Surgical Antibiotic Prophylaxis
Principles of Antibiotic Prophylaxis in Surgery
Principles of Antibiotic Prophylaxis in Surgery
Antibiotic prophylaxis in surgery is the use of antibiotics to prevent post-operative infection.
Are prophylactic antibiotics needed?
- Prophylaxis is recommended for patients undergoing:
- Clean-contaminated and contaminated surgical procedures (see also note below regarding post-operative infection).
- Clean surgical procedures with increased infection risk/devastating consequences of infection such as lower limb vascular surgery, insertion of prosthetic material or on immunocompromised patients.
Choice of antibiotic
- The choice of agent will be determined by the procedure and the likely potential pathogens . These guidelines generally apply to procedures in patients admitted from the community.
- Erythromycin should be avoided - it is not a suitable agent for prophylaxis for a number of reasons including poor tissue penetration.
Timing of administration
- The aim of prophylaxis is to have maximum tissue antibiotic levels at the time of first incision.
- Therefore prophylaxis should be administered within 60 minutes before incision/procedure and is usually given in theatre at induction of anaesthesia.
- Note that fluoroquinolones (e.g. ciprofloxacin) require a longer time for infusion (60 minutes for 400mg IV). Therefore ciprofloxacin should commence within 120minutes before the surgical incision.
Duration of prophylaxis
- In most situations there is no value in continued prophylaxis after wound closure and prophylaxis is usually given as a single dose unless otherwise specified below.
- As per the HSE National Clinical Programme in Surgery (NCPS) Surgical Antibiotic Prophylaxis Duration Position Paper :
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The maximum duration of antibiotic prophylaxis is the duration of the surgical procedure
for the majority of surgical procedures including:
- Obstetrics and gynaecology surgery (including caesarean section)
-
Gastrointestinal surgery (including endoscopic gastrointestinal surgery)
-
This is achieved by administering
a single dose within 60 minutes prior to incision
. An additional intra-operative dose may be required in certain circumstances such as:
- Significant blood loss or,
- If the procedure duration extends beyond three or four hours of the initial dose, this timing will depend on the half-life of the antibiotic.
-
In obstetrics for operative vaginal delivery, this is achieved by administering a single dose within 3 hours of delivery.
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The
maximum duration
of antibiotic prophylaxis is
24 hours
for the following categories of surgical procedure:
- Orthopaedic surgery (including implant surgery but with the exception of open fracture management)
- Cardiology – percutaneous procedures including placement of implantable devices
-
Reconstructive Breast Surgery
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A duration of antibiotic prophylaxis of longer than 24 hours cannot be reasonably justified for any surgical procedure conducted in LUH on the basis of current evidence or by consensus of expert opinion. This applies equally to antibiotics administered by parenteral or oral route.
- Antibiotic prophylaxis should not be continued beyond the time frames identified above on the basis of drains remaining in place.
Additional intra-operative doses
- Additional intra-operative doses of prophylactic antibiotic may be necessary in the following situations:
- Prolonged surgical procedures. Antibiotics such as co-amoxiclav and cephalosporins (e.g. CefUROXime) are short-acting and therefore an additional dose is needed during surgery in procedures lasting longer than four hours. Re-dosing is not recommended for antibiotics such as gentamicin, vancomycin or teicoplanin.
- Blood loss/fluid replacement: In the event of major intra-operative blood loss (>1.5Litres) additional doses of prophylactic antibiotic should be given after fluid replacement . Caution is needed in patients with renal impairment.
