Antibiotic Prophylaxis in General Surgery Antibiotic Guidelines. Contents

Transcription

1 Antibiotic Prophylaxis in General Surgery Antibiotic Guidelines Classification: Clinical Guideline Lead Author: Antibiotic Steering Committee Authors Division: CSS&TM Unique ID: 144TD(C)25(F3) Issue number: 5 Expiry Date: February 2021 Contents Section Who should read this document Key practice points Background/ Scope/ Definitions What is new in this version Policy/Procedure/Guideline Antibiotic prophylaxis in General Surgery (Table of recommendations) Upper GI, oesophageal and gastroduodenal surgery Bariatric Surgery Small bowel surgery Open biliary tract, pancreatic or liver surgery Laporoscopic Cholecystectomy Appendicectomy Appendicectomy Perforated or Gangrenous Hernia repair Inguinal/femoral WITH mesh Hernia repair Inguinal/femoral WITHOUT mesh Hernia repair Incisional Any Emergency Hernia repair Colorectal surgery-uncomplicated Colorectal surgery- complicated by faecal perforation/faecal peritonitis Standards References and Supporting Documents Roles and Responsibilities Document control information (Published as separate document) Document Control Policy Implementation Plan Monitoring and Review Endorsement Equality analysis Page Page 1 of 15

2 Who should read this document? This policy applies to all clinical staff involved the prescribing of antimicrobials. Key Practice Points This policy recommends prophylactic antibiotic regimes for adult patients undergoing general surgical procedures or breast surgery. 1 st and 2 nd line regimes (penicillin allergic patients) and recommendations for patients at risk of MRSA infection are included. Background/ Scope/ Definitions Antimicrobial agents are among the most commonly prescribed drugs and account for 20% of the hospital pharmacy budget. Unfortunately, the benefits of antibiotics to individual patients are compromised by the development of bacterial drug resistance. Resistance is a natural and inevitable result of exposing bacteria to antimicrobials. Good antimicrobial prescribing will help to reduce the rate at which antibiotic resistance emerges and spreads. It will also minimise the many side effects associated with antibiotic prescribing, such as Clostridium difficile infection. It should be borne in mind that antibiotics are not needed for simple coughs and colds. In some clinical situations, where infection is one of several possibilities and the patient is not showing signs of systemic sepsis, a wait and see approach to antibiotic prescribing is often justified while relevant cultures are performed. This document provides treatment guidelines for the most common situations in which antibiotic treatment is required. The products and regimens listed here have been selected by the Trust's Medicines Management Group on the basis of published evidence. Doses assume a weight of 60-80kg with normal renal and hepatic function. Adjustments may be needed for the treatment of some patients. This document provides treatment guidelines for the appropriate use of antibiotics. The recommendations that follow are for empirical therapy and do not cover all clinical circumstances. Alternative antimicrobial therapy may be needed in up to 20% of cases. Alternative recommendations will be made by the microbiologist in consultation with the clinical team. This document refers to the treatment of adult patients (unless otherwise stated). Page 2 of 15

3 What is new in this version? Section on Antibiotic Prophylaxis in Breast surgery removed as this is no longer carried out here. Policy/ Guideline/ Protocol Antimicrobial prophylaxis is indicated during selected clean surgical procedures and during procedures which involve incision of non-sterile mucosal surfaces (oral mucosa, respiratory tract, gastroinstestinal tract and female genito-urinary tract). Local departmental protocols should be followed where available. Prophylactic antibiotics should be prescribed on the single dose/pre-medication section of the prescription chart. Where a patient is at high risk of post-operative MRSA infection, teicoplanin should be included in the prophylaxis regimen. Patients at high risk of MRSA infection include: Patient with or has a history of MRSA colonisation or infection Prolonged pre-operative hospital inpatient stay General Principles 1. The final decision regarding the benefits and risks of antibiotic prophylaxis for an individual patient will depend on: the patient s risk of surgical site infection the potential severity of the consequences of surgical site infection the effectiveness of prophylaxis in that operation the consequences of prophylaxis for that patient (e.g. increased risk of C. difficile colitis) 2. Prophylaxis should be started preoperatively, ideally within 30 minutes of the induction of anaesthesia and within 1 hour of the surgical incision. 3. Penicillin Allergy: Patients with a history of angiodema, anaphylaxis, or severe skin reaction to any beta lactam antibiotics, are likely to have a true penicillin allergy and are therefore at an increased risk of immediate hypersensitivity to penicillins.they should not receive prophylaxis with a beta lactam antibiotic (these include penicillins, cephalosporins, monobactams and carbapenems). Patients with a minor or delayed rash, may not have a true penicillin allergy and can therefore receive prophylaxis with a cephalosporin, monobactam or carbapenem but not a penicillin. Page 3 of 15

