines: Antibiotic, Surgical prophylaxis for ophthalmic surgery. 2014: Melbourne [Available at: www.tg.org.au].

5. Kessel, L., et al., Antibiotic prevention of postcataract endophthalmitis: a systematic review and meta-analysis. Acta Ophthalmologica, 2015. 93(4): p. 303-317.

6. Zhou, A.X., et al., Safety of undiluted intracameral moxifloxacin without postoperative topical antibiotics in cataract surgery. International Ophthalmology, 2016. 36(4): p. 493-8.

7. Miller, M.A., et al., Postoperative hemorrhagic occlusive retinal vasculitis associated with intracameral vancomycin prophylaxis during cataract surgery. Journal of Cataract & Refractive Surgery, 2016. 42(11): p. 1676-1680.

8. Gurusamy, K.S., et al., Antibiotic prophylaxis for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) related complications in surgical patients. Cochrane Database of Systematic Reviews, 2013(8): p. CD010268.

9. Aronson, J., Meyler's Side Effects of Drugs (16th edition). 2016, Elsevier Science & Technology: Oxford, UK.

Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) May 2017, Last reviewed and amended August 2017

SAAGAR has endeavored to ensure that the information in this publication is accurate; however it makes no representation or warranty to this

effect.




http://www.tg.org.au/


Orthopaedic Surgery (Joint Replacement)



prostheses, allergies, obesity, diabetes, remote infection, available pathology or malignancy)


should be scheduled to allow for re-dosing just prior to skin incision

Practice Points

Drug administration


> IV infusion – should be commenced 30-120 minutes prior to skin incision. See below for vancomycin administration.

MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of high risk hospital or unit (where MRSA is endemic) for more than the

last five days)



> Give vancomycin 1g (1.5g for patients > 80kg actual body weight) started 30 to 120 minutes before surgical incision and given at a recommended rate of1g per hour (1.5g over 90 minutes). Note: Infusion can be completed after skin incision.

Repeat doses




Obese patients


Duration of prophylaxis should not exceed 24hrs, irrespective of presence of drains or catheters




Primary Total Hip Replacement

(THR)

OR

Total Knee Replacement (TKR)

cefazolin 2g IV (child: 30mg/kg up to 2g) before

incision, then 8-hourly for 2 more doses

High risk of MRSA :




actual body weight)

Patients requiring revision / re-

operation

cefazolin 2g IV (child: 30mg/kg up to 2g) before

incision, then 8-hourly for 2 more doses

PLUS



AND also (if cement is used)

vancomycin added to tobramycin or

gentamicin bone cement (≤ 5% w:w) (add

vancomycin 500mg per 40g packet of bone

cement)


actual body weight)

AND (if cement is used)

vancomycin added to tobramycin or gentamicin

bone cement (≤ 5% w:w) (add vancomycin 500mg

per 40g packet of bone cement)

Note: Pre-existing infections (known or suspected) – if present, use appropriate treatment regimen

instead of prophylactic regimen for procedure. Doses should be scheduled to allow for re-dosing just

prior to skin incision.

Morcellised allografting at joint

replacement

Add approximately 250mg vancomycin to bone cement for first femoral head equivalent, and 500mg

for more than one head, and no more than 500mg to graft

Routine arthroscopic

procedures

No prophylaxis required

(unless prosthesis is being inserted or patient is immunocompromised)

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Post-Operative Care


surgical drains





IV Intravenous




DRESS/SJS/TEN)

References


Australian Orthopaedic Association. (2014) "Cement in Hip & Knee Arthroplasty – Supplementary Report 2014". National Joint Replacement Registry

[online] https://aoanjrr.dmac.adelaide.edu.au/documents/10180/172288/Cement%20in%20Hip%20%26%20Knee%20Arthroplasty (Accessed Nov

2015)

Belden K, Silibovsky R, Vogt M. "Perioperative Antibiotics". Journal of Orthopaedic Research 2014; 32: S31–S59.

Berbari E, Baddour L. Epidemiology and prevention of prosthetic joint infections (2017). In: Sexton DJ (Ed), UpToDate, Waltham, MA.

[www.uptodate.com]. Accessed Aug 2017

Berrios-Torres, S., et al. (2017). "Centres for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection " JAMA Surgery

May 3. doi: 10.1001/jamasurg.2017.0904. [Epub ahead of print].

