NHS Dumfries And Galloway. Surgical Prophylaxis Guidelines

Transcription

1 NHS Dumfries And Galloway Surgical Prophylaxis Guidelines The aim of surgical prophylaxis is to reduce rates of surgical site and health-care associated infections and so reduce surgical morbidity and mortality. There is however growing evidence that aspects of prescribing practice may themselves be associated with health-care associated infections, notably Clostridium difficile infection. SIGN guideline 104, published in July 2008, has outlined which surgical procedures require prophylactic antibiotics. Principles of prophylaxis have also been outlined, including timing and duration of antibiotic administration. In conjunction with the surgical specialties and anaesthetists within NHS Dumfries and Galloway the Antimicrobial Management Team (AMT) has undertaken to review local prophylaxis policy and to formulate a uniform policy. These guidelines are based on SIGN 104 Antibiotic prophylaxis in surgery 2008 and the Scottish Antimicrobial Prescribing Group Antibiotic Prescribing in antibiotic choice guidance SIGN 104 emphasises that virtually all surgery requires only one dose of each antimicrobial and that it should be prescribed on the medication chart. If further doses are required it should be considered treatment and prescribed in the medication chart as such and a treatment plan included in the operation or medical notes. Each surgical speciality is required to measure their compliance with prophylaxis guidelines on a weekly basis (5 patients per week) as prescribing indicators which are linked to the HEAT target of reducing Clostridium difficile by 30% by These guidelines refer to prophylaxis only. In-patients with surgical infection please follow treatment guidelines. Principles of Policy for NHS Dumfries and Galloway 1. Indication for prophylaxis should comply with SIGN 104 guideline i.e. when recommended or considered within guideline. 2. Timing of antibiotic(s); a. Optimum timing is <=30 minutes prior to skin incision (usually in anaesthetic room at induction of anaesthesia). b. Sub-optimal if >1 hour prior to skin incision or post-skin incision 3. Recording of antibiotic(s); in once only section of in-patient medication chart. This is preferred to recording in the anaesthetic record. 4. Choice of agent(s); avoid cephalosporins, clindamycin, quinolones and coamoxiclav whenever possible and use appropriate narrow spectrum agent(s) when possible. 5. Frequency of administration; usually. 2 nd dose only if; a. >1.5 litre intra-operative blood loss consider further dosing (see table below) b. Operation prolonged (see table below) c. Primary arthroplasty (24 of prophylaxis recommended) 6. Document reason for antibiotic admin beyond 1 st dose (as above) in medical or operation notes. 1

2 7. Document reason for deviation from antibiotic policy in medical or operation notes. 8. De-colonisation therapy prior to surgery when MRSA positive. 9. Complex individual prophylaxis issues should be discussed with microbiology pre-operatively. 10. Post-operative infection. Follow infection management guidelines. If gentamicin required follow treatment guidelines dosing at 8-12 after prophylaxis, checking concentrations at 6-14 hrs post treatment dose. Prescribe on in-patient medication chart as per gentamicin guidelines. IV Antibiotic Administration Guidance: Antibiotic Dose Administration Prolonged surgery >1.5L blood loss redose after fluid replacement Clarithromycin Dissolve in 10ml water for injection then IV infusion in 250ml glucose 5% or sodium chloride 0.9% over 60 minutes into larger proximal vein Clindamycin 600mg Made up to 50ml with glucose 5% or sodium chloride 0.9% then infusion over 20 minutes Co-amoxiclav Reconstitute with 20ml water for injections and bolus over 3-5 minutes Flucloxacillin Bolus over 3 4 minutes in 15 to 20ml of water for injections. Administer by slow intravenous injection Gentamicin Bolus over at least 5min (no dilution required). Can also be added to metronidazole infusion bag Re-dose after 12 Re-dose 600mg after 4 Re-dose after 8 Re-dose after 4 Re-dose after 8. If creatinine clearance less than 20ml/min do not re-dose and gentamicin level must be less than 1mg/l before further doses are given. Metronidazole Infusion over 20 minutes Re-dose after 8 Re-dose 600mg Up to one further dose may be given if creatinine clearance less than 20ml/min do not redose. Teicoplanin 400mg Reconsitute with entire contents of water vial provided and roll gently until dissolved. If foamy stand for 15 minutes give entire vial contents by bolus injection over 3-5 minutes Re-dosing not required Re-dosing not required 2

3 Type of ENT Ophthalmic Head and neck surgery, contaminated Grommet insertion Ear (clean) Head and Neck (Clean) Nose and Sinus surgery Tonsillectomy Adenoidectomy (by curettage) Cataract Glaucoma or corneal grafts Penetrating eye injury Antibiotic/Dose/ Duration Co-amoxiclav IV Betamethasone N (Topical) Cefuroxime Injected into anterior chamber 1. Penicillin allergy 2. MRSA Positive 1. Clarithromycin metronidazole 2. Add teicoplanin 400mg Ortho Lacrimal surgery Total Hip replacement Prosthetic knee joint replacement (regardless of antibiotic cement) Closed fracture fixation Hip fracture repair Spinal fracture Insertion of prosthetic devices Soft tissue surgery of the hand Co-amoxiclav IV single dose Cefuroxime IV 1.5g pre surgery followed by 2 further doses of cefuroxime IV 750mg Teicoplanin IV 400mg gentamicin IV General Orthopaedic surgery without prosthetic device (elective) Colorectal surgery Appendectomy with risk of ruptured viscus/peritoneal contamination Biliary surgery (open and laparoscopic) Percutaneous drainage Biliary drainage/ stenting Percutaneous endoscopic gastrostomy (PEG) Gastroduodenal surgery Oesophageal surgery Small bowel surgery Liver surgery Pancreatic surgery Teicoplanin 400mg IV Breast surgery Laparoscopic or non laparoscopic hernia repair with or without mesh ERCP Diagnostic endoscopic procedures Teicoplanin IV 400mg 3

4 Type of Antibiotic/Dose/ Duration Obstetrics/ Gynaecology surgery Abdominal hysterectomy Vaginal hysterectomy 1. Penicillin allergy 2. MRSA Positive Caesarean section Manual removal of placenta Co-amoxiclav IV Add teicoplanin IV 400mg Perineal 3 rd and 4 th degree tear Co-amoxiclav IV 1.2 g Followed by 5 days oral therapy Clindamycin IV 600mg Followed by 5 days oral therapy Radiological Intervention Urology Surgical termination of pregnancy Percutaneous drainage Biliary drainage/stenting Biopsy Trans-urethral resection of prostate Trans-rectal prostate biopsy Percutaneous nephrolithotomy Endoscopic ureteric stone fragmentation/removal Radical cystectomy Azithromycin oral metronidazole oral 400mg Both 1. No Change 2. Add teicoplanin IV 400mg Vascular surgery Trans-urethral resection of bladder tumours Lower limb amputation Teicoplanin 400mg IV Vascular surgery (abdominal and lower limbs) Both single dos Teicoplanin IV 400mg 4

5 Splenectomy patients Note: Persons without a spleen are at an increased risk of death due to an overwhelming septicaemia with a mortality in excess of 50%. This is normally caused by the encapsulated bacteria which include Haemophilus influenzae type b, the pneumococcus, and Neisseria meningitidis sero group C. Please see NHS D&G Splenectomy Policy. 5