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Antibiotics requiring additional intra-operative doses |
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During procedures lasting over 4 hours or if major blood loss (>1.5L) |
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Antibiotic |
Dose |
Recommended re-dosing interval
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Amoxicillin |
1g |
2 hrs |
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Cefuroxime |
1.5g |
4 hrs |
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Co-amoxiclav |
1.2g |
4 hrs (max 4 doses in 24hrs) |
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Ciprofloxacin |
400mg |
Not applicable |
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Clindamycin |
600-900mg |
6 hrs |
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Flucloxacillin |
1g |
4 hrs |
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Gentamicin |
5mg/kg |
Not applicable |
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Metronidazolde |
400mg |
Not applicable |
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Teicoplanin |
10mg/kg (max dose 800mg**) |
Not applicable |
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*The re-dosing interval may vary depending upon the half-life of the drug in question, and the patients underlying renal and hepatic function. **Discuss dosing in obese patients with Microbiology or Pharmacy. |
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Documenting antibiotic use
- Prophylactic antibiotics administered by the anaesthetic team, either pre-op or intra-op, are always charted in the anaesthetic record and as good practice should be recorded in the Surgical Antimicrobial Prophylaxis (SAP) section on page 4 of the LUH MPAR (drug kardex) (see below), with the time of administration.
- Additional SAP doses are not routinely required for the majority of procedures but if necessary e.g. 24hours in some orthopaedic surgeries, prophylactic antibiotics should be prescribed in the SAP section of the patient’s MPAR (drug kardex).
- Patients should ideally be informed prior to surgery, wherever possible, if they will need antibiotic prophylaxis, and afterwards if they have been given antibiotics during their operation.
- Please note AMRIC have a patient information leaflet available on “ Antibiotics before an operation to reduce risk of infection ”.
Obesity
- The pharmacokinetics of drugs may be altered in obese patients, therefore dose adjustment based on body weight may be warranted. Discuss with Pharmacy/Microbiologist if necessary.
Post-operative infection
- If infection is suspected during surgery or post-operatively within 24 hours, appropriate microbiological samples should be sent. An agent that is appropriate for prophylaxis may not be the optimal agent for treatment of established infection and treatment guidelines should be consulted .
Complex prophylaxis issues
- For patients with complex clinical situations e.g. those with resistant organisms, renal failure, immunocompromised or allergy to agents listed, please obtain advice from a Microbiology consultant.
- Patients at risk for development of endocarditis may require modification of standard antimicrobial prophylaxis regimens. See Prophylaxis of Infective Endocarditis . Please discuss with Microbiology if necessary.
MRSA
- For patients requiring specific surgical prophylaxis against MRSA see Note Regarding Risk Factors for MRSA
Multi-drug Resistant Organisms (MDRO) other than MRSA
- For patients colonised with an MDRO other than MRSA, discuss with Microbiology. See note on MDRO .
Note Regarding Risk Factors for MRSA
Note Regarding Risk Factors for MRSA
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Teicoplanin
IV 10mg/kg (rounded up to 800mg for an average 70kg patient) should be
ADDED
to the recommended regimens (except those containing flucloxacillin, where teicoplanin should replace flucloxacillin), unless teicoplanin or vancomycin are already included, if the patient:
- Is known to be colonised with MRSA
- Was recently colonised with MRSA
- Was an inpatient for more than 72 hours before the procedure and has not had a recent confirmed negative MRSA screen result
- Was admitted from another hospital or nursing home and has not had a recent confirmed negative MRSA screen result
- Is at high risk for colonisation with MRSA for other reasons and has not had a recent confirmed negative MRSA screen result
- In the case of patients known to be colonised with MRSA who are undergoing cardiac, major orthopaedic implant or other complex surgery, it may be advisable to discuss an MRSA eradication protocol with Microbiology in advance of the surgery.
- The recommended dose of teicoplanin is 10mg/kg to ensure adequate tissue levels. The calculated dose is 700mg for an average 70kg patient - the dose is rounded to 800mg (2 x 400mg vials) for a patient with an average weight of 70kg for practical reasons.
- Teicoplanin is used in surgical prophylaxis in preference to vancomycin in most cases, due to ease of administration, as doses up to 800mg can be given by slow intravenous injection over 3 to 5 minutes.
- Doses over 800mg should be given by infusion (in 50ml NaCl 0.9% or Glucose 5%) over 30 minutes.