Bratzler, D., E. P. Dellinger, K. M. Olsen, T. M. Perl, P. G. Auwaerter, M. K. et al. (2013) "Clinical practice guidelines for antimicrobial prophylaxis in

surgery". Am J Health Syst Pharm 70:195-283.

Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) March 2012, Last reviewed and amended May 2016.

SAAGAR has endeavoured to ensure that the information in this publication is accurate; however, it makes no representation or warranty to this

effect.




https://aoanjrr.dmac.adelaide.edu.au/documents/10180/172288/Cement%20in%20Hip%20%26%20Knee%20Arthroplasty



Orthopaedic Surgery (Not Joint Replacement)

This guideline does not apply to open fractures.



prostheses, allergies, obesity, diabetes, remote infection, available pathology or malignancy)


should be scheduled to allow for re-dosing just prior to skin incision

Practice Points

Drug administration

> IV bolus – should be timed ≤ 60 minutes before skin incision (optimal 30 minutes). Administration after skin incision or > 60 minutes before incision reduces effectiveness

> IV infusion – should be commenced 30-60 minutes prior to skin incision (e.g. metronidazole). See below for vancomycin administration





Repeat doses




Obese patients


Duration of prophylaxis should not exceed 24hrs, irrespective of presence of drains or catheters.



*High risk penicillin/cephalosporin allergy

Internal fixation of large bones cefazolin 2g IV (child <12 years: 30mg/kg up to

2g)

THEN

repeat 8-hourly for 2 further doses.

(Max 3 doses irrespective of the presence of

surgical drains)

High risk of MRSA :



actual body weight), may be repeated 12 hours after

initial dose

Other (closed) internal fixation cefazolin 2g IV (child < 12 years: 30mg/kg up to

2g)

High risk of MRSA :




actual body weight), may be repeated 12 hours after

initial dose

Arthroscopic and other clean

procedures not involving foreign

material (e.g. pins, plates)


Lower limb amputation cefazolin 2g IV (child < 12 years: 30mg/kg up to

2g)

THEN

repeat 8-hourly for up to 2 further doses

High risk of MRSA :




actual body weight), may be repeated after 12 hours

PLUS

gentamicin 5mg/kg (adults and children) IV, 15-30

minutes before surgical incision

If limb is ischaemic

ADD to above metronidazole 500mg IV infusion

(child < 12 years: 12.5mg/kg up to 500mg) , may be repeated after 12 hours

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*High risk penicillin/cephalosporin allergy

Spinal procedures cefazolin 2g IV (child < 12 years: 30mg/kg up to

2g)

High risk of MRSA :




actual body weight), may be repeated after 12 hours

Post-Operative Care


surgical drains





IV Intravenous




DRESS/SJS/TEN)

References


Berbari E, Baddour L.(2017). "Epidemiology and prevention of prosthetic joint infections". In: Sexton DJ (Ed), UpToDate, Waltham, MA.


Bratzler, D., E. P. Dellinger, K. M. Olsen, T. M. Perl, P. G. Auwaerter, M. K. et al. (2013). "Clinical practice guidelines for antimicrobial prophylaxis in

surgery." Am J Health Syst Pharm 70: 195-283.

Slobogean, GP, Kennedy, SA, Davidson, D, O'Brien, PJ. (2008). "Single versus multiple-dose antibiotic prophylaxis in the surgical treatment of closed

fractures: a meta-analysis". J Orthop Trauma 22:264-09

Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) March 2012, Last reviewed and amended November

2015


effect.







Plastic and Reconstructive Surgery






Practice Points

Unless otherwise stated, antibiotic prophylaxis is NOT required for the following plastic surgery indications:

> Clean elective surgery with no implants

> Clean trauma with no fracture and less than 24 hours since injury

Drug administration

> IV bolus – should be timed ≤ 60 minutes before skin incision (optimal 15-30 minutes). Administration after skin incision or > 60 minutes before incision reduces effectiveness

> IV infusion – vancomycin should be commenced 30-120 minutes prior to skin incision. See under vancomycin administration.




> Give vancomycin 1g (1.5g for patients > 80kg actual body weight) started 30 to 120 minutes before surgical incision and given at a

recommended rate of 1g per hour (1.5g over 90 minutes). Note: Infusion can be completed after skin incision.

Repeat doses




Obese patients


Topical antibiotics should NOT be applied to the wound during or after surgery




Groin/axilla/neck dissections

Open reduction and internal

fixation of fractures

Insertion of implants, mesh,

prostheses, screws, plates etc.