4 4. An additional dose of prophylactic antibiotic during the operation is indicated if: there is major intra-operative blood loss blood loss of > 1500 ml during surgery. In this case, additional dose of the prophylactic antibiotic should be given after fluid replacement. haemodilution up to 15ml/kg surgery has lasted for more than 4 hours These rules apply with the EXCEPTION of teicoplanin, gentamicin and ciprofloxacin, where additional doses are not required. 5. Fluid replacement bags should not be primed with prophylactic antibiotics because of the potential risks of contamination and calculation errors Page 4 of 15

5 Antibiotic prophylaxis in General Surgery (Upper GI surgery, Lower GI surgery, Biliary tract surgery and hernia repair) Operation Upper GI, oesophageal and gastroduodenal surgery 1 st line Prophylaxis Regimen 2 nd line Regimen (for true penicillin allergy) Gentamicin IV* and IV on High risk of MRSA infection 1 st or 2 nd line regimen 400mg on Other comments Bariatric Surgery Teicoplanin 800mg IV and Ciprofloxacin 400mg IV and Metronidazole 1g IV. Teicoplanin 800mg IV and Ciprofloxacin 400mg IV and Metronidazole 1g IV. Small bowel surgery Gentamicin IV* and IV on 1 st or 2 nd line regimen 400mg on Page 5 of 15

6 Open biliary tract, pancreatic or liver surgery No infection induction Gentamicin IV* and metronidazole 500mg IV on 1 st or 2 nd line regimen 400mg on. If underlying infection potentially/ actually present Co-amoxiclav 1.2g IV at induction followed by IV Amoxicillin 1g 8 hourly, Metronidazole 500mg IV 8 hourly and Gentamicin IV* 24 hourly for 72 hours. IV Teicoplanin 400mg, IV gentamicin* and IV followed by oral ciprofloxacin 500mg bd, and IV metronidazole 500 mg 8 hourly for 72 hours. IV Teicoplanin 400mg, IV gentamicin* and IV followed by oral ciprofloxacin 500mg bd, and IV metronidazole 500 mg 8 hourly for 72 hours. If active MRSA infection suspected- IV vancomycin should be started 12 hours post op. Discuss with microbiology. Consider IV to oral switch after hours. If more than 72 hours of antibiotics are required, contact microbiology. Page 6 of 15

7 Laporoscopic Cholecystectomy Appendicectomy Appendicectomy Perforated or Gangrenous induction induction followed by IV Amoxicillin 1g 8 hourly, Metronidazole 500mg IV 8 hourly and Gentamicin IV* 24 hourly for 72 hours. Gentamicin IV* and metronidazole 500mg IV on Clindamycin 600mg IV and Gentamicin IV* on IV Teicoplanin 400mg, IV gentamicin* and IV followed by oral ciprofloxacin 500mg bd, and IV metronidazole 500 mg 8 hourly for 72 hours. 1st or 2nd line regimen 400mg on induction 1st or 2nd line regimen 400mg on induction IV Teicoplanin 400mg, IV gentamicin* and IV followed by oral ciprofloxacin 500mg bd, and IV metronidazole 500 mg 8 hourly for 72 hours. If active MRSA infection suspected- IV vancomycin should be started 12 hours post op. Discuss with microbiology. Clindamycin should be diluted in 50ml 0.9% sodium chloride and infused over 20 minutes. If more than 72 hours of antibiotics are required, contact microbiology. Refer to Trust Gentamicin policy for more advice on prescribing and monitoring of once daily gentamicin. Consider IV to oral switch after hours. Page 7 of 15

