CLINICAL GUIDELINE Antibiotic Prophylaxis For use in (clinical areas): For use by (staff groups): For use for (patients): Document owner: Status: All clinical areas All clinicians Microbiology Consultants Approved Purpose of the Guideline To provide rational guidelines for prophylaxis in a single document to complement the antibiotic guidelines published separately (CG10118-3). Doses where stated refer to adult patients. Contents 1. Medical conditions requiring prophylaxis & prevention of secondary cases of infectious diseases Prevention of endocarditis Prevention of infection in patients with an absent or dysfunctional spleen Prevention of secondary case of meningococcal meningitis/septicaemia Prevention of secondary case of Haemophilus influenzae type b disease Prevention of TB Tetanus-prone wounds 2. Surgical prophylaxis: general points 2.1 Timing and duration 2.2 MRSA & other multi-resistant organisms 2.3 Penicillin allergy 2.4 Gentamicin 2.5 Vancomycin 2.6 Other points of consideration 3. Surgical prophylaxis: Specialty-specific recommendations 3.1 Gastro-intestinal and general surgery 3.2 Urology 3.3 Orthopaedics 3.4 Obstetrics & gynaecology 4. Development of this guideline Source: Microbiology dept. Issue date: February 2008 Page 1 of 14
1. Medical conditions requiring prophylaxis & prevention of secondary cases of infectious diseases Condition Recommendations Prevention of endocarditis in patients with heart-valve lesion, septal defect, patent ductus, prosthetic valve or history of endocarditis Prevention of infection in patients with an absent or dysfunctional spleen Prevention of secondary case of meningococcal meningitis/septicaemia See guidelines in section 5.1, table 2 of BNF. Refer to infection control manual policy CG10034-2 Guidelines for the Prevention of Infection in those with an Absent or Dysfunctional Spleen Discuss with Health Protection Unit (01473-329583 during office hours or via switchboard out of hours). Refer to infection control manual policy CG10025-2 Meningococcal Disease: Protocol for Diagnosis and Antibacterial Management Prevention of secondary case of Haemophilus influenzae type b disease Prevention of TB in susceptible close contacts or those who have become tuberculin positive Discuss with Health Protection Unit (01473-329583 during office hours or via switchboard out of hours). Tetanus-prone wounds See chapter 30 'Immunisation against Infectious Diseases 2006' (the Green Book) http://www.dh.gov.uk/en/poli cyandguidance/healthandso cialcaretopics/greenbook/d H_4097254 See section 5.1, table 2 of BNF Discuss with Consultant Respiratory Physician (lead for TB) Source: Microbiology dept. Issue date: February 2008 Page 2 of 14
2. Surgical prophylaxis: general points This guideline is intended to help clinicians use the most appropriate antibiotics to prevent surgical site infection as well as reduce the incidence of side effects, including Clostridium difficile associated diarrhoea, and prevent the emergence of antibiotic resistant organisms. 2.1 Timing & Duration Antibiotics are given as single doses (unless stated) at induction to achieve maximum tissue concentrations at the time of operation. However, vancomycin must be given as an infusion over 100 minutes and consequently timed to commence on the ward 100 minutes before the operation (and in the case of orthopaedic surgery 100 minutes before application of the tourniquet). Where 5mg/kg gentamicin is given (see individual procedures) it must be given as an infusion over 60 minutes and therefore must be commenced on the ward 60 minutes before the operation. should not normally be given for more than 24 hours but additional doses of antibiotics may be required if there has been excessive blood loss or haemodilution or surgery has been prolonged. 2.2 MRSA & other multi-resistant organisms (e.g. ESBL-producing coliforms) Check patients notes and APEX results for evidence of these organisms before prescribing prophylaxis a) MRSA If the patient is known to be MRSA positive consider adding/substituting vancomycin. Teicoplanin should only be prescribed in situations where vancomycin cannot be used and after discussion with a Consultant Microbiologist. b) ESBL-producing coliforms There are very few antibiotic options for the treatment/prophylaxis of these multi-resistant bacteria and prophylaxis is likely to require the use of ertapenem or meropenem. Please discuss individual cases with the duty consultant microbiologist. 