Makindo Medical Notes.com

General Considerations

• Effective prophylaxis: Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection, with a few notable exceptions.
• Should be given intravenously in a fully therapeutic dose, Should be given around 30 minutes before the first incision (usually with induction of anaesthesia).
• An additional intra-operative dose should only be considered if the operation: Is long (>5 hours) Involves substantial blood loss (>1.5L) or Involves substantial haemodilution (>15 ml/kg)
• Continuing prophylaxis into the postoperative period: Is no more effective for preventing surgical site infections than a single preoperative dose. Encourages the emergence of resistant bacteria (eg MRSA and VRE). Increases the likelihood of adverse effects such as C. difficile diarrhoea.
• Surgical prophylaxis is not recommended for "clean" surgery
• The doses of all antibiotics may need adjustment depending upon the patient's renal function. Discuss with a Consultant Microbiologist

Oesophageal/Gastroduodenal

• Gram positive bacteria (upper respiratory flora) and Gram-negative bacteria (enterics)
• Usually antibiotics are not recommended unless there is a risk factor e.g. obesity, oesophageal obstruction, decreased gastric acidity/motility then consider Co-Amoxiclav 1.2g IV single dose at induction
• Penicillin allergy use Gentamicin 120mg IV single dose

Hepatobiliary surgery (including open cholecystectomy)

• Gram negative bacilli(enterics), enterococci and anaerobes
• Usually antibiotics are not recommended for clean surgery.
• If indicated Co-Amoxiclav 1.2g IV at induction
• Penicillin allergy use Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
• Laparoscopic cholecystectomy: Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage. Gentamicin 120mg IV single dose at induction

Colorectal

• Gram negative bacilli (enterics) enterococci anaerobes including Clostridium sp.
• Co-Amoxiclav 1.2g IV at induction. A second dose may be needed if significant blood loss or prolonged operation (ie >5hrs)
• Penicillin allergy use Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
• Appendicectomy: Co-Amoxiclav 1.2g IV just before the procedure. Penicillin allergy use Gentamicin 120mg IV

Gastrointestinal endoscopy

• Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure followed by Amoxicillin 500mg po 6 hours later
• Penicillin allergy - Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just before the procedure
• ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis: Piperacillin/Tazobactam 2.25g IV single dose just before the procedure. Penicillin allergy use Gentamicin 120mg IV
• PEG insertion: Co-Amoxiclav 1.2g IV just before the procedure. Penicillin allergy use Gentamicin 120mg IV

GENITOURINARY

• If preoperative urine is positive, treat according to culture result for 48 hrs before operation. Gram-negative bacilli (enterics) and enterococci
• Cystoscopy: Rigid cystoscopy Gentamicin 120mg IV just before procedure. Flexible cystoscopy for patients with a high risk of infection only - Gentamicin as above
• Urodynamics: Trimethoprim 200mg PO bd 3/7
• Transrectal ultrasound scan (TRUS) and biopsy of the prostate: Oral Ciprofloxacin 1g just before the procedure; Gentamicin 120mg IV plus metronidazole 1g PR after biopsy followed by: oral Ciprofloxacin 500mg at 12 hours post-procedure
• Transurethral resection of prostate(TURP): Gentamicin 120mg IV at induction (if CSU/MSU positive treat according to sensitivity)
• Transurethral resection of bladder tumour : Gentamicin 120mg IV at induction (if CSU/MSU positive treat according to sensitivity)
• Open renal surgery: Gentamicin 120mg IV at induction
• Radical retropubic prostatectomy: Gentamicin 120mg IV at induction
• Radical perineal prostatectomy: Co-Amoxiclav 1.2g IV tds for 48 hours. Penicillin allergic: discuss with Consultant Microbiologist
• Cystectomy +/-reconstruction Gentamicin 120mg IV plus Metronidazole 1g PR at induction followed by Metronidazole 1g PR 12 hours post-procedure
• Stent operation Gentamicin 120mg IV at induction
• Stone removal (open) Gentamicin 120mg IV at induction
• Shock wave lithotripsy Gentamicin 120mg IV at induction

