Neurosurgery Antibiotic Prophylaxis Guideline Full Title of Guideline: Author (include email and role): Division & Speciality: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Summary of evidence base this guideline has been created from: Neurosurgery Antibiotic Prophylaxis Guideline for Adult and Paediatric Patients Mr Tim Hills (Lead Pharmacist Antimicrobials and Infection Control) Dr Shanika Crusz (Consultant Microbiologist) Mr Graham Dow (Consultant Neurosurgeon) Mr Luke Dowdeswell (Senior Clinical Pharmacist) Neurosurgery - MSKN Trust Wide June 2020 Adult and paediatric patients undergoing Neurosurgical procedures outlined within the guideline 1. Adult dose Teicoplanin increased to 800mg 2. Paediatric dose teicoplanin increased to max 800mg 3. Gliadel moved to special implants section 4. Extended 24h prophylaxis for special implants 5. MSSA/MRSA decolonisation prior to special implant surgery 6. Addition of of gentamicin to the teicoplanin for severe penicillin/cephalosporin allergic patients undergoing clean/contaminated surgery 7. Addition of cefuroxime to the teicoplanin and metronidazole for the MRSA positive open injury trauma patient 8. Addition of gentamicin to the teicoplanin and metronidazole for the severe penicillin/cephalosporin allergic open injury trauma patient National SIGN guidelines on Surgical Antibiotic Prophylaxis Guideline 104 available from www.sign.ac.uk S. aureus screening and decolonisation reduces the risk of surgical site infections in patients undergoing deep brain stimulation surgery. Lefebvre et al Journal of Hospital Infection 95 (2017) 144-7 Recommended best practice based on clinical experience of guideline developers. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust. Nottingham Antibiotic Guidelines Committee Page 1 of 6
Contents Page 1. Introduction 3 2. Risk of infection 3 3. Antibiotic Prophylaxis Principles 4 3.1 Timing for Administration 4 4 3.2 Additional Intra-operative doses 3.3 Post-operative antibiotic prophylaxis 4 4. MRSA decolonisation 4 5. Summary Table for Neurosurgery Antibiotic Prophylaxis Regimens 5 5.1 Adults 5 5.2 Paediatrics 6 Nottingham Antibiotic Guidelines Committee Page 2 of 6
1.Introduction: Surgical site infection (SSI) is one of the most common healthcare associated infections resulting in an average additional hospital stay of 6.5 days per case. In operations with a higher risk of infection (e.g. clean-contaminated surgery), perioperative antibiotic prophylaxis has been shown to lower the incidence of infection. High antibiotic levels at the site of incision for the duration of the operation are essential for effective prophylaxis. Studies have shown that the administration of prophylactic antibiotics after wound closure does not reduce infection rates further and can result in harm (see below). Administration of antibiotics also increases the prevalence of antibiotic-resistant bacteria and predisposes the patient to infection with organisms such as Clostridium difficile, a cause of antibiotic-associated colitis. This risk increases with the duration that antibiotics are given for and is higher in the elderly, immunosuppressed, patients who have a prolonged hospital stay or who have received gastro-intestinal surgery. 2. Risk of infection: The risk of SSI depends on a number of factors; these can be related to the patient or the operation and some of them are modifiable (see Table 1): Patient Age Nutritional status Diabetes Smoking Obesity Coexistent infections at a remote body site Colonization with microorganisms (e.g. Staph. aureus) Immunosuppression (inc. taking glucocorticoid steroids or immunosuppressant drugs) Length of preoperative stay Coexistent severe disease that either limits activity or is incapacitating. Malignancy Operation Duration of surgical scrub / Skin antisepsis Preoperative shaving/ preoperative skin prep. Length of operation Appropriate antimicrobial prophylaxis Operating room ventilation Inadequate sterilization of instruments Foreign material in the surgical site Surgical drains Surgical technique inc. haemostasis, poor closure, tissue trauma Post-operative hypothermia Table 1 Risk factors that increase the rate of SSI The risk is also related to the amount of contamination with microorganisms the socalled