2.3 Penicillin allergy The most important side-effect of the penicillins is hypersensitivity which causes rashes and anaphylaxis and can be fatal. Allergic reactions to penicillins occur in 1 10% of exposed individuals; anaphylactic reactions occur in fewer than 0.05% of treated patients. Individuals with a history of anaphylaxis, urticaria, or rash immediately after penicillin administration are at risk of immediate hypersensitivity to a penicillin; these individuals should not receive a penicillin, a cephalosporin or another beta-lactam antibiotic. Individuals with a history of a minor rash (i.e. non-confluent rash restricted to a small area of the body) or a rash that occurs more than 72 hours after penicillin administration are probably not allergic to penicillin but the possibility of an allergic reaction should be borne in mind. Source: Microbiology dept. Issue date: February 2008 Page 3 of 14
Alternative antibiotic options are given in the tables. Antibiotics to be avoided in major penicillin allergy: Amoxicillin / ampicillin Aztreonam Benzylpenicillin Cephalosporins (all) Carbapenems (meropenem, ertapenem) Co-amoxiclav Augmentin Flucloxacillin Phenoxymethylpenicllin / penicillin V Piperacillin/tazobactam Tazocin Antibiotics to be used with caution in those with non-severe allergy (minor rash) Aztreonam Cephalosporins (all) Carbapenems 2.4 Gentamicin Gentamicin prophylaxis will usually be given as a single dose of either 160mg, or 120mg for patients who weigh less than 60kg. Single doses of gentamicin do not require serum levels to be measured. Where additional doses are required to be given it is important to ensure that the dose and timing is appropriate for the patients weight and renal function to prevent over-dosing. Serum levels will need to be monitored. There are a few indications for gentamicin to be given at a treatment dose of 5mg/kg dose (these are detailed in the following tables). In these cases, the total dose needs to be calculated using the ideal body weight. This must be given as an infusion over 60 minutes and therefore needs to be commenced on the ward 60 minutes before the operation. Source: Microbiology dept. Issue date: February 2008 Page 4 of 14
Calculation of Ideal Body Weight For non obese patients use actual body weight For obese patients (>120% of Ideal Body Weight) use Obese Dosing Weight as calculated from the equations below. Male Ideal Body Weight (kg) = 50 + (2.3 x inches over 5 feet) Female Ideal Body Weight (kg) = 45.5 + (2.3 x inches over 5 feet) Obese Dosing Weight (in kg) = Ideal Body Weight + 0.4 (Actual Body Weight Ideal Body Weight) Please note that the maximum daily dose is 480mg Where gentamicin 5mg/kg once-daily is used and continued post-operatively for the treatment of infection (e.g. where extensive tissue soiling has occurred), serum levels will need to be assayed. Please refer to the Trust policy: CG10100-1 Trust Guideline for the Use of Gentamicin as a Once Daily Dose in Adults. There is additional guidance in the Trust Antibiotic Guidelines CG10118-3. 2.5 Vancomycin Vancomycin should be given as an infusion over 100 minutes to complete before the operation commences. Where vancomycin is continued post-operatively please refer to the guidance in the pharmacy section of the pink book for monitoring serum levels. Single stat doses of vancomycin do not require serum levels to be measured. There is additional guidance in the Trust Antibiotic Guidelines CG10118-3. 2.6 Other points of consideration These guidelines MUST be used in conjunction with the patient s microbiology results. For example, do not automatically prescribe gentamicin prophylaxis if a gentamicin-resistant organism has been isolated. Check there are no contra-indications for your individual patient e.g. drug allergies, interactions with other medication, pregnancy etc and that the dose prescribed is appropriate for your patient s ideal weight & renal function. These guidelines cannot provide options for every eventuality. If in doubt, discuss with the duty consultant microbiologist. Source: Microbiology dept. Issue date: February 2008 Page 5 of 14
