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Part VI: Guidelines for surgical prophylaxis

General principles in surgical prophylaxis

Duration of prophylaxis: The duration of antimicrobial prophylaxis should not routinely exceed 24 hours (1 dose at induction and 2 more doses postoperatively, i.e. 3 doses in total). There is wide consensus that only a single dose of I.V. antimicrobial agent is needed for surgical prophylaxis in the great majority of cases including orthopaedic surgery with prosthesis. Published evidence shows that antimicrobial prophylaxis after wound closure is unnecessary even in the presence of a drain. Most studies comparing single- with multiple-dose prophylaxis have not shown benefit of additional doses.
Timing: For many prophylactic antimicrobial agents, the administration of an initial dose should be given within 30 minutes before incision (coinciding with the induction of anaesthesia) to achieve a bactericidal serum and tissue concentration at the time of initial incision. This can be facilitated by having the anaesthesiologist administer the drug in the operating room at induction.
Antimicrobial dosing: The dose should be adequate based on the patient’s body weight. An additional dose of antimicrobial agent should be given (intraoperatively) if the operation is still continuing after two half-lives of the initial dose or massive intraoperative blood losses occur References: (409–491).

Table 6.1 Suggested initial dose and time to re-dose for selected antimicrobial agents used for surgical prophylaxis

Antimicrobial agent	Standard I.V. dose ¹	Recommended re-dosing interval (hour)
Cefazolin	1–2 g	2–5
Cefuroxime	1.5 g	3–4
Clindamycin	600–900 mg	3–6
Amoxicillin-clavulanate	1.2 g	2–3
Ampicillin-sulbactam	1.5 g	2–3
Metronidazole	500 mg	6–8
Vancomycin	1 g infuse over 60 min	6–12

¹In patient with normal renal function and not morbidly obese.

Table 6.2 Antimicrobial prophylaxis in clean operations

Type of operation	Indications	Recommended drugs¹
Cardiac²	Prosthetic valve Coronary artery bypass Pacemaker implant Open heart surgery	I.V. cefazolin 1 g³ then every 4 hours Note: The duration of antimicrobial prophylaxis should not be longer than 48 hours.
Thoracic²	Pulmonary resection Closed tube thoracostomy for chest trauma	I.V. cefazolin 1 g³ OR I.V. cefuroxime 1.5 g OR I.V. amoxicillin-clavulanate 1.2 g⁴
Vascular	Abdominal aortic operations Prosthesis Groin incision Lower extremity amputation for ischaemia	I.V. cefazolin 1 g³ OR I.V. cefuroxime 1.5 g OR I.V. amoxicillin-clavulanate 1.2 g⁴
Neurosurgery²	Craniotomy Ventriculoperitoneal shunt Implantation of intrathecal pump (492)	I.V. cefazolin 1 g³ OR I.V. cefuroxime 1.5 g
Neurosurgery²	Re-exploration or microsurgery	I.V. cefuroxime 1.5 g OR I.V. amoxicillin-clavulanate 1.2 g⁴
Orthopaedic & Traumatology²	Total joint replacement with prosthesis Internal fixation of closed fractures	I.V. cefazolin 1 g³ OR I.V. cefuroxime 1.5 g Note: Antimicrobial agents should be completely infused before inflating the tourniquet if applied.
Orthopaedic & Traumatology²	Prophylactic antibiotic is indicated for all open fractures and should be given as soon as possible⁵ Wound cultures and sensitivity testing are useful for informing subsequent choice of antimicrobials (493–495) For Gustilo type III tibial fractures, prophylaxis given within 1 hr was associated with reduced infection risk (496)	I.V. amoxicillin-clavulanate ± gentamicin⁵ OR I.V. ceftriaxone 2 g ± I.V. penicillin G⁵ other third generation cephalosporin ± I.V. penicillin G⁵ Note: The duration of prophylactic antibiotic for open fractures depends on the classification: 24hr (for Gustilo type I and II open fractures) and up to 72 hr (for Gustilo type III open fractures). Antibiotics should not be given for more than 24 hr after soft tissue coverage of the wound, whichever occurs first.
Thyroid & parathyroid glands		Antimicrobial prophylaxis is not indicated

