Antibiotic Guidelines Antibiotic Prophylaxis in Urology Classification: Clinical Guideline Lead Author: Antibiotic Steering Committee Additional author(s): Authors Division: DCSS & Tertiary Medicine Unique ID: 144TD(C)25(F5) Issue number: 5 Date approved: Medicines Management Group June 2017 Contents Section Who should read this document 2 Key practice points 2 Background/ Scope/ Definitions 2 What is new in this version 2 Policy/Procedure/Guideline 4 Surgical Prophylaxis Principles 4 Antibiotic Prophylaxis in Urology table of recommendations 6 Standards 9 References and Supporting Documents 9 Roles and Responsibilities 9 Document control information (Published as separate document) Document Control 10 Policy Implementation Plan Monitoring and Review Endorsement Equality analysis Page 1 of 8
Who should read this document? This policy applies to all clinical staff involved the prescribing of antimicrobials. Key Practice Points This policy recommends surgical prophylaxis options for adult patients undergoing specified urological procedures. 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). Please refer to up to date BNF/SPC for a full list of cautions, contraindications, interactions and adverse effects of individual drugs. Page 2 of 8
What is new in this version? Prophylaxis for Sacral neuromodulator prosthesis reviewed at the request of the Urologists to determine if a second post operative dose is necessary as this currently results in the patient requiring an in-patient bed when they could otherwise be treated as a day case. There is very limited research on SNM prophylaxis and what evidence exists does not mention post-op dosing (French guideline) and there are comparable procedures where single dose is accepted (eg cardiac pacemakers, and in SRFT deep brain and spinal cord stimulators are put in with single dose prophylaxis). As a result the policy has been changed to just a single dose of teicoplanin and gentamicin at induction. Policy/ Guideline/ Protocol Surgical Prophylaxis Principles Antimicrobial prophylaxis is indicated during selected clean surgical procedures and during procedures which involve incision of non-sterile mucosal surfaces (oral mucosa, respiratory tract, gastrointestinal tract and female genito-urinary tract). Local departmental protocols should be followed where available. Prophylactic antibiotics should be prescribed on the EPMAR (using the relevant prescribing order set where available). 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: Patients with a history of any MRSA colonisation or infection (EVEN IF SUBSEQUENT NEGATIVE SCREENS) Patients without a negative MRSA screen from this admission or pre-op clinic who o Are admitted from a residential or nursing home o Are healthcare workers o Have had an inpatient admission in the past 12 months (UK or overseas) o Have had a 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) Page 3 of 8
2. Prophylaxis should be administered 60 minutes prior to surgical incision (administration must be complete before the surgical incision, and before inflation of the tourniquet when used). During induction of anaesthesia great care must be taken to prevent drug substitution errors between anaesthetic drugs and antibiotics (which has the potential to lead to unintentional awareness). 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. 4. Teicoplanin, gentamicin and ciprofloxacin have long half lives and additional doses during surgery are not required. Where other antibiotics are used, 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 Page 4 of 8
Antibiotic Prophylaxis in Urology General points: 1. Where there is evidence of ongoing infection or particular clinical concern then a longer course of antibiotics may be necessary. Discuss problematic cases with microbiology. 2. In the case of PCNL / complex stone surgery / ureteroscopy procedures a larger dose of gentamicin (3-5 mg /kg adjusted body weight) may be indicated at the discretion of the consultant. This dosage needs to be reviewed if there is evidence of renal impairment. 3. Prophylaxis in joint replacements (in flexible cystoscopy): use antibiotics if within 3 months of prosthetic insertion. 4. Prophylaxis in heart valve disease (in flexible cystoscopy): Antibiotics are not usually indicated. See Trust policy on Endocarditis Prophylaxis. Operation Prophylaxis Prophylaxis if known to be penicillin allergic or ever colonised or infected with MRSA at any site Cystoscopy Not recommended routinely unless a below factor present Cystoscopy with any of: Bacteriuria Manipulation e.g. cystodiathermy Immunocompromise Gentamicin IV 120mg + IV amoxicillin 1g at induction TRUS of prostate and biopsy Oral Ciprofloxacin 1000 mg 30 minutes prior to biopsy mg + oral ciprofloxacin 1000 mg 30 minutes prior to biopsy Page 5 of 8