8 Hernia repair Inguinal/femoral WITH mesh induction Clindamycin 600mg IV and Gentamicin IV* on 1st or 2nd line regimen 400mg on induction Clindamycin should be diluted in 50ml 0.9% sodium chloride and infused over 20 minutes. (Laproscopic or nonlaporoscopic) Hernia repair Inguinal/femoral WITHOUT mesh (Laproscopic or nonlaporoscopic) As above if risk factors present: 1. Age > 75years 2. Obesity 3. Presence of urinary catheter Hernia repair Incisional WITH or WITHOUT mesh induction Clindamycin 600mg IV and Gentamicin IV* on 1st or 2nd line regimen 400mg on induction Clindamycin should be diluted in 50ml 0.9% sodium chloride and infused over 20 minutes. (Laporoscopic or non-laporoscopic) Page 8 of 15

9 Any Emergency Hernia repair induction Clindamycin 600mg IV and Gentamicin IV* on 1st or 2nd line regimen 400mg on induction Clindamycin should be diluted in 50ml 0.9% sodium chloride and infused over 20 minutes. Colorectal surgeryuncomplicated IV Teicoplanin 400mg, IV gentamicin* and IV on IV Teicoplanin 400mg, IV gentamicin* and IV on Colorectal surgerycomplicated by faecal perforation/faecal peritonitis induction followed by IV Piperacillin/tazobactam 4.5g 8 hourly for 72 hours. IV Teicoplanin 400mg, IV gentamicin* and IV followed by oral ciprofloxacin 500mg bd, and IV metronidazole 500 mg 8 hourly for 72 hours. IV Teicoplanin 400mg, IV gentamicin* and IV followed by oral ciprofloxacin 500mg bd, and IV metronidazole 500 mg 8 hourly for 72 hours. If active MRSA infection suspected- IV vancomycin should be started 12 hours post op. Discuss with microbiology. If more than 72 hours of antibiotics are required, contact microbiology. Refer to Trust Gentamicin policy for more advice on prescribing and monitoring of once daily gentamicin. Clindamycin should be diluted in 50ml 0.9% sodium chloride and infused over 20 minutes. Page 9 of 15

10 * Gentamicin dose: Estimated Body Weight (kg) Normal renal function (egfr>30ml/min, creatinine <200umol/L) Ready made bags/vials to be used CKD stage 4-5 (egfr<30mls/min, creatinine >200umol/L) Ready made bags/vials to be used <60 240mg 1 x 240mg bag 120mg 1.5 x 80mg vials mg 1x 360mg bag 160mg 2 x 80mg vials >90 480mg 2x 240mg bags 240mg 1 x 240mg bag Page 10 of 15

11 Standards Document the Indication/rationale for antimicrobial therapy, including clinical criteria relevant to this. Review and document the patient s allergy status Ensure the choice of antibiotic complies with the antibiotic guidelines and you have documented any clinical criteria relevant to the choice of agent. Document a management plan including a stop or review date. Where relevant, consider drainage of pus or surgical debridement/removal of foreign material. Explanation of terms & Definitions N/A References and Supporting Documents 1. SIGN. Antibiotic prophylaxis in surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; NICE clinical guideline 74. Surgical Site Infection. October Association of Surgeons of Great Britain and Ireland. Groin Hernia Guidelines. May Bratzler DW, Houck PM. Surgical Infection Prevention Guideline Writers Workgroup: Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Am J Surg 2005; 189(4): Aufenacker T, Koelemay M, Gouma D, Simons M. Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia. Wiley Interscience Roles and responsibilities All clinical staff involved in the prescribing of antimicrobials to adhere to this policy including full documentation on EPMAR as detailed. Page 11 of 15

