Prophylaxis
This guideline aims to assist healthcare workers with antibiotic prescribing for common clinical syndromes in adult patients in South Africa, utilizing Local and International guidelines, key publications, and expert opinion.
Surgery
Surgical prophylaxis aims to prevent infection following a predictable exposure to bacteria. Antibiotics are only required during exposure and a single dose taken pre-operatively is usually sufficient. A repeat dose should only be given if surgery is prolonged or there is massive blood loss.
Choice of antibiotic depends on which bacteria are likely to be introduced by the operation, usually normal colonisers of skin or bowel. Examples are given below but refer to local policies for guidance.
| Type of surgery | Prophylaxis |
| Cardiothoracic Upper GI Neurosurgery Orthopaedic (elective non-‐trauma) |
Cefazolin 2g IV |
| Lower limb amputation Colorectal Biliary Pelvic ENT |
Cefazolin 2g IV plus Metronidazole 500mg IV |
| Lower limb amputation Colorectal Biliary Pelvic ENT |
Chloramphenicol 0.5% drops |
| ERCP with obstruction | Ciprofloxacin 500mg po 2h prior to the procedure or cefuroxime 1.5g IV or PIP/TZ 4.5g IV, both 1h prior to the procedure |
| Surgery for the implantation of any permanent prosthetic material |
Cefazolin 2g IV or cefuroxime 1.5g IV or vancomycin 1g IV as single dose |
| Penetrating abdominal trauma or open fracture | Cefazolin 2g IV + metronidazole 500mg IV and second dose if procedure > 3h |
Head injuries
Closed head injuries with non-penetrating wounds do not require antibiotic prophylaxis even if there is a CSF leak. Compound depressed skull fractures and penetrating spinal cord injuries do require prophylaxis/pre-emptive treatment e.g. ceftriaxone plus metronidazole for 5 days.
Open long bone fractures
If early (< 5 hours) washout and debridement, provide prophylaxis with cefazolin 1g iv 12-hourly for 48 hours only. If long delay to washout or significant contamination, treat with coamoxiclav 1.2 g iv 8-hourly for 5 days.
Infective endocarditis
The evidence base is weak and guidelines are largely based on expert opinion, which differs between countries and region. In general only those at the highest risk of infective endocarditis should be offered prophylaxis and then only when the risk of bacteraemia from the procedure is high.
Conditions requiring prophylaxis
- Significant congenital or acquired cardiac abnormalities
- Prosthetic valves or valvular repair utilising prosthetic material
- Previous infective endocarditis
Procedures requiring prophylaxis
- Dental procedures involving manipulations if the gingival or perapical region of the teeth or perforating the oral mucosa.
Examples of regimens are given in the table:
| Procedure | Regimen | Alternative |
| Dental, oral or upper respiratory tract | Amoxicillin 3g po | Clindamycin 600mg IV |
| Genitourinary, gastrointestinal or biliary | Ampicillin 2g IV Plus gentamicin 1.5mg/kg |
Vancomycin 1g IV Plus gentamicin 1.5mg/kg |
Rheumatic fever
- Secondary prophylaxis should be prescribed for all patients following rheumatic fever to prevent recurrences
Duration
- Without carditis 5 years after last attack or 21 years (whichever is longer)
- With mild carditis 10 years after last attack or 21 years (whichever is longer)
- With carditis and residual heart disease 10 years or until age 40 (whichever is longer). Sometimes life-‐long prophylaxis.
Regimen
- Benzathine penicillin 1.2MU IM every 3-4 weeks or penicillin V 250mg po 12-hourly. If penicillin allergic azithromycin 250mg daily.