3. Specialty-specific recommendations 3.1 Gastro-intestinal and general surgery Gastro intestinal and general GI surgery prophylaxis (excluding appendicitis) Appendicitis - uncomplicated 1 st Choice Alternative (e.g. if true penicillin allergy or MRSA positive) Gentamicin 160mg and 500 mg Metronidazole 500mg at induction or 1g suppository given 2 hours before surgery Vancomycin 1g, gentamicin 160mg and 500 mg If intra-abdominal sepsis please use antibiotic treatment as specified below Give 120mg gentamicin if patient weighs <60kg - complicated Treat as intraabdominal sepsis (see below) Intra-abdominal sepsis incl. pancreatic & biliary (as in Trust Antibiotic Guidelines CG- 10118-3) Piperacillintazobactam 4.5g tds & gentamicin 5mg/kg od* Vancomycin 1g bd*, gentamicin 5mg/kg od*and 500mg tds Antibiotics will need to be continued post-operatively *Doses and intervals may need adjustment if renal impairment. Gentamicin and vancomycin levels will need to be monitored. Oral options for follow-on therapy include co-amoxiclav, and cephradine with and will need to be tailored to microbiology results. Please refer to Table 2 in Trust Antibiotic Guidelines CG-10118-3. Source: Microbiology dept. Issue date: February 2008 Page 6 of 14
Gastro intestinal and general Hernia surgery (laparoscopic or nonlaparoscopic) with a mesh If indicated* 1 st Choice Alternative (e.g. if true penicillin allergy or MRSA positive) Co-amoxiclav 1.2g Gentamicin 160mg and 500 mg Add Vancomycin 1g if MRSA positive *Cochrane review 2007: antibiotic prophylaxis for elective inguinal hernia repair cannot be universally recommended but its administration cannot either be recommended against when high rates of wound infection are observed No indication for prophylaxis in hernia surgery without a mesh. Give 120mg gentamicin if patient weighs <60kg ERCP Gentamicin 160mg Give 120mg gentamicin if patient weighs <60kg PEG insertion Flucloxacillin 1g Vancomycin 1g Breast surgery (if required) Flucloxacillin 1g Vancomycin 1g Prophylaxis not routinely given Pre-warming used instead. Vascular surgery Flucloxacillin 1 g Vancomycin 1g Extra dose in prolonged surgery or if excessive blood loss. Add gentamicin 160mg if operation extends to/below groin. Add gentamicin 160mg if operation extends to/below groin. Add 500mg at induction and give all antibiotics for 48 hrs if bowel ischaemia suspected. Give 120mg gentamicin if patient weighs <60kg Ophthalmological surgery See ophthalmology department protocol Source: Microbiology dept. Issue date: February 2008 Page 7 of 14
3.2 Urology Urological 1 st choice Alternative (e.g. if true penicillin allergy or MRSA positive) Whenever possible, bacteriuria should be detected and treated before any surgical procedure on the urogenital tract, and the subsequent prophylactic regimen will need to cover the organism isolated. Please send urine samples at least 72 hours preprocedure where possible. If patient has had resistant organisms including MRSA, ESBL-producing coliforms & VRE isolated from urine then discuss with duty consultant microbiologist. Insertion of urinary catheter Open surgery involving bowel/vagina (and penile prosthesis insertion) If antibiotics indicated gentamicin 160mg stat or if history of ESBL infections then use ertapenem 1g stat or meropenem 500mg stat (if ertapenemresistant organism isolated in past) Amoxicillin 1g & gentamicin 160mg & 500mg Vancomycin 1g & gentamicin 160mg & 500mg Antibiotics not required in every case but can be given if urinary tract infection suspected or at risk of infection/bacteraemias. If catheter being inserted postoperatively may not require further gentamicin dose if has already received it as preoperative prophylaxis. Give 120mg gentamicin if patient weighs <60kg May require additional doses if prolonged surgery Give 120mg gentamicin if patient weighs <60kg Removal of postoperative catheters No indication for routine use, but if required gentamicin 80mg can be given 1hour prior to procedure. See notes opposite if urine infected. Prophylaxis should take account of current urinary culture susceptibilities, particularly if MRSA / resistant coliforms are present. Source: Microbiology dept. Issue date: February 2008 Page 8 of 14