Table 6.3 Antimicrobial prophylaxis in clean-contaminated operations

Type of operation	Indications	Recommended drugs¹
Oral-pharyngeal / nasal	Tonsillectomy Maxillofacial Rhinoplasty Turbinate/septoplasty	I.V. amoxicillin-clavulanate 1.2 g⁴ OR If Pseudomonas is suspected: I.V. amoxicillin-clavulanate 1.2 g⁴ + I.V. gentamicin OR I.V. amoxicillin-clavulanate 1.2 g⁴ + I.V. ceftazidime 1–2 g
Ear	Myringotomy Tympanostomy tube insertion	Quinolone or Sofradex eardrop
Upper gastrointestinal tract	Gastro-duodenal (high risk): Obstruction Haemorrhage Gastric ulcer Malignancy H₂ blocker Proton pump inhibitor Morbid obesity Gastric bypass Percutaneous endoscopic gastrostomy	I.V. cefuroxime 1.5 g OR I.V. amoxicillin-clavulanate 1.2 g⁴
Upper gastrointestinal tract	Oesophageal operation with manipulation of pharynx	I.V. cefuroxime 1.5 g OR I.V. cefazolin 1 g³ ± metronidazole 500 mg
Hepato-biliary system Laparoscopic gall bladder surgery	High risk: Age more than 70 years Acute cholecystitis / pancreatitis Obstructive jaundice Common bile duct stones Morbid obesity Intraoperative cholangiogram Bile spillage Pregnancy Immunosuppression Insertion of prosthetic devices Laparoscopic converts to laparotomy	I.V. amoxicillin-clavulanate 1.2 g⁴ OR I.V. cefuroxime 1.5 g + I.V. metronidazole 500 mg
Endoscopic retrograde cholangio-pancreatography (ERCP)	Biliary obstruction	P.O. ciprofloxacin 500–750 mg 2 hours prior to procedure OR I.V. piperacillin-tazobactam 4.5 g 1 hour prior to procedure
Appendectomy		I.V. amoxicillin-clavulanate 1.2 g⁴ OR I.V. cefuroxime 1.5 g + I.V. metronidazole 500 mg
Colorectal	Most procedures require parenteral ± oral prophylaxis (497–500)	Parenteral I.V. amoxicillin-clavulanate 1.2 g⁴ OR I.V. cefuroxime 1.5 g + I.V. metronidazole 500 mg Oral P.O. neomycin and erythromycin base 1 g each t.d.s. the day before operation
Abdominal / vaginal hysterectomy		I.V. cefazolin 1 g³ OR When vaginal wound is present: I.V. cefuroxime 1.5 g + I.V. metronidazole 500 mg OR I.V. amoxicillin-clavulanate 1.2 g⁴
Caesarean section (502)	All caesarean sections are indicated for antibiotic prophylaxis (503)	I.V. cefazolin 1 g³ OR When vaginal wound is present: I.V. cefuroxime 1.5 g + I.V. metronidazole 500 mg OR I.V. amoxicillin-clavulanate 1.2 g⁴ Note: For caesarean section, the initial dose of antimicrobial agents should be given before surgical incision instead of after clamping the umbilical cord (501).
Abortion	Antimicrobial prophylaxis should be based on individual clinical condition and local epidemiology (504–505)	Refer to footnote 6
Urology⁷	Significant bacteriuria Transurethral resection of the prostate (TURP), transurethral resection of bladder tumour (TURBT) Stone operations Nephrectomy Total cystectomy	Treat according to mid-stream urine culture result prior to elective procedures
Hernia repair⁸	Non mesh hernia repair	Antimicrobial prophylaxis is not indicated
Hernia repair⁸	Adult hernia mesh repair	I.V. cefazolin 1 g³ OR I.V. cefuroxime 1.5 g
Breast cancer surgery⁸ (506)		I.V. cefazolin 1 g³ OR I.V. cefuroxime 1.5 g

