Summary Of Adult Surgical Antibiotic Prophylaxis Guidelines For Acute Sector Staff Working Within NHS Grampian Co-ordinators: Specialist Antibiotic Pharmacists Consultation Group: Antimicrobial Management Team Approver: Medicine Guidelines and Policies Group Signature: Signature: Identifier: NHSG/Guid/NHSG_SPr_SU /MGPG770 Review Date: September 2017 Date Approved: September 2015 Uncontrolled when printed Version 1.2 (Updated February 2017) Executive Sign-Off This document has been endorsed by the Director of Pharmacy and Medicines Management Signature:
Title: Unique Identifier: Summary Of Adult Surgical Antibiotic Prophylaxis Guidelines For Acute Sector Staff Working Within NHS Grampian NHSG/Guid/NHSG_SPr_SU/MGPG770 Replaces: NHSG/Guid/NHSG_SPr_SU/MGPG770, Version 1.1 Across NHS Boards Organisation Wide Directorate Clinical Service Sub Department Area This controlled document shall not be copied in part or whole without the express permission of the author or the author s representative. Lead Author/Co-ordinator: Subject (as per document registration categories): Key word(s): Process Document: Policy, Protocol, or Guideline Document application: Purpose/description: Specialist Antibiotic Pharmacists Prescribing Policy Guideline, summary, surgical, surgery, prophylaxis, antibiotic, antimicrobial Guidelines NHS Grampian To provide a summary of the adult surgical antibiotic prophylaxis recommendations agreed by specialities within NHS Grampian. Responsibilities for implementation: Organisational: Corporate: Departmental: Area: Hospital/Interface services: Operational Management Unit: Policy statement: Review: Chief Executive and Management Teams Senior Managers Heads of Service/Clinical Leads Line Managers Assistant General Managers and Group Clinical Directors Unit Operational Managers It is the responsibility of all staff to ensure that they are working to the most up to date and relevant policies, protocols procedures. This policy will be reviewed in two years or sooner if current treatment recommendations change UNCONTROLLED WHEN PRINTED Review Date: September 2017 Identifier: NHSG/Guid/NHSG_SPr_SU/MGPG770 - i -
This document is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on (01224) 551116 or (01224) 552245. Responsibilities for review of this document: Responsibilities for ensuring registration of this document on the NHS Grampian Information/ Document Silo: Physical location of the original of this document: Job/group title of those who have control over this document: Responsibilities for disseminating document as per distribution list: Antimicrobial Management team Specialist Antibiotic Pharmacists Pharmacy and Medicines Directorate, Westholme Specialist Antibiotic Pharmacists Specialist Antibiotic Pharmacists Revision History: Revision Date Previous Revision Date Summary of Changes (Descriptive summary of the changes made) 11/10/2016 n/a Obstetrics section - Intrauterine device removed (included in gynaecology section). Caesarean spelling corrected. Evacuation of incomplete miscarriage surgical and/or medical added. Manual removal of placenta comments Recommended for patients with Chlamydia or gonorrhoea replaced with Before beginning of procedure. 03/02/2017 n/a Cardiology section choice changed from IV flucloxacillin/clindamycin plus 3 days oral to IV teicoplanin single dose. Changes Marked* (Identify page numbers and section heading ) Obstetrics p6 Cardiology p2 * Changes marked should detail the section(s) of the document that have been amended, i.e. page number and section heading. UNCONTROLLED WHEN PRINTED Review Date: September 2017 Identifier: NHSG/Guid/NHSG_SPr_SU/MGPG770 - ii -