Endourological surgery ESWL (extracorporeal shock wave lithotripsy) Not routinely required unless risk factors present i.e. - Bacteriuria or - Immunocompromise If so then give: Gentamicin IV 120mg + IV amoxicillin 1g at induction TURP TURBT Urethrotomy Change of stent/s Ureteroscopy for stone treatment Gentamicin IV 120mg + IV amoxicillin 1g at induction Nephrostomy Percutaneous nephrolithotomy (PCNL) IV Co-amoxiclav 1.2g + IV Gentamicin 120mg at induction Given the possibility of preexisting infection, alternative agents may be appropriate if based on culture results e.g.iv piperacillin-tazobactam 4.5g tds commenced before the procedure (+/- gentamicin) Open Urinary Tract Surgery and Laparoscopic procedures Clean procedures (surgery without entry into the urinary tract) Scrotal surgery Groin surgery Circumcision Antibiotic prophylaxis not routinely recommended, however if adequate skin preparation is difficult then give IV Co-amoxiclav 1.2g at induction 120mg + IV metronidazole 500 mg at induction Page 6 of 8
Clean contaminated procedures (opening of the urinary tract) Nephrectomy Prostatatectomy Cystectomy IV Co-amoxiclav 1.2g + IV gentamicin * (dosed as per table below) at induction followed by a second dose 4 hours later of Co-amoxiclav 1.2g only if operation > 4 hours or > 1500 ml blood loss mg + IV gentamicin * (dosed as per table below) at induction Contaminated procedures Procedures involving bowel Implantation procedures Prosthesis: Penile/Sphincter/Test is Prosthesis : Sacral Neuromodulation NB: for cystectomy, further doses may be given depending on the clinical situation although there is insufficient evidence for routine prolonged prophylaxis. IV Co-amoxiclav 1.2g + IV gentamicin * (dosed as per table below) at induction followed by a second dose 4 hours later of Co-amoxiclav 1.2g only if operation > 4 hours or > 1500 ml blood loss. mg + IV gentamicin 120 mg at induction, and a second dose of mg 12 hours later mg + IV gentamicin 120 mg at induction mg + IV gentamicin * (dosed as per table below) + IV metronidazole 500 mg at induction followed by second dose 4 hours later of IV metronidazole 500 mg if operation >4 hours or >1500ml blood loss 120 mg at induction, and a second dose of IV teicoplanin 400 mg 12 hours later *Gentamicin dose in clean/contaminated & contaminated procedures: 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 <60 160 2 x 80mg vials 120mg 1.5 x 80mg vials 60-90 240 1 x 240mg bag 160mg 2 x 80mg vials >90 360 1 x 360mg bag 240mg 1 x 240mg bag Page 7 of 8
Standards Document the Indication/rationale for antimicrobial therapy. Review and document the patient s allergy status. Ensure the choice of antibiotic complies with the antibiotic guidelines. Prescribe single dose antibiotics for surgical prohylaxis, unless policy states otherwise. Administer antibiotic prophylaxis within 60 minutes prior to surgical incision (administration must be complete before the incision, and before inflation of the tourniquet when used) Explanation of terms & Definitions NA References and Supporting Documents 1. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guidelines Network. Guideline No.104; ISBN 978 90581334 6; July 2008 2. Burden H, Ranasinghe W, Persad R. Antibiotics for Transrectal Ultrasonography-Guided prestate biopsy: Are we practising evidencebased medicine? BJU International 2008;101(10):1202-1204 3. Grabe M. Antibiotic prophylaxis in urological surgery, a European viewpoint. Int J Antimicrob Agents 2011;38s:58-63 4. Bootsma AM, Laguna Pes MP, Geerlings SE, Goossens A. Antibiotic prophylaxis in urologic procedures: a systematic review. Eur Urol 2008;54(6):1270-86 5. Zani EL, Clark OAC, Rodrigues Netto Jr N. Antibiotic prophylaxis for transrectal prostate biopsy. Cochrane Database Syst Rev 2011, Issue 5. Art. No.: CD006576. DOI: 10.1002/14651858.CD006576.pub2 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 8 of 8