3.13.1 - Surgical [updated]

Principles of Surgical Prophylaxis:

The antimicrobial agent should be started within 60 minutes prior to incision Antibiotic administration must be completed before surgical incision (120 minutes for Vancomycin or Fluoroquinolones).

While single-dose prophylaxis is usually sufficient, the duration of prophylaxis for all procedures should be less than 24 hours (48 hours for cardiac surgery) to minimize adverse effects, the development of resistance, and costs.

Antimicrobial agents with the narrowest spectrum of activity required for efficacy in preventing infection to prevent resistance.

Intraoperative redosing is needed if the duration of the procedure exceeds two half-lives of the drug (from the time of initiation of the preoperative dose [see Table], if prolonged or excessive bleeding occurs or if there are other factors that may shorten the half-life of the prophylactic agent (e.g. extensive burns).

Intraoperative redosing may not be warranted in patients whom the half-life of the agent may be prolonged (e.g. patients with renal insufficiency or failure).

MRSA decolonization is recommended in MRSA carriers.

For patients known to be colonized with methicillin-resistant Staphylococcus aureus, it is reasonable to add a single preoperative dose of intravenous Vancomycin 15 mg/kg (maximum 2g) to the recommended agent(s) 120 minutes before incision.

The use of antimicrobial agents for dirty procedures or established infections is classified as treatment of presumed infection, not prophylaxis.

The predominant organisms causing SSIs after clean procedures are skin flora, including S. aureus and coagulase-negative staphylococci. In procedures involving the abdomen, heart, kidney, and liver, the predominant organisms are gram-negative rods and enterococci in addition to skin flora.

Antimicrobial prophylaxis in gastroduodenal procedures should be considered for patients at highest risk for postoperative infections, including risk factors such as increased gastric pH (e.g. patients receiving acid-suppression therapy), gastroduodenal perforation, decreased gastric motility, gastric outlet obstruction, gastric bleeding, morbid obesity, ASA classification of ≥3, and cancer.

For most patients undergoing colorectal surgery, a mechanical bowel preparation combined with oral Neomycin Sulphate plus oral Erythromycin base or with oral Neomycin Sulphate plus oral Metronidazole should be given in addition to IV prophylaxis.

For patient with beta lactam antibiotic allergy, Vancomyicn or ^Clindamycin ± ^^Gentamicin is recommended unless stated otherwise.

Δ Cefazolin dosage in obese patient

2gm (<120kg body weight)

3gm (≥ 120kg body weight)

^Clindamycin 900mg STAT

^^Gentamicin 5mg/kg STAT

Pre-existing infections (known or suspected) if present:

Use appropriate treatment regimen instead of prophylactic regimen for procedure.

Doses should be scheduled to allow for re-dosing just prior to skin incision.

To add/ to change to Vancomycin 15 mg/kg STAT (Max 2g)

  • In patients who are colonized with MRSA or

  • Allergic to Penicillins or Cephalosporins.

Procedure

Preferred

Alternative

Comments

Cardiovascular Surgeries

Cardiac surgery including coronary artery bypass, reconstruction abdominal aorta, procedures on the leg that involves groin incision, any vascular procedure that inserts prosthesis / FB (e.g. pacemaker implantation, ventricular assist devices)

Commonest Pathogens for surgical site infection (SSI): S. aureus, S. epidermidis

ΔCefazolin 2gm IV q8H for 1-2 days

Cefuroxime 1.5 gm IV q8H for 1 - 2 days

For patients with beta lactam antibiotic allergy:

Clindamycin 900 mg IV 30 - 60 mins before procedure and q6H thereafter for 1 - 2 days

*Cefazolin is preferred over Cefuroxime, given increasing resistance to second-generation Cephalosporins

For procedures if suspecting enteric gram-negative bacilli, may add another drug such as an aminoglycoside (gentamicin 5 mg/kg IV)

There is no benefit to extend the duration of antimicrobial prophylaxis pending removal of indwelling lines, drains, and catheters

Thoracic Procedures

Non cardiac procedures (including lobectomy, pneumonectomy, lung resection, and thoracotomy), video-assisted thoracoscopic surgery (VATS)

Common pathogens of SSI

Staphylococcus aureus, Staphylococcus epidermidis, Streptococci, enteric gram-negative bacilli

ΔCefazolin 2gm IV

±

***Metronidazole 500mg IV infusion, repeated 12 hourly for 2 more doses commencing 6 hours after initial dose for pneumonectomy/lobectomy, but for decortication/pleurectomy or VATS, no additional dose required

Ampicillin-Sulbactam 3g IV

Pre-existing infections (known or suspected) if present:

Use appropriate treatment regimen instead of prophylactic regimen for procedure.