- If continued antibiotic treatment is necessary post surgery, switch to vancomycin .
Classification of Surgical Procedures
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Classification of Surgical Procedures |
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Clean |
Clean-contaminated |
Contaminated/Dirty |
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No breach of respiratory, alimentary or genito-urinary tracts Non-traumatic No inflammation No break in aseptic technique |
Non-traumatic but with break in aseptic technique or breach of respiratory, alimentary or genito-urinary tract No significant spillage |
Contaminated: Major break in aseptic technique; acute inflammation (without pus); operations where there is visible contamination of wound e.g. gross spillage from a hollow viscus during surgery or fresh (less than 4 hours) traumatic wound from relatively clean source. Dirty: operations in the presence of pus e.g. where there is a previously perforated hollow viscus or compound/open injuries that are old (more than 4 hours) or from a dirty source. |
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Prophylaxis NOT usually recommended UNLESS clinical setting indicates an increased infection risk e.g. lower-extremity vascular procedures, or where infection may have devastating consequences e.g. orthopaedic implant surgery or placement of other prosthetic devices) , or if the patient is immunocompromised e.g. neutropenic, receiving immunosuppressive agents, malnourished. |
Prophylaxis indicated (see individual speciality) |
Prophylaxis indicated (see individual speciality). Treatment course may be required (usually 5 to 7 days - duration will depend on clinical response). Discuss with Microbiology consultant if necessary. |
Breast Surgery
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Antibiotics for Breast Surgery |
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Type of Surgery |
Procedure |
1 st Line Antibiotic |
Penicillin allergy: delayed onset non-severe reaction |
Penicillin allergy: immediate or severe delayed reaction |
Number & Timing of Doses |
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See penicillin hypersensitivity section for further information |
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Prophylaxis in Breast Surgery See Note Regarding Risk Factors for MRSA See Note Regarding Multi-drug Resistant Organisms (MDRO) |
Surgery for benign breast lump where no axillary procedure performed |
Surgical prophylaxis generally not indicated. |
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Breast surgery (including mastectomy, wide local excision, axillary clearance, breast reduction, duct excision)
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Flucloxacillin IV 1g (one dose only) If risk factors for or colonised with MRSA Replace Flucloxacillin with Teicoplanin IV 10mg/kg (Max 800mg*) (one dose only) |
CefUROXime IV 1.5g (one dose only) If risk factors for or colonised with MRSA Replace CefUROXime with Teicoplanin IV 10mg/kg (Max 800mg*) (one dose only) |
Teicoplanin IV 10mg/kg (Max 800mg*) (one dose only) |
One dose within 60 minutes before incision. |
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Reconstructive breast surgery with or without tissue expander |
Co-amoxiclav IV 1.2g every 8 hours (up to maximum 3 doses)
If risk factors for or colonised with MRSA Add Teicoplanin IV 10mg/kg (Max 800mg*) every 12 hours (up to maximum 2 doses) |
CefUROXime IV 1.5g every 8 hours (up to maximum 3 doses)
If risk factors for or colonised with MRSA Add Teicoplanin IV 10mg/kg (Max 800mg*) every 12 hours (up to maximum 2 doses) |
Teicoplanin IV 10mg/kg (Max 800mg*) every 12 hours (up to maximum 2 doses) + Gentamicin IV one dose only, dose per GAPP App calculator |
1 st dose within 60 minutes before incision. Maximum 24 hours duration. |
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* Discuss dosing in obese patients with Microbiology or Pharmacy. |
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Cardiac Surgery
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Antibiotics for Cardiac Surgery |
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Type of Surgery |
Procedure |
1 st Line Antibiotic |
In penicillin allergy |
Number & Timing of Doses |
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See penicillin hypersensitivity section for further information |