class of the operation (see Table 2): Class Definition Clean Operations in which no inflammation is encountered and the respiratory, alimentary or genitourinary tracts are not entered. There is no break in aseptic operating theatre technique. Clean-contaminated Operations in which the respiratory, alimentary or genitourinary tracts are entered but without significant spillage. Contaminated Operations where acute inflammation (without pus) is encountered, or where there is visible contamination of the wound. Examples include gross spillage from a hollow viscus during the operation or compound/open injuries operated on within four hours Dirty Operations in the presence of pus, where there is a previously perforated hollow viscus, or compound/open injuries more than four hours old. Table 2 Definitions of operation class. Nottingham Antibiotic Guidelines Committee Page 3 of 6
Peri-operative antibiotics are generally recommended for clean-contaminated or contaminated operations. Dirty operations (e.g. perforated appendectomy) generally require treatment with antibiotics. 3 Antibiotic Prophylaxis 3.1 Timing for Administration Antibiotic prophylaxis administered too early or too late increases the risk of SSI. Studies suggest that antibiotics are most effective when given 30 minutes before skin is incised. The pragmatic approach is to administer prophylaxis towards the end of induction and ensure that surgery starts within 30 minutes of this time wherever possible. 3.2 Additional Intra-operative doses Antibiotic High antibiotic levels, at the site of incision, for the duration of the operation, Cefuroxime 4 hours, give 1.5g IV are essential for effective prophylaxis. Flucloxacillin 3 hours, give 1g IV Patients who experience major blood loss Gentamicin (greater than 1500ml) should have fluid Metronidazole resuscitation, followed by re-dosing with Teicoplanin the recommended prophylaxis regimen for that operation (see section 5). For operations lasting more than 4 hours re-dosing may be necessary (see table 3) Recommended re-dosing interval/adult dose to give re-dosing not recommended 8 hours, give 500mg IV re-dosing not recommended Table 3: Recommend re-dosing interval 3.3 Post-operative antibiotic prophylaxis Studies have shown that giving additional antibiotic prophylaxis after wound closure does not reduce infection rates further. Post-operative antibiotics should only be given to treat active/on-going infection unless specifically recommended against the surgical procedure (see section 5 special implants). 4. MRSA / MSSA decolonisation prior to: Special implants Elective surgery If pre-op screen positive: Mupirocin 2% (Bactroban) nasal ointment (topically to each nostril) TDS for 5 days prior to surgery PLUS Octenisan washes OD for 5 days and wash hair twice in the five days starting prior to surgery. Emergency surgery Send screen and start Mupirocin 2% (Bactroban) nasal ointment (topically to each nostril) TDS, stop if screen negative continue if positive for 5 days at the point of admission PLUS Octenisan washes OD for 5 days and wash hair twice in the five days at the point of admission. Nottingham Antibiotic Guidelines Committee Page 4 of 6
Section 5.0: Summary Table for Neurosurgical Antibiotic Prophylaxis Regimens in Adult Patients Procedure Standard Antibiotic Dose / Route (if necessary) If MRSA positive Severe Penicillin / Cephalosporin Allergy (NB will cover for MRSA) Clean Neurosurgery (incl (craniotomy, burr holes, tumours, haematomas, shunt, EVDs, ommaya reservoir) Clean-contaminated (trans-sphenoidal, Acoustic neuroma, repair of CSF leak) Trauma Closed injury/no contamination Open injury/open depressed fracture elevation/retained foreign body Spinal (Laminectomy, discectomy, tumours, dural patches, spinal cord tethers, meningocoele repairs) Special implants (excl (any spinal implant/cage/disc replacement, Baclofen pumps, spinal cord stimulators, cranioplasty, gliadel, deep brain stimulators) IV Cefuroxime 1.5g 800mg 800mg IV Cefuroxime 1.5g IV Cefuroxime 1.5g plus IV Teicoplanin 800mg 800mg + IV Gentamicin 2mg/kg IV Cefuroxime 1.5g 800mg 800mg IV Cefuroxime 1.5g TDS + IV Metronidazole 500mg TDS for 72 hrs IV Flucloxacillin 2g + IV Gentamicin 2mg/kg or if mild allergy* IV Cefuroxime 1.5g + IV