Doses should be scheduled to allow for re-dosing just prior to skin incision.

Cefazolin is preferred over cefuroxime, given increasing resistance to second-generation cephalosporins. Cefazolin has both gram positive and gram negative coverage.

***If anaerobic cover required

Gastroduodenal Procedures

Biliary tract

Common pathogens causing SSI

Gram +ve, gram -ve bacilli

- Open procedure (include Whipple procedure and liver resections***)

- Laparoscopic cholecystectomy

ERCP for ongoing cholangitis/sepsis

Or

where no adequate biliary drainage

ERCP for patient with primary sclerosing cholangitis and strictures or hilar cholangiocarcinoma or communicating pancreatic cyst or pseudocyst

(obstruction)

Or

EUS with aspiration of cysts or drainage of pseudocysts only

Percutaneous Endoscopic Gastrostomy / Jejunostomy (high risk only*)

Common pathogens causing SSI

Enteric gram-negative bacilli, gram-positive cocci

ΔCefazolin 2gm IV

+

Metronidazole 500mg IV

ΔCefazolin 2gm IV

+

Metronidazole 500mg IV (OMIT metronidazole if at low risk* )

Cefuroxime 1.5gm IV

+

Metronidazole 500mg IV

OR

For patients with beta lactam antibiotic allergy

Co-Amoxiclav 1.2g IV

OR

For patients with beta lactam antibiotic allergy

* High-risk-

marked obesity, obstruction, decrease gastric acid or reduce motility

* Low risk

Biliary tract surgery: patient < 60yrs of age; no diabetes; elective cholecystectomy with low risk of exploration of common bile duct

*** liver resection

Clean, uncontaminated-

ΔCefazolin 2gm IV q8H for 1-2 days

If already on appropriate antibiotic treatment no additional prophylactic antibiotics are required.

To refer intra-abdominal infection section (4.07) for the treatment guide

ΔCefazolin 2gm IV

+

Metronidazole 500mg IV

±

OR

***Piperacillin/Tazobactam IV 4.5g

Cefuroxime IV 1.5g

+

Metronidazole 500mg IV

OR

###Vancomycin 15 mg/kg (max 2 gm) IV

+

Metronidazole 500mg IV

***If Profoundly immunosuppressed (e.g. Neutrophils < 1.0 x 10 9 /L)

##For patients with beta lactam antibiotic allergy

### If Profoundly immunosuppressed (e.g. Neutrophils < 1.0 x 10 9 /L) and patient is allergic to penicillin (or has had a course of a penicillin in the last 2 weeks or is on a penicillin)

General Surgery

Hernia Repair (Hernioplasty and Herniorrhaphy)

Common pathogens causing SSI

Aerobic gram-positive organisms

Breast surgery

-breast cancer surgery

-breast reshaping procedures

-breast surgery with implant (reconstructive or aesthetic)

Clean

Include thyroidectomy and lymph node excisions.

Clean with Placement of Prosthesis (Excludes Tympanostomy Tubes)

Common pathogens causing SSI

Staphylococcus aureus, S. epidermidis, Streptococci

Clean-contaminated procedure

(procedures that involve an incision through the oral/ pharyngeal mucosa; parotidectomy, submandibular gland excision, tonsillectomy, adenoidectomy, rhinoplasty, complex tumor debulking, mandibular fracture repair requiring reconstruction)

Common pathogens causing SSI

Anaerobes, enteric gram-negative bacilli, S. aureus

Bowel surgery

Common pathogens causing SSI

Enteric gram-negative bacilli, gram-positive cocci, anaerobes, enterococci

Gastro-duodenal Surgery (include gastrectomy or gastrointestinal reconstruction)

- Procedures involving entry into lumen of gastrointestinal tract

Enteric gram-negative bacilli, gram-positive cocci

Procedures not involving entry into lumen of gastrointestinal tract (selective vagotomy, anti-reflux)

Enteric gram-negative bacilli, gram-positive cocci

high risk only:

Morbid obesity, gastrointestinal (GI) obstruction, decreased gastric acidity or GI motility, gastric bleeding, malignancy or perforation, or immunosuppressant

Appendectomy for uncomplicated appendicitis

Common pathogens causing SSI

Enteric gram-negative bacilli, anaerobes, enterococci

ΔCefazolin 2gm IV

ΔCefazolin 2gm IV

ΔCefazolin 2gm IV

+ Metronidazole 500 mg IV

OR

Ampicillin/Sulbactam 3g IV STAT

ΔCefazolin 2gm IV

+

Metronidazole 500 mg IV

Oral antibiotics for colorectal surgery prophylaxis (used in conjunction with a mechanical bowel preparation)