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Prophylaxis in Cardiology Procedures See Note Regarding Risk Factors for MRSA See Note Regarding Multi-drug Resistant Organisms (MDRO) |
Cardiovascular Implantable Electronic Device placement (including permanent pacemakers and Implantable cardioverter-defibrillator (ICD)) |
Flucloxacillin IV 2g (one dose only) If risk factors for or colonised with MRSA Replace Flucloxacillin with Teicoplanin IV 10mg/kg (Max 800mg*) (one dose only) |
Any history of penicillin allergy:
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One dose within 60 minutes before incision. |
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Note: an alternative glycopeptide can be used instead of Teicoplanin as directed by the Cardiologist i.e. Vancomycin– please note this has a much longer infusion time. Dose as per LAPP App calculator . |
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EP study +/- ablations Loop insertions & removals Cardioversions Angiograms |
Antimicrobial prophylaxis not indicated. |
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| * Discuss dosing in obese patients with Microbiology or Pharmacy. | |||||
Gastrointestinal Surgery
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Antibiotics in Gastrointestinal Surgery |
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Type of Surgery |
Procedure |
1 st Line Antibiotic |
Penicillin allergy: delayed onset non-severe reaction |
Penicillin allergy: immediate or severe delayed reaction |
Duration |
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See penicillin hypersensitivity section for further information |
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Prophylaxis in Gastro-intestinal Surgery See Note Regarding Risk Factors for MRSA See Note Regarding Multi-drug Resistant Organisms (MDRO) |
Upper GIT (e.g. oesophageal, gastro-duodenal, small-intestinal, gastric bypass) |
Co-amoxiclav IV 1.2g (one dose only) |
CefUROXime IV 1.5g (one dose only) + Metronidazole IV 500mg (one dose only) |
Ciprofloxacin IV 400mg (one dose only) + Metronidazole IV 500mg (one dose only) |
One dose within 60 minutes before incision. See note below re ciprofloxacin infusion 2 |
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Lower GIT (e.g. colon, rectum, appendix 1 ) |
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Gall–bladder surgery (open) Gall-bladder surgery (laparoscopic)- prophylaxis recommended for high-risk 3 patients only |
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Percutaneous endoscopic gastrostomy (PEG) |
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Hernia repair: antibiotic prophylaxis NOT recommended unless mesh insertion Splenectomy: NOT generally recommended for procedure unless immunocompromised. Post-splenectomy prophylaxis is discussed elsewhere in these guidelines (See Appendix 3 ). |
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Diagnostic laparoscopy
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Prophylaxis NOT recommended |
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1 If appendix perforated or associated with peritonitis, treatment course may be required. 2 Ciprofloxacin requires a longer time for infusion (60 minutes for 400mg IV). Therefore ciprofloxacin infusion should commence within 120 minutes before the surgical incision. 3 Consider antibiotic prophylaxis for high-risk patients : intra-operative cholangiogram, pancreatic pseudo-cyst, immunosuppression, incomplete biliary drainage, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, pregnancy (discuss choices with Microbiology), insertion of prosthetic device e.g. T-tube, primary sclerosing cholangitis, age >70years, diabetes, likely prolonged procedure. |
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Head and Neck Surgery
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Antibiotics for Head and Neck Surgery |
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Type of Surgery |
Procedure |
1st Line Antibiotic |
Penicillin allergy: delayed onset non-severe reaction |
Penicillin allergy: immediate or severe delayed reaction |
Number & Timing of Doses |
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See penicillin hypersensitivity section for further information |