OBSTETRIC & GYNAECOLOGICAL SURGERY

• Gram negative bacilli (enterics) enterococci and anaerobes including Clostridium perfringens
• Vaginal, abdominal or laparoscopic hysterectomy. Co-Amoxiclav 1.2g IV at induction. A second dose may be needed if significant blood loss or prolonged operation (ie >5 hours). Penicillin allergy use Gentamicin 120mg IV plus Metronidazole 500mg IV
• Termination of pregnancy/ERPC. Metronidazole 1g PR at induction Followed by: Doxycycline 100mg bd for 7 days OR Azithromycin 1g PO stat (use only if likely poor compliance unless the patient was screened negative for chlamydia
• Trans vaginal tape Gentamicin 120mg IV single dose at induction
• Caesarean section Single dose of Co-Amoxiclav 1.2g IV alone after the umbilical cord is clamped. For Penicillin allergy use Gentamicin 120mg IV plus Metronidazole 500mg IV
• Prevention of perinatal infection with streptococcal group B Follow local guidelines

ORTHOPAEDIC

• S. aureus, S. epidermidis, Clostridium
• Prosthetic joint surgery (implant) and open bone surgery e.g. open fracture reduction. Mainly Staphylococci. Flucloxacillin 1g IV and Gentamicin 120mg IV at induction followed by 2 further doses of Flucloxacillin 1g at 6 hourly intervals For Penicillin allergy use Teicoplanin 400mg 1g IV infusion plus Gentamicin IV 120mg IV at induction followed by Teicoplanin 400mg 12 hours later If the patient is past or present MRSA positive or has not been screened for MRSA (See MRSA policy) Use Teicoplanin and Gentamicin as above
• Compound fracture repair. Polymicrobial Co-Amoxiclav 1.2g IV at induction followed by 2 further doses at 8 hourly intervals For Penicillin allergy use Teicoplanin 400mg IV plus Metronidazole 500mg IV plus Gentamicin 120mg IV at induction and repeat all three 12 hours later.
• Amputation For prevention of gas gangrene in high (lower limb) amputations or following major trauma Benzylpenicillin 600mg qds IV for 5 days. For Penicillin allergy use Metronidazole 500mg TDS IV for 5 days.

VASCULAR SURGERY

• with or without graft - Staphylococci, Streptococci
• Co-Amoxiclav 1.2g IV at induction followed by one further dose 8 hours later
• For Penicillin allergy - Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction repeated 12 hours later
• MRSA screen is required if the patient is having a graft or falls into risk category
• MRSA (see MRSA policy)
• If known MRSA patient is having a graft or falls into a risk category and has not been screened, use Teicoplanin and Gentamicin as above

THORACIC SURGERY

• Staphylococci, Streptococci, Gram negative bacilli (enteric)
• Co-Amoxiclav 1.2g IV at induction For Penicillin allergy - Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction

HEAD and NECK SURGERY

• Staphylococci, Streptococci, Gram negative bacilli
• As for thoracic surgery

Endocarditis prophylaxis

• Acquired valvular disease with stenosis or regurgitation
• Valve replacement
• Structural congenital heart disease;
• hypertrophy cardiomyopathy
• Previous infective endocarditis)

  Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64, March 2008) for most procedures (discuss with a Cardiologist if unsure) EXCEPT If patients at risk of endocarditis are undergoing a gastrointestinal or genito-urinary tract procedure at a site where infection is suspected, they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis. (Discuss with a Consultant Microbiologist)

Pacemaker implantation

• Co-Amoxiclav 1.2g IV single dose just before the procedure.
• Penicillin allergic patients or MRSA carriers - Teicoplanin 400mg IV single dose just before the procedure

Splenectomy or dysfunctional spleen

• Phenoxymethylpenicillin (Penicillin V) 500mg PO bd (life long)
• Penicillin allergy - Erythromycin 500mg PO od (life long)
• Vaccination against Streptococcus pneumoniae, H. influenzae and group C meningococci should be given, preferably a minimum of 2 weeks prior to removal of the spleen. Annual influenza vaccination is also required.
• Contact Microbiologist if in doubt