Neomycin 1 gm PO for 1-3 doses (if is 3 doses, administer- 19Hour, 18 hours and 9 hours before surgery)

+

Erythromycin base 1 gm PO for 1-3 doses, if is 3 doses, administer 19Hour, 18 hours and 9 hours before surgery

or

Metronidazole 1 g PO every 3-4 hours for 3 doses

ΔCefazolin 2gm IV

ΔCefazolin 2gm IV

None

ΔCefazolin 2gm IV

ΔCefazolin 2gm IV

+

Metronidazole 500mg IV

Cefuroxime 1.5g IV

Cefuroxime 1.5g IV

Ampicillin/Sulbactam 3gm IV

OR

Co-Amoxiclav 1.2gm IV

Ampicillin/Sulbactam 3g IV

OR

Co-Amoxiclav 1.2g IV

None

Cefuroxime 1.5gm IV

Or

If ruptured viscus, therapy is often continued for approximately five days.

Cefazolin is preferred over Cefuroxime, given increasing resistance to second-generation Cephalosporins

Neurosurgery

Classification of Neurosurgery Operations

Pre-existing infections (known or suspected) – if present, use appropriate treatment regimen instead of prophylactic regimen for procedure.

Common pathogens causing SSI

Staphylococcus aureus, S. epidermidis

Elective Craniotomy and Cerebrospinal Fluid-Shunting Procedures

Implantation of Intrathecal Pump

Transnasal Surgery

ΔCefazolin 2gm IV

Or

Cefuroxime 1.5gm IV

+

Metronidazole 500mg IV

ΔCefazolin 2gm IV

ΔCefazolin 2gm IV

Gynaecology Procedures

Repair of 3rd or 4th Degree Vaginal Laceration

Caesarean Delivery (elective)

Antibiotic prophylaxis is recommended for all caesarean deliveries unless the patient is already receiving an antibiotic regimen with equivalent broad spectrum coverage (eg, chorioamnionitis)

Caesarean Delivery (emergency)

For non-elective caesarean delivery during labour or with membrane rupture (Women with membrane rupture for at least 4 hours, regardless of whether labour had started)

Hysterectomy (Vaginal or Abdominal)

ΔCefazolin 2gm IV

ΔCefazolin 2gm IV

+

Azithromycin 500mg IV

ΔCefazolin 2gm IV

+

Metronidazole 500mg IV

ΔCefazolin 2gm IV

+

Metronidazole 500 mg IV

Co-amoxiclav 1.2 gm IV

Co-amoxiclav 1.2 gm IV

Ophthalmic Procedures

Ophthalmic

Topical Neomycin–Polymyxin B–Gramicidin or fourth-generation topical Fluoroquinolones (Gatifloxacin or Moxifloxacin) given as 1 drop every 5 –15 mins for 5 doses

None

Addition of Cefazolin 100 mg by subconjunctival injection or intracameral Cefazolin 1 – 2.5 mg or Cefuroxime 1 mg at the end of procedure is optional.

Orthopaedic Procedures

Spinal Procedures With and Without Instrumentation

Hip Fracture Repair

Implantation of Internal Fixation Devices (e.g., nails, screws, plates, wires)

Total Joint Replacement

Common pathogens causing SSI

Staphylococcus aureus, Staphylococcus epidermidis

Orthopedic

Clean operations involving hand, knee, or foot and not involving implantation of foreign materials

If :

prolonged surgery > 2 hr

Multiple incisions

Extensive dissection

Hand surgery

ΔCefazolin 2gm IV

None

ΔCefazolin 2gm IV

cefazolin

None

Urology Procedures

The goals of antimicrobial prophylaxis in urologic procedures are:

· To prevent bacteremia

· To prevent Surgical Site Infection (SSI)

· To prevent postoperative bacteriuria

Besides general risk factors for SSI as of other surgery, urologic-specific risk factors include:

· Anatomic anomalies of the urinary tract

· Urinary obstruction

· Urinary stone

· Indwelling or externalized catheters

· Length of postoperative catheterization

· Mode of irrigation (closed versus open)

· Postoperative pyuria

SSI after urological surgery can involve the skin and or deep tissues for example bladder, ureter or prostatic bed. Furthermore surgical instrumentation of the urogential tract can give rise to frank urinary tract infection, septicaemia or epididymo-orchitis.