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Prophylaxis in Head & Neck Surgery See Note Regarding Risk Factors for MRSA See Note Regarding Multi-drug Resistant Organisms MDRO |
Head and neck surgery: clean-contaminated and contaminated (including radical neck dissection) |
Co-amoxiclav IV 1.2g every 8 hours (up to maximum 3 doses) |
CefUROXime IV 1.5g every 8 hours (up to maximum 3 doses) + Metronidazole IV 500mg every 8 hours (up to maximum 3 doses) |
Teicoplanin* IV 10mg/kg (max 800mg) every 12 hours (up to maximum 2 doses) + Gentamicin IV one dose only, dose per LAPP App calculator + Metronidazole IV 500mg every 8 hours (up to maximum 3 doses) |
1 st dose within 60 minutes before incision. Duration no longer than 24 hours unless extensive head and neck flap reconstruction. |
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Clean head and neck surgery with no mucosal breach (e.g. parotid or thyroid surgery) |
Surgical prophylaxis not routinely required. |
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*Discuss dosing in obese patients with Microbiology or Pharmacy. |
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Obstetric and Gynaecological Surgery
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Antibiotics for Obstetric and Gynaecological Surgery |
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Type of Surgery |
Procedure |
1 st Line Antibiotic |
Penicillin allergy: delayed onset non-severe reaction |
Penicillin allergy: immediate or severe delayed reaction |
Number & Timing of Doses |
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See penicillin hypersensitivity section for further information |
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Prophylaxis in Obstetric & Gynaecological Surgery See Note Regarding Risk Factors for MRSA See Note Regarding Multi-drug Resistant Organisms (MDRO) |
Hysterectomy: Vaginal hysterectomy, total abdominal hysterectomy, total laparoscopic hysterectomy, transvaginal hysterectomy (vNOTE) and oophorectomy. |
Co-amoxiclav IV 1.2g (one dose only) |
CefUROXime IV 1.5g (one dose only) + Metronidazole IV 500mg (one dose only) |
Ciprofloxacin IV 400mg (one dose only) + Metronidazole IV 500mg (one dose only) |
One dose within 60 minutes before incision. See note below re ciprofloxacin infusion 1 . |
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Caesarean section (elective and emergency) |
Co-amoxiclav IV 1.2g (one dose only) |
CefUROXime IV 1.5g (one dose only) + Metronidazole IV 500mg (one dose only) |
Clindamycin IV 900mg (one dose only) + Gentamicin IV one dose only, dose per LAPP App calculator (Use booking weight to calculate). If evidence of current/previous Clindamycin resistant GBS or if patient is unwell : ADD Teicoplanin IV 10mg/kg (Use booking weight. Max 800mg 2 ) (one dose only) |
One dose within 60 minutes before incision. |
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Operative vaginal delivery: vacuum, forceps Prophylaxis should be offered to all women as soon as possible after delivery. For detailed guideline see QPulse WAC Directorate guidelines Management of Assisted Vaginal Birth (access via Linkopolis- Applications-HCI QPulse and search CLN-LW-0067-update in progress)
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Co-amoxiclav IV 1.2g (one dose only) |
CefUROXime IV 1.5g (one dose only) + Metronidazole IV 500mg (one dose only) |
Clindamycin IV 900mg (one dose only) + Gentamicin IV one dose only, dose per LAPP App calculator (Use booking weight to calculate). If evidence of current/previous Clindamycin resistant GBS or if patient is unwell : ADD Teicoplanin IV 10mg/kg (Use booking weight. Max 800mg 2 ) (one dose only) |
One dose as soon as possible after delivery. |
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Manual evacuation of placenta or ERPC (Postpartum in setting of Endometritis) For full detailed guidelines see QPulse WAC Directorate guidelines for the Manual Removal of the placenta (access via Linkopolis- Applications-HCI QPulse and search CLN-LW-0029)
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Co-amoxiclav IV 1.2g (one dose only)
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CefUROXime IV 1.5g (one dose only) + Metronidazole IV 500mg (one dose only)
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Clindamycin IV 900mg (one dose only) + Gentamicin IV one dose only, dose per LAPP App calculator (Use booking weight to calculate).