Table 6.4 Antimicrobial prophylaxis in contaminated-infected operations

Type of operation	Indications	Recommended drugs¹
Ruptured viscus⁹	For treatment of established infection	I.V. cefuroxime 1.5 g + I.V. metronidazole 500 mg OR I.V. amoxicillin-clavulanate 1.2 g⁴ (Therapy is often continued for about 5 days)
Bite wound⁹	For treatment of established infection	I.V. amoxicillin-clavulanate 1.2 g⁴ OR P.O. amoxicillin-clavulanate 1g
Traumatic wound⁹	For treatment of established infection	I.V. cefazolin 1–2 g³ OR I.V. cefuroxime 1.5 g OR I.V. amoxicillin-clavulanate 1.2 g⁴

Footnotes for Tables 6.2–6.4:

¹The dose of antimicrobial agents recommended in the guidelines is based on adult patient with normal renal function. Special attention should be paid to patient with renal impairment, on renal replacement therapy, or if there is potential drug-drug interaction. Consultation to clinical microbiologist, infectious disease physician and clinical pharmacist is required in complicated cases.
²For hospitals or units with a high incidence of postoperative wound infections by MRSA or methicillin-resistant Staphylococcus epidermidis, screening for MRSA may be indicated to identify patients for additional preoperative measures such as chlorhexidine bath, 2% mupirocin nasal ointment [Bactroban Nasal] and/or the use of vancomycin as preoperative prophylaxis. Evidence is strongest for cardiothoracic and orthopaedic surgery with implantation (507–508).
³Give cefazolin 2 g for patients with body weight greater than 80 kg. For patients allergic to cefazolin, vancomycin 1 g infused over 1 hour should be given after premedication with an antihistamine. Rapid I.V. administration of vancomycin may cause hypotension, which could be especially dangerous during induction of anaesthesia.
⁴Amoxicillin-clavulanate and ampicillin-sulbactam are similar in spectrum coverage and centres may choose to use ampicillin-sulbactam.
⁵Choice of agent(s) depends on the type of open fractures by the Gustilo classification and the likely organisms contaminating the wound. In general, prophylactic antibiotic should be directed against Gram-positive organisms for Gustilo type I and II open fractures; additional Gram-negative coverage should be added for Gustilo type III open fractures. In the setting of faecal or potential clostrial contamination (e.g. soil exposure), a penicillin should be included in the regimen.
⁶The optimal antibiotic and dosing regimens for abortion are unclear. The antimicrobial prophylaxis for abortion stated in Royal College of Obstetricians and Gynaecologists (United Kingdom) (422) clinical guidelines is Level C recommendations and may be suitable. They include: metronidazole 1 g rectally at the time of abortion plus doxycycline 100 mg orally b.d. for 7 days, commencing on the day of abortion; OR metronidazole 1 g rectally at the time of abortion plus azithromycin 1 g orally on the day of abortion.
⁷For transrectal ultrasound (TRUS)-guided biopsy of the prostate, prophylactic regimen is evolving because of increasing fluoroquinolone resistance in E. coli. (509). If a fluoroquinolone is used, administer the drug 1–2 hours before the procedure to allow maximum tissue penetration (510). Ensure adequate drug level in the body by giving a full standard dose (500 mg to 750 mg for levofloxacin and ciprofloxacin). If post-biopsy infection develops, antibiotic treatment regimen should include coverage against ESBL-producing organisms given the high prevalence of this resistance mechanism in Hong Kong (Table 1.3).
⁸Amoxicillin-clavulanate may be used if the operation is such that anaerobic coverage is needed, such as in diabetic foot, hernia repair with bowel strangulation or incarcerated/ strangulated hernia or mastectomy with implant or foreign body.
⁹Antimicrobial agents should be considered postoperatively for operations with suppurative, ruptured and gangrenous conditions.