Antimicrobial prophylaxis is unnecessary after wound closure or upon termination of an endoscopic procedures, with the exception of:

· Placement of prosthetic material

· Presence of existing infection

If an existing infection is present (e.g., bacteriuria at the time of endourological procedures, devitalized tissue, colonized stone, etc.), a therapeutic course of antimicrobials should be commenced in an attempt to sterilize the field. Co-existing infection should be treated prior to procedure to reduce the rate of SSI and antibiotic should be chosen based on susceptibility testing.

If the existing infection could not be eradicated prior to procedures, in such cases, the aim of pre-operative antimicrobial therapy is to suppress the bacterial count prior to surgery.

The subsequent course of antimicrobials, is for therapeutic purpose rather than prophylactic purpose.

Clean-contaminated:

Cystectomy and urinary diversion

Clean with or without entry into urinary tract:

Nephrectomy, Scrotal Surgery, Prosthetic Implant, Nephroureterectomy, Ureteropelvic Junction Repair, Total Radical Prostectomy, Partial Bladder Resection, Involving Implanted Prosthesis

Urologic

Lower tract instrumentation :

Diagnostic ureteroscopy

TURP, TURBT

Ureteoscopy stone

Percutaneous stone management

Transrectal prostate biopsy

Co-amoxiclav 1.2g IV

Norfloxacin 400mg q12H PO

Start the night before the day of the surgery (total 6 doses)

Co-amoxiclav 1.2 gm IV

±

Gentamicin 5 mg/kg IV (if involving implanted prosthesis)

Co-amoxiclav 1.2 gm IV

ΔCefazolin 2gm IV

ΔCefazolin 2gm IV

Contact ID/Clinical Microbiology for advice (Multi Drug Resistant Organism).

Stool culture

Rectal swab

Transplant

If patients known to be colonized with multi-drug resistant organism, to tailor according to individual susceptibilities

If patient is being treated for an active infection at the time of organ transplantation, the antibiotic regimen should be altered to target specific pathogens based on the current infection and individual risk factors

Liver

Common pathogens causing SSI are Gram‐negative organisms (predominantly Enterobacteriaceae, Acinetobacter species, and more rarely Pseudomonas); there are also high rates of infection with Enterococci, S aureus, coagulase‐negative Staphyloccus spp, and Candida species

Cefoperazone 2gm IV STAT then 2gm q12H for 1-2 days

+

Metronidazole 500mg IV STAT then 500mg IV q8h for 1-2 days

+

Ampicillin 2gm IV STAT then 2gm q6H for 1-2 days

OR

Co-amoxiclav 1.2gm IV STAT then 1.2gm q8H for 1-2 days

Peadiatric recipient-

Cefoperazone 50mg/kg/dose STAT then q8H for 1-2 days

+

Ampicillin 25mg/kg/dose STAT then q6H for 1-2 days

±

metronidazole 7.5mg/kg/dose STAT

Pre op- both donor and recipient

Cefuroxime 1.5g IV STAT

Post op (donor)- 2 more doses of Cefuroxime 750mg IV q8H

Post op (recipient) - cerufoxime 750mg q8H for at least 1 week which coincides with removal of catheter or drain.

Co-amoxiclav 1.2gm q8h for 1-2 days

Universal antifungal prophylaxis is probably not necessary, since the risk of invasive candidiasis is low in uncomplicated cases.

Antifungal prophylaxis is generally reserved for patients with two or more of the following risk factors:

· Need for reoperation,

· Re-transplantation,

· Renal failure,

· Known colonization with Candida species.

Renal

Common pathogens causing SSI

Gram‐positive organisms including S aureus, coagulase‐negative Staphylococci (CoNS), and Enterococcus species. Less commonly, Gram‐negative organisms and yeast can also cause SSI

Risk of fungal infection is also increased with prolonged initial procedure or transfusion of >40 units of cellular blood products, but this cannot be predicted before the procedure.

Choice of antifungal would be

Micafungin 100mg IV single dose

or

Amphotericin B Lipid Complex 5mg/kg single dose

or

Fluconazole 400 mg IV single dose

(*take note on drug-drug interaction with Tacrolimus)

Peadiatric-

Micafungin 1mg/kg stat

Fluconazole 6mg/kg STAT

if high risk for invasive fungal infection (duration depends on the individual risk)

*to consider Piperacillin-Tazobactam if the suspicion for pseudomonas infection is high

if the patient is being treated for an active infection at the time of organ transplantation, the antibiotic regimen should be altered to target specific pathogens based on the current infection and individual risk factors

Plastic Surgeries

Clean with risk factors or clean-contaminated

ΔCefazolin 2gm IV q8H