ADD Teicoplanin IV 10mg/kg (Use booking weight. Max 800mg 2 ) (one dose only) |
One dose within 60 minutes before incision. |
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If concerns patient is developing sepsis/septic shock – please see treatment of infection Sepsis section (and/or discuss with Microbiology). |
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Repair of 3 rd and 4 th degree perineal tears involving the anal sphincter/rectal mucosa. For detailed guideline see WAC directorate guidelines for the Management of 3 rd and 4 th Degree Tears ( access via Linkopolis- Applications-HCI QPulse and search CLN-LW-0022) |
Co-amoxiclav IV 1.2g every 8 hours for a total of 3 doses (24 hour cover) |
CefUROXime IV 1.5g every 8 hours for a total of 3 doses (24 hour cover) + Metronidazole IV 500mg every 8 hours for a total of 3 doses (24 hour cover) |
Clindamycin IV 900mg every 8 hours for a total of 3 doses (24 hour cover) + Gentamicin IV one dose only , dose per LAPP App calculator (Use booking weight to calculate). If evidence of current/previous Clindamycin resistant GBS or if patient is unwell : ADD Teicoplanin IV 10mg/kg (Use booking weight. Max 800mg 2 ) every 12 hours (up to maximum 2 doses) |
One dose within 60 minutes before incision and continued for a total of 24 hours . |
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Laparoscopy (without breach of bowel, uterine, vaginal mucosa), Dilation and curettage (D&C), Intrauterine device insertion, Cervical cerclage, Hysteroscopy, Endometrial ablation 3 |
Surgical prophylaxis is NOT generally recommended |
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1 Ciprofloxacin requires a longer time for infusion (60 minutes for 400mg IV). Therefore ciprofloxacin infusion should commence within 120 minutes before the surgical incision. 2 Discuss dosing in obese patients with Microbiology or Pharmacy. 3 List of procedures NOT requiring prophylaxis is not exhaustive. Please see section on “Additional intra-operative doses” if Prolonged surgical procedure or major blood loss i.e. >1.5Litres . |
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Orthopaedic and Trauma Surgery
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Antibiotics for Orthopaedic and Trauma Surgery |
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Type of Surgery |
Procedure |
1 st Line Antibiotic |
Penicillin allergy: delayed onset non-severe reaction |
Penicillin allergy: immediate or severe delayed reaction |
Number & Timing of Doses |
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See penicillin hypersensitivity section for further information |
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Prophylaxis in Orthopaedic and Trauma Surgery See Note Regarding Risk Factors for MRSA See Note Regarding Multi-drug Resistant Organisms (MDRO) |
Closed clean orthopaedic procedures without implant of foreign material (e.g. arthroscopy) |
Antimicrobial prophylaxis NOT required |
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Minor metalwork insertion (e.g. K-wires, screws, small orthopaedic plates) |
Co-amoxiclav IV 1.2g (one dose only)
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CefUROXime IV 1.5g (one dose only) |
Teicoplanin IV
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One dose within 60 minutes before incision. Give antibiotic prophylaxis at least 15 minutes prior to tourniquet inflation. |
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Minor metalwork extraction |
Where infection is not suspected surgical antimicrobial prophylaxis is not indicated. |
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Orthopaedic implant surgery (total joint replacement or revision) Open reduction with internal fixation of closed fractures |
Co-amoxiclav IV 1.2g every 8 hours for a total of 3 doses (24 hour cover)
If risk factors for or
Teicoplanin IV 10mg/kg (Max 800mg*) every 12 hours for a total of 2 doses (24 hour cover) |
CefUROXime IV 1.5g every 8 hours for a total of 3 doses (24 hour cover)
If risk factors for or colonised with MRSA Add: Teicoplanin IV 10mg/kg (Max 800mg*) every 12 hours for a total of 2 doses (24 hour cover) |
Teicoplanin IV
+ Gentamicin IV one dose only, dose per GAPP App calculator |
1 st dose within 60 minutes before incision & continued for 24 hours. Give antibiotic prophylaxis at least 15 minutes prior to tourniquet inflation. |
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Debridement surgery/patients with chronic bone infection |
Prophylactic antibiotic depends on infecting organism(s).Check results of previous cultures if available. Discuss with Microbiology if necessary. |
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Open fracture intervention
+/- insertion of nail/screw (includes acute trauma with contaminated wounds).