High risk of MRSA infection :



actual body weight)

Clean bone or soft tissue injury

Hand surgery (without implants)

Non-infected lesions & minor

excisions


Post-Operative Care


surgical drains.





IV Intravenous




DRESS/SJS/TEN)

October 2017


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References

Anderson, DJ., Sexton, DJ. (2017). "Antimicrobial prophylaxis for prevention of surgical site infection in adults". In: Harris, A (ed). UptoDate. Waltham,

MA. [www.uptodate.com] Accessed July 2017.

Antibiotic Expert Group.(2014) Therapeutic Guidelines: Antibiotic, Version 15. Melbourne: Therapeutic Guidelines Limited.


Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) March 2012, Last reviewed and amended November

2015


effect.






Thoracic Surgery







Practice Points

Drug administration

> IV bolus – should be timed 60 minutes before skin incision (optimal 30 minutes). Administration after skin incision or > 60 minutes before incision reduces effectiveness

> IV infusion – should be commenced 30-60 minutes prior to skin incision (e.g. metronidazole). See below for vancomycin administration.





Repeat doses


> for delayed or prolonged surgery (> 4 hours from the time of first preoperative dose) when a short-acting agent is used (e.g. cefazolin), OR


Obese patients





Pneumonectomy / Lobectomy cefazolin 2g IV (child: 30mg/kg up to 2g)

THEN

cefazolin 2g IV (child: 30mg/kg up to 2g) 8-

hourly for 2 more doses commencing 4 hours

after the initial dose

If anaerobic cover required (empyema or

abscess) then ADD:


12.5mg/kg), repeated 12 hourly for 2 more

doses commencing 6 hours after initial dose





actual body weight)

THEN


80kg actual body weight) 12 hourly for 2 more

doses commencing 8 hours after the initial dose

If anaerobic cover required (empyema or abscess)

then ADD:


12.5mg/kg), repeated 12 hourly for 2 more doses

commencing 6 hours after initial dose

Decortication / Pleurectomy cefazolin 2g IV (child: 30mg/kg up to 2g)

If anaerobic cover required ADD:


12.5mg/kg)




actual body weight)

If anaerobic cover required ADD:


12.5mg/kg)

Video-assisted thoracoscopic

surgery (VATS)




vancomycin 1g by IV infusion (1.5g for patients >



October 2017


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Post-Operative Care


surgical drains.





IV Intravenous




DRESS/SJS/TEN)

References


Anderson DJ, Sexton DJ (2017). "Antimicrobial prophylaxis for prevention of surgical site infection in adults ". In: Harris, A (ed), UpToDate, Waltham, MA. [www.uptodate.com] Accessed Aug 2017


Chang, SH., Krupnick AS (2012). "Perioperative antibiotics in thoracic surgery". Thorac Surg Clin 22 (1):35-45.



effect.






Urology



prostheses, urinary catheters or stents, allergies, obesity, diabetes, remote infection, available pathology or malignancy).



Pre-operative urine screening: Where possible exclude or treat urinary infection prior to surgery. If surgery is urgent in the presence of confirmed

infection or bacteriuria, use gentamicin 3mg/kg IV as a single preoperative dose. Higher doses may be required if systemic symptoms are present.


Practice Points

Drug administration


> IV infusion – should be commenced 30-60 minutes prior to skin incision (e.g. metronidazole). See below for vancomycin administration.






> Dosing should be based on ideal body weight, provided ideal body weight is less than actual body weight.

Repeat doses




Obese patients





Open/laparoscopic procedures

when:

> urinary tract entered

> urinary tract not entered but:

patient is at risk of post-

operative infection (e.g. urinary

tract obstruction/

abnormalities);

prosthetic material is inserted;

OR

bacteriuria cannot be

excluded.


PLUS

gentamicin 2mg/kg IV (adults and children)

If risk of entry into bowel lumen then ADD:



High risk of MRSA :



actual body weight)

PLUS



metronidazole 500mg IV infusion (child: 12.5mg/kg

up to 500mg)

Open/laparoscopic procedures

when urinary tract not entered and

urine is sterile (e.g. vasectomy,

scrotal surgery, varicocele ligation)






Open prostatectomy / Robotic

prostatectomy

cefazolin 2g IV

PLUS




High MRSA risk:



actual body weight)

PLUS




Endoscopic procedures

> removal of calculi

> Extracorporeal Shock Wave

Lithotripsy only if high risk of

infection

> specific risk for postoperative

infection


Known urinary MRSA colonisation:





Removal of calculi

Transurethral resection of

prostate (TURP)