12 Document Control Information Antibiotic Prophylaxis in General Surgery Antibiotic Guidelines Lead Author: Antibiotic Steering Committee Additional authors: as above Document owner: Christine Khan Contact details: 0161 Classification: Clinical guideline Scope: Trust-wide Applies to: Clinical staff Document for public display: Yes Keywords: Antibiotic, Infection, General Surgery Associated Documents: Trusts Medicines Policy. Unique Identifier: 144TD(C)25(F3) Issue number: 5 Replaces: Antibiotic Guidelines: Antibiotic Prophylaxis in General Surgery Issue 4 Authorised by: Medicines Management Committee Authorisation date: February 2018 Next review: February 2021 Policy Implementation Plan The guideline will form part of the Trust Antibiotic Policy and thus can be accessed via the Antibiotic and Infection Control hotlinks area on the front page of Synapse. In addition, adherence to the policy will be encouraged through FY1 and FY2 teaching sessions. Monitoring and Review The guidelines will be reviewed on a two-yearly basis. Audits of compliance with the guideline will be conducted on a regular basis. Page 12 of 15

13 Endorsement Endorsed by: Name of Lead Clinician/Manager or Committee Chair Position of Endorser or Name of Endorsing Committee Date Dr Paul Chadwick Antibiotic Steering Committee June 2012, September 2013, November 2013, Feb 2018 Dr John MacDonald Medicines Management Committee July 2012, October 2013, January 2014, Feb 2016 Dr Alex Peel Antibiotic Steering Committee Jan 2016, Jan 2018 Page 13 of 15

14 Screening Equality Analysis Outcomes The Trust is required to ensure that all our policies/procedures meet the requirements of its service users, that it is accessible to all relevant groups and furthers the aims of the Equality Duty for all protected groups by age, religion/ belief, race, disability, sex, sexual orientation, marital status/ civil partnership, pregnancy/ maternity, gender re-assignment. Due consideration may also be given to carers & socioeconomic factors. Have you been trained to carryout this assessment? YES/NO If 'no' contact Equality Team for details. Name of policy or document : Antibiotic Guidelines: Antibiotic Prophylaxis in General Surgery Key aims/objectives of policy/document (impact on both staff & service users): This document provides treatment guidelines for the most common situations in which antibiotic treatment is required and provides guidelines for the most appropriate use of antibiotics 1) a) Whom is this document or policy aimed at? 2) a) Is there any evidence to suggest that your end users have different needs in relation to this policy or document; (e.g.health/employment inequality outcomes) (NB If you do not have any evidence you should put in section 8 how you will start to review this data) 3) a) Does the document require any decision to be made which could result in some individuals receiving different treatment, care, outcomes to other groups/individuals? b) If yes, on what basis would this decision be made? (It must be objectively justified) 4) a) Have you included where you may need to make reasonable adjustments for disabled users or staff to ensure they receive the same outcomes to other groups? 5) a) Have you undertaken any consultation/involvement with service users or other groups in relation to this document? b) If yes, what format did this take? face/face or questionnaire? (please provide details of this) 1a) All staff who prescribe or administer antibiotics 2a) No 3a) Yes 3b) Alternative choices recommended for some patients with allergy (to avoid harm) and for pregnant patients (to protect the baby). 4a) Not applicable 5a) Yes 5b) distribution to consultant staff for comments. Discussions at Antibiotic Steering Group and Medicines Management Group. Page 14 of 15

15 c)has any amendments been made as a result? 6) a) Are you aware of any complaints from service users in relation to this policy? b) If yes, how was the issue resolved? Has this policy been amended as a result? 5c) No 6a) No 6b) Not Applicable 7) a) To summarise; is there any evidence to indicate that any groups listed below receive different outcomes in relation to this document? Age Disability Sex Race Religion & Belief Sexual orientation Pregnancy & Maternity Marital status/civil partnership Gender Reassignment Carers *1 Socio/economic**2 Positive Yes No unsure Negative* 1: That these two categories are not classed as protected groups under the Equality Act. 2: Care must be taken when giving due consideration to socio/economic group that we do not inadvertently discriminate against groups with protected characteristics Negative Impacts *If any negative impacts have been identified you must either a) state below how you have eliminated these within the policy or b) conduct a full impact assessment: 8) How will the future outcomes of this policy be monitored? Through audits, AIRs and complaints. 9) If any negative impact has been highlighted by this assessment, you will need to undertake a full equality impact assessment: Will this policy require a full impact assessment? Yes/No (delete) (if yes please contact Equality Team, 62598/67204, for further guidance) High/Medium/Low signed Alex Peel date: January 2018 Page 15 of 15