Urological 1 st choice Alternative (e.g. if true penicillin allergy or MRSA positive) Prostatic biopsy Co-amoxiclav 625mg PO at least 60 minutes preprocedure Add doxycycline 200mg PO or vancomycin 1g if MRSA positive Give 120mg gentamicin if patient weighs <60kg Oral antibiotics to continue for 2-3 days post-procedure. or Gentamicin 160mg and 500 mg Urodynamic assessments / Endoscopic procedures Co-amoxiclav 625mg at lease 60 minutes preprocedure PO or gentamicin 160mg If penicillin allergic: gentamicin 160mg If MRSA positive please discuss with duty microbiologist Prostatectomy (open or transurethral) Cystoscopy +/- resection of bladder tumour Gentamicin 160mg If MRSA positive vancomycin 1g with gentamicin 160mg Give 120mg gentamicin if patient weighs <60kg Cystectomy & ileal conduit formation Amoxicillin 1g & gentamicin 5mg/kg (ideal body weight) infusion oncedaily dosing regimen & 500mg Vancomycin 1g & gentamicin 5mg/kg (ideal body weight) infusion once-daily dosing regimen & 500mg Continue antibiotics for 5 days. Vancomycin & gentamicin levels will be required. Renal surgery (clean, noninfected) Prophylaxis not indicated Source: Microbiology dept. Issue date: February 2008 Page 9 of 14
Urological 1 st choice Alternative (e.g. if true penicillin allergy or MRSA positive) Renal & ureteric surgery (infected) Gentamicin 5mg/kg (ideal body weight) infusion oncedaily dosing regimen If MRSA positive vancomycin 1g & gentamicin 5mg/kg (ideal body weight) infusion once-daily dosing regimen A course of antibiotics will be required. Vancomycin & gentamicin levels will be required. Nephrostomy &/or stent insertion i) If no culture sent / results unavailable / urine sterile, give stat dose of Gentamicin 5mg/kg (Ideal Body weight) ii) If urine culture and sensitivity results available, use these to guide prophylaxis If the patient has ever had MRSA or is currently infected or colonised with MRSA, give Gentamicin 5mg/kg as above, PLUS Teicoplanin 400mg single dose In ALL cases send specimen of urine / pus to Microbiology, even if a pre procedure urine was sent iii) If the patient has ever had an ESBL coliform infection, check sensitivities with Microbiologist if possible. Give a stat dose of 1g Ertapenem infusion starting just prior to procedure. Seek advice from Duty Microbiologist if necessary. Source: Microbiology dept. Issue date: February 2008 Page 10 of 14
3.3 Orthopaedics Orthopaedics 1 st choice Alternative (e.g. if true penicillin allergy or MRSA positive) Joint replacement including hip and knee Traumatic open / compound fractures For prevention of gas gangrene in high lower-limb amputations or following major trauma Flucloxacillin 2g & gentamicin 160mg at induction, then flucloxacillin 500mg for 3 further doses 6 hourly Flucloxacillin 1g qds & gentamicin* 5mg/kg (ideal body weight) infusion once-daily regimen & 500 mg tds Benzylpenicillin 600mg -1.2g qds for 5 days Vancomycin 1g and a further 1g dose of vancomycin 12 hours later* Give gentamicin 160mg when/if the patient is catheterized perioperatively. Vancomycin 1g bd* & gentamicin* 5mg/kg (ideal body weight) infusion once-daily regimen & 500 mg tds Metronidazole 500mg at induction and then 400mg PO tds for 5 days For revisions, discuss with microbiologist since prophylaxis should be tailored to cover any previous isolate Give 120mg gentamicin if patient weighs <60kg *assumes normal renal function. Will need adjusting if renal impairment. Antibiotics may need to be continued post-operatively. *Assumes normal renal function. Will need adjusting if renal impairment. Vancomycin & gentamicin levels will be required. Refer to policies in pharmacy section of pink book Also, see section on prevention of gas gangrene below Don't forget to check the tetanus status. Lower limb amputation Flucloxacillin 1g Vancomycin 1g Add 500mg tds (starting at induction) if anaerobes likely Source: Microbiology dept. Issue date: February 2008 Page 11 of 14