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Open fracture - Type I & II (based on the Gustilo-Anderson Classification )
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Co-amoxiclav IV 1.2g every 8 hours
See comment re duration |
CefUROXime IV 1.5g every 8 hours + Metronidazole IV 500mg every 8 hours
See comment re duration
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Clindamycin IV 900mg every 8 hours + Gentamicin IV dose per GAPP App calculator every 24 hours
See comment re duration |
1 st dose within 60 minutes before incision. Duration maximum 24 hours post final wound closure. It is vital that any patient with an open fracture be closely observed for signs of sepsis. Please discuss with Microbiology if necessary and if treatment with gentamicin is extended beyond 3 days. |
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Open fracture - Type III (A, B, C) (based on the Gustilo-Anderson Classification )
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Co-amoxiclav IV 1.2g every 8 hours
+
See comment re duration |
CefUROXime IV 1.5g every 8 hours
+
+ Gentamicin IV dose per LAPP App calculator every 24 hours See comment re duration
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Clindamycin IV 900mg every 8 hours + Gentamicin IV dose per LAPP App calculator every 24 hours See comment re duration |
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* Discuss dosing in obese patients with Microbiology or Pharmacy. |
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Reference:
Kim P.H., Leopald S.S. Gustilo-Anderson Classification. Clin Orthop Relat Res (2012) 470:3270–3274 DOI 10.1007/s11999-012-2376-6. Accessed via: 11999_2012_Article_2376.pdf
Plastic Surgery
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Antibiotics for Plastic Surgery |
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Type of Surgery |
Procedure |
1 st Line Antibiotic* |
Penicillin allergy: immediate or severe delayed reaction |
Number & Timing of Doses |
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See penicillin hypersensitivity section for further information |
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Prophylaxis in Plastic Surgery See Note Regarding Risk Factors for MRSA See Note Regarding Multi-drug Resistant Organisms (MDRO) |
Consider surgical prophylaxis for patients with risk factors for surgical site infection. |
Co-amoxiclav* IV 1.2g (one dose only) |
Clindamycin* IV 900mg (one dose only) |
1 st dose within 60 minutes before incision |
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*Antibiotic choice should be guided by microbiological culture results, where an additional agent may be indicated. Discuss with Microbiology where necessary. |
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Urological Surgery
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Antibiotics for Urological Surgery |
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Type of Surgery |
Procedure |
1 st Line Antibiotic |
In penicillin allergy |
Number & Timing of Doses |
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Prophylaxis in Urological Surgery Whenever possible submit a pre-operative/pre-catheter removal urine sample. If urine culture is positive, base prophylaxis on the susceptibility report. See Note Regarding Risk Factors for MRSA See Note Regarding Multi-drug Resistant Organisms (MDRO) |
Transrectal prostatic biopsy See Note Regarding Multi-drug Resistant Organisms (MDRO) |
Ciprofloxacin PO 750mg every 12 hours for a total of 2 doses + Gentamicin IV one dose only, dose per LAPP App calculator |
Ciprofloxacin PO 2 doses: 1 st dose 60 minutes prior to procedure; 2 nd dose 12 hours post-biopsy Gentamicin : One dose 30 minutes before biopsy. |
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Transperineal prostatic biopsy Brachytherapy Consider prophylaxis in patients at high risk of infection e.g. immunocompromised, poor general health, diabetes, immunosuppressive therapy |
If indicated, use regimen above for transrectal prostatic biopsy |
If indicated, use regimen above for transrectal prostatic biopsy. |
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Transurethral resection of prostate (TURP), nephrectomy, percutaneous nephrolithotomy (PCNL), radical prostatectomy, changing of stents/nephrostomy change |