Summary Of Adult Surgical Antibiotic Prophylaxis Guidelines For Acute Sector Staff Working Within NHS Grampian Introduction The aim of surgical prophylaxis is to reduce rates of surgical site and healthcareassociated infections (HAIs) and so reduce surgical morbidity and mortality. NHS Grampian surgical prophylaxis guidelines are primarily based on recommendations in SIGN Guideline 104 1 (updated in April 2014), advice published by the Scottish Antimicrobial Prescribing Group (SAPG) 2, local information about surgical site infections and HAIs and expert advice from local clinicians. The following summary table lists the locally agreed antibiotic prophylaxis options for the majority of surgical procedures in NHS Grampian following consultation with the specialities. The overview of the principles of surgical antibiotic prophylaxis and the individual speciality guidelines should be referred to for further details on administration, redosing and classification of high risk patients. UNCONTROLLED WHEN PRINTED Review Date: September 2017 Identifier: NHSG/Guid/NHSG_SPr_SU/MGPG770-1 -
The following summary table lists the locally agreed antibiotic prophylaxis options for the majority of surgical procedures in NHS Grampian. Refer to the overview of the principles of surgical antibiotic prophylaxis and to individual speciality guidelines for further details on administration, re-dosing and classification of high risk patients. Speciality BREAST (single dose unless otherwise stated) Breast surgery with implants (reconstructive or aesthetic) Flucloxacillin 1g IV Clarithromycin 500mg IV Breast surgery with manipulation of ducts Breast cancer surgery Breast reshaping procedures Prophylaxis (as above) if patient has risk factors (see full guideline for details) Continued orally until drains removed Prophylaxis (as above) if patient has risk factors and/or has had neoadjuvant chemotherapy or repeat surgery (see full guideline for details) Prophylaxis (as above) if patient has risk factors (see full guideline for details) CARDIOLOGY Pacemaker Insertion Teicoplanin IV - if 40kg 400mg, if > 40kg 800mg Antibiotics may be injected into the pocket at the discretion of the operator: Gentamicin 80mg when device inserted. Teicoplanin provides 24 hour cover. CARDIOTHORACIC Cardiac surgery (e.g. valves/bypass) Major Thoracic surgery (including lobectomy, thoracotomy, pectus surgery, pulmonary resection) Minor Thoracic surgery (including thoracoscopy, lung biopsy, pleurodesis) Cefuroxime 1.5g IV then 750mg IV 8 hourly for 2 doses Cefuroxime 1.5g IV then 750mg IV 8 hourly for 2 doses Teicoplanin 400mg IV then 400mg IV 12 hourly for 2 doses Teicoplanin 400mg IV then 400mg IV 12 hourly for 2 doses Antibiotic duration for open heart surgery should be no more than 48 hours may be given for high risk patients on the advice of a senior surgeon ( see full guideline for detail) EAR, NOSE & THROAT (ENT) Ear Surgery Routine nose/sinus/endoscopic sinus surgery Complex septorhinoplasty (including grafts or revision) Tonsillectomy Adenoidectomy (by curettage) Grommet Insertion Clarithromycin 500mg IV Co-amoxiclav 1.2g IV Local practice is not to give antibiotic prophylaxis Antibiotic duration should not be more than 24 hours UNCONTROLLED WHEN PRINTED Review Date: September 2017 Identifier: NHSG/Guid/NHSG_SPr_SU/MGPG770-2 -
/ scenario Ongoing cholangitis or sepsis elsewhere (single dose unless otherwise stated) Guided by recent culture results (patients should already be on antibiotics) May need advice from microbiology ENDOSCOPY - ERCP Biliary obstruction and/or common bile duct stones and/or straightforward stent change When complete biliary drainage unlikely to be achieved Communicating pancreatic cyst or pseudocyst Biliary complications following liver transplant Antibiotic prophylaxis not indicated Piperacillin/ tazobactam 4.5g IV Consult microbiology Patients with a history of MRSA consult microbiology - Endoscopic ultrasound Fine needle aspiration of solid lesions Fine needle aspiration of cystic lesions in or near pancreas, or drainage of cystic cavity - Percutaneous endoscopic gastrostomy (PEG) Antibiotic prophylaxis not indicated Piperacillin/ tazobactam 4.5g IV Co-trimoxazole 960mg IV OR Flucloxacillin 1g IV Consult microbiology Patients with a history of MRSA consult microbiology ENDOSCOPY - Profound immunocompromise Antibiotic prophylaxis only indicated in procedures with high risk of bacteraemia e.g. sclerotherapy, dilatation, ERCP with obstructed system Discuss with haematologist and/or microbiology FACIAL Open reduction and internal fixation of compound mandibular fractures Intraoral bone grafting Orthognathic Surgery Co-amoxiclav 1.2g IV then 1.2g IV 8 hourly for 2 doses Clarithromycin 500mg IV then 500mg IV after 12 hours then 500mg IV 8 hourly for 2 doses Antibiotic duration should be no more than 24 hours Facial Plastic Surgery (with implant) Facial Surgery (clean) UNCONTROLLED WHEN PRINTED Review Date: September 2017 Identifier: NHSG/Guid/NHSG_SPr_SU/MGPG770-3 -