Stent insertion

Ureteroscopy/instrumentation of

upper tract (incl. retrograde

pyelogram)


OR (if gentamicin contraindicated)





OR (if gentamicin contraindicated)

trimethoprim 300mg PO 1hr prior to insertion



Transperineal prostatic biopsy cefazolin 2g IV

High MRSA risk:



actual body weight)

Transrectal prostatic biopsy ciprofloxacin 500mg PO as a single dose, 1-2 hours before procedure. Dose may be repeated 12 hours

after the first dose if procedure delayed beyond 6 hours

If there is a history of overseas travel (India, South East Asia, Southern Europe) in the last 6 months, the

patient may be colonised with multi-resistant organisms. Contact ID/Clinical Microbiology for advice.

Other clean procedures /

diagnostic cystoscopy without

manipulation of urinary tract


Post-Operative Care


surgical drains.





IV Intravenous


PO Per oral



DRESS/SJS/TEN)

October 2017


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References


Benway BM, Andriole GL (2017). "Prostate biopsy". In: Richie J (ed), UpToDate, Waltham, MA. [www.uptodate.com] Accessed Aug 2017

Mirmilstein G, Ferguson J (2015). "Stable post-TRUS biopsy sepsis rates and antibiotic resistance over 5 years in patients from Newcastle, New South Wales". Med J Aust 202(5): 237.

Wagenlehner, FM., Van Oostrum E, Tenke P, et al (2013). "Infective complications after prostate biopsy: outcome of the Global Prevalence Study of Infections in Urology (GPIU) 2010 and 2011, a prospective multinational prostate biopsy study." Eur Urology 63: 521-7.



effect.






Vascular Surgery



prostheses, urinary catheters or stents, allergies, obesity, diabetes, remote infection, available pathology or malignancy).



Practice Points

Drug administration


> IV infusion – should be commenced 30-60 30 minutes prior to skin incision (e.g. metronidazole). See below for vancomycin administration

MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of high risk hospital or unit (where MRSA is endemic) for more than the

last five days)



> Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion, starting 30-120 minutes before surgical incision and given at a recommended rate of 1g per hour (1.5g over 90 minutes). Note: Infusion can be completed after skin incision.

Repeat doses




Obese patients





Vascular reconstruction

(e.g. abdominal aorta, graft/stent

insertion, groin incision)

cefazolin 2g IV (child: 30mg/kg up to 2g),

repeated 8-hourly for 2 further doses post-

operatively

High risk of MRSA :


vancomycin 1g IV infusion (1.5g > 80kg actual body

weight), may repeat 12 hours after initial dose

Amputation of ischaemic limb cefazolin 2g IV (child: 30mg/kg up to 2g)

repeated 8-hourly for 2 further doses post-

operatively

PLUS


12.5mg/kg up to 500mg), repeated 12 hours

after initial dose

High risk of MRSA :



weight), repeated 12 hours after initial dose

PLUS


12.5mg/kg up to 500mg), repeated 12 hours after

initial dose

Primary autogenous

arteriovenous fistula (AVF)

formation

No prophylaxis required

AVF revision or AVF with

insertion of prosthetic material

(e.g Dacron graft)


High risk of MRSA :



weight)

All other clean procedures

(e.g. thoracoscopic

sympathectomy)


October 2017


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Post-Operative Care


surgical drains





IV Intravenous




DRESS/SJS/TEN)

References

Antibiotic Expert Group (2014). Therapeutic Guidelines: Antibiotic, Version 15. Melbourne: Therapeutic Guidelines Limited.

Kalapatapu V. (2017). "Lower extremity amputation". In: Mills JL Snr and Eidt JF (eds), UpToDate, Waltham, MA. [www.uptodate.com] Accessed Aug

2017

McIntosh, J., Earnshaw, JJ. (2009) "Antibiotic prophylaxis for the prevention of infection after major limb amputation". Eur J Vasc Endovasc Surg 37

(6): 696 - 703.

Salman, L., Asif, A. (2009) "Antibiotic Prophylaxis: Is it needed for dialysis access procedures?". Seminars in Dialysis 22(3): 297-9.

Stone, PA., AbuRahma, AF, Campbell, JR et al (2015). "Prospective randomized double-blinded trial comparing 2 anti-MRSA agents with

supplemental coverage of cefazolin before lower extremity revascularization". Ann Surg 262: 495-501.



effect.





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Surgical Antimicrobial Prophylaxis Clinical Guideline

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