Gentamicin 2mg/kg IV Flucloxacillin 2g at induction, 3 further doses of 1g every 6 hours** + IV Gentamicin 2mg/kg or if mild allergy* IV Cefuroxime 1.5g at induction then 2 further doses of 750mg every 8 hours + IV Gentamicin single dose 2mg/kg * Mild allergy - mild penicillin allergy only (No urticarial rash within the first 72 hours, anaphylaxis or angioedema) **Give the second dose early at 3 hours post induction if the patient is still intra-operative. Give the second dose early at 4 hours post induction if the patient is still intra-operative. IV Teicoplanin 12mg/kg starting on induction then every 12 hours for 3 doses then 12mg/kg (maximum 800mg) once daily + IV Cefuroxime 1.5g TDS + IV Metronidazole 500mg TDS all for 72hrs IV Flucloxacillin 2g + IV Gentamicin 2mg/kg or if mild allergy* IV Cefuroxime 1.5g + IV Gentamicin 2mg/kg IV Flucloxacillin 2g at induction, 3 further doses of 1g every 6 hours** + IV Gentamicin 2mg/kg single dose or if mild allergy* IV Cefuroxime 1.5g at induction then 2 further doses of 750mg every 8 hours + IV Gentamicin 2mg/kg IV Teicoplanin 12mg/kg starting on induction then every 12 hours for 3 doses then 12mg/kg (maximum 800mg) once daily + IV Metronidazole 500mg TDS both for 72hrs + IV Gentamicin 2mg/kg at induction IV Teicoplanin 800mg single dose + IV Gentamicin 2mg/kg IV Teicoplanin 800mg single dose + IV Gentamicin 2mg/kg Nottingham Antibiotic Guidelines Committee Page 5 of 6
Section 6.0: Summary Table for Neurosurgical Antibiotic Prophylaxis Regimens in Paediatric Patients (1 month to 18 years) Procedure Clean Neurosurgery (incl (craniotomy, burr holes, tumours, haematomas, shunt, EVDs, ommaya reservoir) Clean, contaminated (trans-sphenoidal, Acoustic neuroma, repair of CSF leak) Trauma Closed injury/no contamination Open injury/open depressed fracture elevation/ retained foreign body Spinal (Laminectomy, discectomy, tumours, dural patches, spinal cord tethers, meningocoele repairs) Special implants (excl (any spinal implant/cage/disc replacement, Baclofen pumps, spinal cord stimulators, cranioplasty, gliadel, deep brain stimulator) Standard Antibiotic Dose / Route (if necessary) IV Cefuroxime 50mg/kg (max 1.5g) IV Cefuroxime 50mg/kg (max 1.5g) IV Cefuroxime 50mg/kg (max 1.5g) IV Cefuroxime 50mg/kg (max 1.5g) TDS + IV Metronidazole 7.5mg/kg (max 500mg) TDS for 72 hrs IV Flucloxacillin 50mg/kg (max 2g) + IV Gentamicin 4mg/kg** or if mild allergy* IV Cefuroxime 50mg/kg (max 1.5g) + IV Gentamicin 4mg/kg** IV Flucloxacillin 50mg/kg at induction, further doses of 25mg/kg every 6 hours + IV Gentamicin 4mg/kg** OD for 24 hours or if mild allergy* IV Cefuroxime 50mg/kg (max 1.5g) every 8 hours + IV If MRSA positive Severe Penicillin / Cephalosporin Allergy (NB will cover for MRSA) 10mg/kg (max 800mg) IV Cefuroxime 50mg/kg (max 1.5g) plus 10mg/kg (max 800mg) 10mg/kg (max 800mg) IV Teicoplanin 10mg/kg (max 800mg) every 12 hours for 3 doses then 10mg/kg (max 800mg) once daily + IV Cefuroxime 50mg/kg (max 1.5g) TDS + IV Metronidazole 7.5mg/kg (max 500mg) TDS all for 72hrs IV Flucloxacillin 50mg/kg (max 2g) + IV Gentamicin 4mg/kg** or if mild allergy* IV Cefuroxime 50mg/kg (max 1.5g) + IV Gentamicin 4mg/kg** IV Flucloxacillin 50mg/kg at induction, further doses of 25mg/kg every 6 hours + IV Gentamicin 4mg/kg for 24 hours or if mild allergy* IV Cefuroxime 50mg/kg (max 1.5g) every 8 hours + IV Gentamicin 4mg/kg** 10mg/kg (max 800mg) 10mg/kg (max 800mg) + IV Gentamicin 4mg/kg 10mg/kg (max 800mg) IV Teicoplanin 10mg/kg (max 800mg) every 12 hours for 3 doses then 10mg/kg (max 800mg) once daily + IV Metronidazole 7.5mg/kg (max 500mg) TDS both for 72hrs + IV Gentamicin 4mg/kg at induction 10mg/kg (max 800mg) + IV Gentamicin 4mg/kg** 10mg/kg (max 800mg) + IV Gentamicin 4mg/kg** single dose Gentamicin 4mg/kg** OD for 24 hours OD for 24 hours * Mild allergy mild penicillin allergy only (No urticarial rash within the first 72 hours, anaphylaxis or angioedema) **Give the second dose early at 3 hours post induction if the patient is still intra-operative. Give the second dose early at 4 hours post induction if the patient is still intra-operative. Give the second dose early at 4 hours post induction if the patient is still intra-operative Nottingham Antibiotic Guidelines Committee Page 6 of 6