Oesophageal (single dose unless otherwise stated) GASTROINTESTINAL Upper GI Stomach and Duodenal Gastric Bypass Clarithromycin 500mg IV OR Co-trimoxazole 960mg IV Small Intestine Hepatobiliary Bile Duct Pancreatic Liver Gall Bladder Open Co-trimoxazole 960mg IV If gentamicin not suitable and there is a supply issue with cotrimoxazole injection, use piperacillin/tazobactam 4.5g IV or contact duty microbiologist for advice Lower GI Abdomen Spleen Gall Bladder Laparoscopic Appendicectomy Colorectal Surgery Hernia repair - groin (inguinal/femoral or laparoscopic /- mesh) Hernia repair (Incisional /- mesh) Open/laparoscopic surgery with mesh (e.g. gastric banding or rectoplexy) Splenectomy unless high risk patient (see full guideline for details) - use option above If perforated appendix and/or peritonitis found continue treatment antibiotics post-op for 3-7 days but should be considered in high risk patients (see full guideline for details) - use option(s) below: Clarithromycin 500mg IV OR Co-trimoxazole 960mg IV but should be considered in high risk patients (see full guideline for details) - use option(s) below: Clarithromycin 500mg IV Flucloxacillin 1g IV OR Co-trimoxazole 960mg IV UNCONTROLLED WHEN PRINTED Review Date: September 2017 Identifier: NHSG/Guid/NHSG_SPr_SU/MGPG770-4 -
GYNAECOLOGICAL Laparoscopic hysterectomy (assisted / total) Laparoscopic treatment of significant endometriosis (single dose unless otherwise stated) Minimal access surgery Diagnostic laparoscopies, laparoscopic tubal/ovarian procedures Hysteroscopic procedures (diagnostic, operative, endometrial ablation, Essure) Abdominal Abdominal hysterectomy (with or without removal of ovaries) Colposuspension, Abdominal Sacrocolpopexy, Abdominal Sacro-hysteropexy, Myomectomy Co-amoxiclav 1.2g IV Pelvic floor / Urological Any type of Pelvic floor repair or Vaginal hysterectomy (with or without mesh), Sacrospinous colpopexy, Sacrospinous hysteropexy, Vault repair, Mid-urethral incontinence surgery (any type) Cystoscopy except in high risk patients or in those with evidence of UTI Fertility related See next page UNCONTROLLED WHEN PRINTED Review Date: September 2017 Identifier: NHSG/Guid/NHSG_SPr_SU/MGPG770-5 -
GYNAECOLOGICAL Continued Fertility related HEAD & NECK INTRACRANIAL Egg collection Surgical sperm aspiration Induced abortion Surgical and/or Medical Intrauterine contraceptive device (IUCD) insertion Head and neck surgery (clean, benign) Head and neck surgery (clean, malignant; neck dissection) Head and neck surgery (contaminated/ clean-contaminated) Craniotomy Cerebrospinal Fluid (CSF) Shunt Spinal Surgery Trans-sphenoidal surgery (single dose unless otherwise stated) Metronidazole 800mg oral stat Azithromycin 1g oral stat for all patients <18 years, and for those over 18 with no confirmed negative chlamydia result Clindamycin 600mg oral stat Azithromycin 1g oral stat for all patients <18 years, and for those over 18 with no confirmed negative chlamydia result For treatment of chlamydia / gonorrhea follow empirical antimicrobial guidelines except for emergency IUCD insertion for women at risk of STIs at time of unprotected sex where azithromycin 1g oral stat should be considered Co-amoxiclav 1.2g IV Flucloxacillin 1g IV Co-amoxiclav 1.2g IV Clarithromycin 500mg IV Teicoplanin 400mg IV Clarithromycin 500mg IV Antibiotic prophylaxis should be considered Antibiotic duration should be no more than 24 hours Cerebrospinal leaks require antibiotic prophylaxis Consider giving one additional dose after 8 hours Caesarean section Cefuroxime 1.5g IV Clindamycin 900mg IV Re-dose if operation > 4hours Assisted Delivery OBSTETRIC Perineal tear Manual Removal of placenta Cefuroxime 1.5g IV Clindamycin 900mg IV During the repair procedure Before beginning of procedure Evacuation of incomplete miscarriage Surgical and/or Medical UNCONTROLLED WHEN PRINTED Review Date: September 2017 Identifier: NHSG/Guid/NHSG_SPr_SU/MGPG770-6 -