Orthopaedics 1 st choice Alternative (e.g. if true penicillin allergy or MRSA positive) Skull fracture with or without CSF leak Withhold antibiotics and monitor closely There is still uncertainty over the role of prophylaxis in skull fracture, but the Infection in Neurosurgery Working Party of the BSAC and a Cochrane Review concluded that the available evidence does not support the use of prophylactic antibiotics in patients with a skull fracture and CSF fistulae. 3.4 Obstetrics and gynaecology Obstetrics and gynaecology Hysterectomy 1 ST choice Alternative (e.g. if true penicillin allergy) Co-amoxiclav 1.2g at induction Gentamicin 160mg & Metronidazole 500mg (or 1g suppository PR) If known MRSA positive please discuss with microbiologist Caesarian section Co-amoxiclav 1.2g immediately after cord is clamped Clindamycin 600mg or Gentamicin 160mg immediately after cord is clamped & consider addition of 500mg if patient is at high risk of anaerobic infection e.g. PROM prior to section If known MRSA positive please discuss with microbiologist Group B Streptococci prophylaxis during labour Refer to departmental policy Give 120mg gentamicin if patient weighs <60kg Source: Microbiology dept. Issue date: February 2008 Page 12 of 14
4. Development of the Guidelines Amendment made to version 3 (CG10049-3) on 20 February 2008 as follows: Urology section, page 8. Removal of post-operative catheters: if required, gentamicin 80mg to be given (instead of using 160mg or 120mg ). Second version (CG10049-2) in use from 7 January 2008 & amended 28 January 2008 Amendment to orthopaedic section: 2 nd line prophylaxis for Joint Replacement including hip & knee : gentamicin to be given only when/if catheterized (in addition to vancomycin). Changes compared to first document (CG10049-1) This guideline (CG10049-2) replaces CG10049-1, issued March 2004 New sections on: timing and duration of prophylaxis; patients with MRSA or multi-resistant organisms; vancomycin and gentamicin prescribing and penicillin allergy. Reduction in the use of broad-spectrum cephalosporins and ciprofloxacin, antibiotics known to induce Clostridium difficile infection. Nephrostomy &/or stent insertion and PEG insertion prophylaxis guidelines incorporated into this document Group B streptococci prophylaxis in labour cross-referenced to departmental policy Ophthalmology prophylaxis cross-referenced to departmental policy Statement of clinical evidence Sources used: SIGN intercollegiate guidelines Publication 45 (July 2000): 'Antibiotic Prophylaxis in Surgery' http://www.sign.ac.uk/guidelines/fulltext/45/index.html BNF Section 5 Infections in surgery: 1 Gastrointestinal and biliary surgery. Drugs and Therapeutics Bulletin 2003; 41: 83-86 in surgery: 2 Urogenital, obstetric and gynaecological surgery. Drugs and Therapeutics Bulletin 2004; 42: 9-13 Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical infection Prevention Project, D.W Bratzler & P.M Houck, Clinical Infectious Diseases 2004:38 1706-1715 Quality standard for antimicrobial prophylaxis in surgical procedures, E. Patchen Dellinger et al, Clinical Infectious Diseases 1994;18:422-7 Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. for hernia repair. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003769. DOI: 10.1002/14651858.CD003769.pub3. BSG Working party Consensus on Antibiotic Prophylaxis in Endoscopy: Currently in Limbo, British Society of Gastroenterology 2007 Use of antibiotics in penetrating craniocerebral injuries: "Infection in Neurosurgery" Report of a BSAC Working Party Source: Microbiology dept. Issue date: February 2008 Page 13 of 14
Ratilal B, Costa J, Sampaio C. for preventing meningitis in patients with basilar skull fractures. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004884. DOI: 10.1002/14651858.CD004884.pub2 Undertaking A Transrectal Ultrasound Guided Biopsy of the Prostate, Prostate Cancer Risk Management Programme Guide No. 1, December 2006 Contributors and peer review The original guideline was written by the then consultant microbiologists Dr C Tremlett and Dr E Wright and Chief Pharmacist, Mr. J Anthistle. The changes in this third edition have been reviewed by the consultant microbiologists Dr R Tilley Dr E Wright and Dr C Barker and the Chief Pharmacist, Mr. S Whitworth. The draft was sent to all consultants in the Trust for comment. Distribution list/dissemination method All relevant staff via Pink Book and Trust e-mail Document configuration information Author(s): Other contributors: Approved by: Issue no: 2 File name: Supercedes: Additional Information: Dr R Tilley, Dr C Barker, Dr E Wright, Mr. S Whitworth General and orthopaedic surgeons, urologists, obstetricians and gynaecologists, anaesthetists, gastroenterologists and pharmacists. Drugs & Therapeutics Committee CG10049 ERCP request form & urology patient leaflets to be updated Source: Microbiology dept. Issue date: February 2008 Page 14 of 14