Gentamicin IV one dose only, dose per LAPP App calculator + Co-amoxiclav IV 1.2g (one dose only) |
Gentamicin IV one dose only, dose per LAPP App calculator + Teicoplanin IV 10mg/kg (Max 800mg 1 ) (one dose only) |
One dose within 60 minutes before incision. |
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Extracorporeal shock wave lithotripsy
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Gentamicin IV one dose only, dose per LAPP App calculator *
* Additional stat dose of Co-amoxiclav may be used at the discretion of consultant Urologist for stone removal. |
One dose within 60 minutes before incision. |
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Cystourethroscopy with manipulation (includes transuretheral resection of bladder tumour-TURBT, any biopsy, resection, fulguration, foreign body removal, urethral dilatation, ureteral instrumentation including catheterisation, stent placement/removal, stone removal) |
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Procedure |
1 st line antibiotic |
Penicillin allergy: delayed onset non-severe reaction |
Penicillin allergy: immediate or severe delayed reaction |
Number & Timing of Doses |
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See penicillin hypersensitivity section for further information |
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Urological procedures involving bowel e.g. radical cystectomy
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Co-amoxiclav IV 1.2g |
CefUROXime IV 1.5g (one dose only) + Metronidazole IV 500mg (one dose only) |
Teicoplanin IV 10mg/kg (Max 800mg 1 ) (one dose only) + Gentamicin IV one dose only, dose per LAPP App calculator + Metronidazole IV 500mg (one dose only) |
One dose within 60 minutes before incision. |
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Cystoscopy |
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Routine prophylaxis is NOT recommended for urethral catheterisation or removal of urinary catheter . However, on removal of urinary catheter following recent urological surgery it may be appropriate to give gentamicin IV one dose only, dose per LAPP App calculator, infusion to be completed within one hour of catheter removal. 1. Discuss dosing in obese patients with Microbiology or Pharmacy |
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References
References
- AMRIC Surgical Antibiotic Prophylaxis Duration Position Paper October 2021
- Bratzler et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery Am J Health Syst Pharm.2013;70:195-283
- SIGN 104: Antibiotic Prophylaxis in Surgery July 2008, updated April 2014
- Scottish Medicines Consortium – Scottish Antimicrobial Prescribing Group 20221121-gprs-for-redosing-antibiotics-for-surgical-prophylaxis.pdf
- Allegranzi B, Bischoff P, de Jonge S, Kubilay NZ, Zayed B, Gomes SM, et al. 2016. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016;16(12):e276-e87.
- The Sanford Guide to Antimicrobial Therapy Digital Update Feb 2018
- Bennett and Brachman's "Hospital Infections" Lippincott, Williams and Wilkins. 6th edition 2013
- European Society Guidelines. ISPD Catheter-related Infection Recommendations: 2023. Update. Peritoneal Dialysis International. 2023. 1-19.
- HPRA Summary of Product Characteristics Teicoplanin (Himka) 200mg powder for injection (Accessed December 2024)
- European Society of Cardiology Guidelines on Cardiac pacing and Cardiac resynchronization therapy 2021 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy (Accessed December 2024)
- National Immunisation Advisory Committee (NIAC). Immunisations for Ireland. Chapter 3 https://www.rcpi.ie/Healthcare-Leadership/NIAC/Immunisation-Guidelines-for-Ireland (Accessed December 2024)
- WAC Directorate guidelines Management of Assisted Vaginal Birth (access via Linkopolis- Applications-HCI QPulse and search CLN-LW-0067-update in progress)
- WAC Directorate guidelines for the Manual Removal of the placenta (access via Linkopolis- Applications-HCI QPulse and search CLN-LW-0029)
- WAC directorate guidelines for the Management of 3 rd and 4 th Degree Tears (access via Linkopolis- Applications-HCI QPulse and search CLN-LW-0022)
- RCOG guidance 2020 : Assisted Vaginal Birth Green-top Guideline No. 26 April 2020 Murphy DJ, Strachan BK, Bahl R, on behalf of the Royal College of Obstetricians Gynaecologists. BJOG 2020 ;127:e70–e112.