OPHTHALMIC ORTHOPAEDIC / LIMB Elective Trauma Cataract Surgery Glaucoma / Cornea Grafts Lachrymal Surgery / Oculoplastics Penetrating Eye Injury Vitreoretinal Surgeries (single dose unless otherwise stated) Cefuroxime 1mg Intracameral OR 125mg/1mL Subconjunctival Cefuroxime 1mg Intracameral Local policy is not to give antibiotic prophylaxis Cefuroxime 1mg Intracameral Cefuroxime 125mg/1mL Subconjunctival Gentamicin 20mg/0.5ml Subconjunctival Gentamicin 20mg/0.5ml Subconjunctival Gentamicin 20mg/0.5ml Subconjunctivital Gentamicin 20mg/0.5ml Subconjunctival Arthroplasty Cefuroxime 1.5g IV Clarithromycin 500mg IV Gentamicin may be painful or toxic to endothelium and retina if inadvertently injected into the eye Gentamicin may be painful or toxic to endothelium and retina if inadvertently injected into the eye Up to 24 hours of antibiotic prophylaxis should be considered Spinal Cases Flucloxacillin 2g IV Clarithromycin 500mg IV Second dose 4 hours post-op Up to 24 hours of antibiotic prophylaxis should be considered. Internal Fixation or Arthroplasty Flucloxacillin 1g IV Clarithromycin 500mg IV In severe renal impairment Gentamicin 1.5mg/kg IV Gentamicin 1.5mg/kg IV omit gentamicin, OR if Gramnegative cover required consider switching to cefuroxime alone. Open fracture - At first debridement Open fracture - At definitive closure or skeletal stabilisation Co-amoxiclav 1.2g IV Gentamicin 1.5mg/kg IV Gentamicin 1.5mg/kg IV Vancomycin 1g IV Cefuroxime 1.5g IV OR Clindamycin 600mg IV Gentamicin 1.5mg/kg IV Gentamicin 1.5mg/kg IV Teicoplanin 800mg IV Co-amoxiclav 1.2g IV (or penicillin allergy option) given in A&E and as indicated until first debridement. Continue until soft tissue closure or for maximum 72 hours Orthopaedic surgery (without implant) Other Lower limb amputation Refer to Vascular surgery guidelines Hand soft tissue surgery Local policy is not to give prophylactic antibiotics UNCONTROLLED WHEN PRINTED Review Date: September 2017 Identifier: NHSG/Guid/NHSG_SPr_SU/MGPG770-7 -
(single dose unless otherwise stated) Shock-wave lithotripsy (SWL) Antibiotic prophylaxis not routinely recommended UROGENITAL Endourological surgery and SWL Cystolitholapaxy, Ureteric stent insertion, Ureteric conduit stent and nephrostomy Percutaneous nephrolithotomy Endoscopic ureteric stone fragmentation/removal Transurethral resection of prostate (TURP) Transurethral resection of bladder tumours Co-trimoxazole 960mg IV* (*If supply problem with IV co-trimoxazole use ciprofloxacin as an alternative) UROGENITAL Open or laparoscopic surgery UROGENITAL Diagnostic procedures Radial Cystectomy and/or ileal conduit formation Urethroplasty (with buccal mucosal graft) Anastomotic urethroplasty, Nephrouterectomy, Open cystostomy Laparoscopic nephrectomy, Partial / radical nephrectomy, Laparoscopic prostatectomy, Orchidectomy (without implant) Implant of prosthetic testicular device Co-trimoxazole 960mg IV* A second dose may be given after 6 hours if necessary (*If supply problem with IV co-trimoxazole use ciprofloxacin as an alternative) Antibiotic prophylaxis not routinely recommended - but may be given on the advice of a senior surgeon for high risk patients (choice usually based on culture results) Co-amoxiclav 1.2g IV Clarithromycin 500mg IV Transrectal prostate biopsy Ciprofloxacin 500mg oral Co-amoxiclav 625mg oral Cystoscopy Repeat single dose given 6 hours post-procedure except in high risk patients or in those with evidence of UTI UNCONTROLLED WHEN PRINTED Review Date: September 2017 Identifier: NHSG/Guid/NHSG_SPr_SU/MGPG770-8 -
(single dose unless otherwise stated) Lower limb amputation Benzylpenicillin 1.2g IV Teicoplanin 400mg IV VASCULAR / LIMB Carotid endarterectomy with prosthetic patch Vascular Surgery (abdominal and lower limb arterial reconstruction) Flucloxacillin 1g IV Benzylpenicillin 1.2g IV Teicoplanin 400mg IV Upper limb renal access Flucloxacillin 1g IV Teicoplanin 400mg IV Soft tissue surgery of the hand Local policy is not to give prophylactic antibiotics UNCONTROLLED WHEN PRINTED Review Date: September 2017 Identifier: NHSG/Guid/NHSG_SPr_SU/MGPG770-9 -