GuidelinesEML (Adult Hospital STG)
Surgical Antibiotic Prophylaxis
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition
GENERAL PRINCIPLES
- Prophylactic antibiotic therapy reduces the risk of surgical site infection.
- The need for surgical antibiotic prophylaxis depends on the nature of the expected wound from the procedure.
- Wounds that are expected to be clean (defined as no inflammation encountered; and the respiratory, alimentary, genital, or uninfected urinary tracts were not entered) generally do not require antibiotic prophylaxis, except where the consequences of surgical site infection could be severe (e.g. joint replacement in orthopaedic surgery).
- Antibiotic prophylaxis is indicated for procedures with clean-contaminated wounds (defined as entering the respiratory, alimentary, genital, or uninfected urinary tracts under controlled conditions; and without unusual contamination).
- A course of antibiotic treatment, not antibiotic prophylaxis, is required for procedures with contaminated wounds (defined as fresh open accidental wounds, or operations with major breaks in sterile technique), or dirty or infected wounds (defined as old traumatic wounds with retained devitalized tissue; and those that involve existing clinical infection or perforated viscera). (See chapter: Emergencies and injuries for antibiotic treatment).
- The antibiotic of choice should be active against Gram positive organisms, notably Staphylococcus aureus, which is the commonest cause of surgical site infections, with additional cover for other common pathogens according to the surgical site (e.g. anaerobic bacteria for GIT surgery).
- Give prophylaxis at induction.
- If a tourniquet is used at the site of surgery, administer the entire antibiotic dose before the tourniquet is inflated.
- Implement perioperative glycaemic control and use blood glucose target levels less than 11.1 mmol/L in patients with and without diabetes.
- Maintain perioperative normothermia.
- Antibiotic prophylaxis should be used in conjunction with good pre-, intra-, and post-operative infection control strategies.
- Advise patient to shower or bathe with soap or antiseptic agent on at least the night before the procedure.
- Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation. If hair removal is necessary, remove immediately before the operation, with clippers.
Dosage recommendations:
- Cefazolin, IV.
- < 60 kg: 1 g
- 60-120 kg and BMI <35: 2 g
- >120 kg OR BMI > 35: 3 g
- Pregnant women:
- <60 kg: 1 g
- 60-100 kg: 2 g
- >100 kg: 3 g
- Metronidazole, IV, 500 mg.
- Azithromycin, IV, 500 mg.
- Gentamycin IV, 6mg/kg (See Prescribing Information for Specific Medicines, for guidance on prescribing).
- Clindamycin, IV, 600 mg.
In most instances a single antibiotic dose prior to the procedure is sufficient for prophylaxis. Postoperative antimicrobial administration is not recommended for most surgeries as this selects for antimicrobial resistance. LoE:I11
- Additional intra-operative doses should be administered in circumstances of significant blood loss (>1500 mL) in order to ensure an adequate antimicrobial level until wound closure. LoE:III12
- With prolonged procedures, antibiotics are required to be re-dosed (i.e. >4 hours for cefazolin; >8 hours for metronidazole; >6 hours for clindamycin and gentamycin). LoE:III13
ANTIBIOTIC PROPHYLAXIS
| Type of surgery | Antibiotic recommended | |
| Cefazolin, IV | Cefazolin, IV PLUS |
|
| Orthopaedic surgery | Primary total hip/ total knee replacement; internal fixation of hip; spinal procedures; open reduction and internal fixation of fractures; insertion of prostheses, screws, plates, etc. | - |
| Gastrointestinal surgery | Gastric/ duodenal/ oesophageal hernia repair | Biliary, colorectal, manipulation of viscera, appendicectomy, division of adhesions, exploratory laparotomy: ADD Metronidazole, IV. |
| Thoracic surgery (specialist) |
- | Pneumonectomy/ lobectomy: ADD Metronidazole, IV. |
| Cardiac surgery (specialist) | Coronary artery bypass surgery/routine cardiac valve surgery (continue cefazolin, IV, 8 hourly for 24 hours); cardiac device insertion (pacemaker implantation). | - |
| Vascular surgery (specialist) (Prophylaxis is not recommended for other clean procedures). |
Vascular reconstruction: abdominal aorta, groin incision (continue 8 hourly for 24 hours); AV fistula formation; and ligation of varicose veins. | Lower limb amputation: ADD Metronidazole, IV. |
| Urology | Clean procedures | Clean-contaminated procedures: ADD Metronidazole, IV. |
| Plastic and reconstructive surgery (Prophylaxis is not recommended for clean bone or soft tissue surgery). |
Craniotomy procedures | - |
| Otorhinolaryngology/ head and neck surgery (Prophylaxis is not recommended for other procedures such as tonsillectomy, sinus procedures, etc.). |
No incision through the oropharyngeal mucosa. | With incision through the oropharyngeal mucosa: ADD Metronidazole, IV. |
| Obstetrics/ gynaecology (Prophylaxis is not recommended for early suction termination). |
- | Hysterectomy, laparotomy procedures, vaginal repair: ADD Metronidazole, IV. |
| - | Caesarian delivery: ADD Azithromycin, IV. |
|
| Neurosurgery (Prophylaxis is not recommended for other minor clean procedures). |
Craniotomy; CSF shunt/drain; laminectomy. | - |
| Endoscopic gastrointestinal procedures (Prophylaxis is not recommended for all other procedures, with or without biopsy). |
Percutaneous endoscopic gastrostomy insertion/revision. | - |
| General Surgery (Prophylaxis is not recommended for uncomplicated clean procedures or clean excision procedures i.e. wound revision, excision of scar tissue, etc.). |
Clean contaminated procedures (mastectomy, node biopsy, etc.), splenectomy. |
- |
Beta lactam allergies:
Avoid beta-lactam antimicrobials in patients with a history of anaphylaxis, bronchospasm, urticaria, or angioedema after exposure to one of these agents.
- Clindamycin, IV.
ADD
- Gentamicin, IV for the procedures listed below: (See Prescribing Information for Specific Medicines, for guidance on prescribing).
- Gastrointestinal surgery, urology procedures (clean-contaminated), and obstetric/gynaecological surgery (hysterectomy, laparotomy procedures, vaginal repair).
Note
Clindamycin has good coverage against Gram positive organisms and anaerobes, so the addition of metronidazole is unnecessary.
Ophthalmic surgery:
- Chloramphenicol 0.5% ophthalmic drops, instil 1 drop 2–4 hourly for 24 hours prior to surgery.
SPECIAL CONSIDERATIONS
- Elective splenectomy patients should be vaccinated at least 14 days prior to surgery. If splenectomy was urgent, or if vaccination was omitted before elective splenectomy, vaccinate at least 14 days post-splenectomy.
- The following vaccines should be administered:
| Vaccine | Schedule |
| Polyvalent pneumococcal vaccine, 0.5mL, SC. | - PCV13, SC, 2 weeks before surgery. - PPS23, SC, 8 weeks later. - Revaccinate with PPS23 after 5 years and then at 65 years. LoE:II17 |
| Haemophilus influenza type B, 0.5mL, intramuscular. | - |
| Meningococcal polysaccharide vaccine (ACW135Y), 0.5mL, SC. | Revaccinate every 5 years. |
| Influenza vaccine, 0.5mL, IM. | Revaccinate annually. |
PROCESS MEASURES
Measure the percentage of procedures in which antimicrobial prophylaxis was appropriately provided.
These include:
- Correct type of antibiotic.
- Correct dose.
- Administration of the antibiotic(s) within 1 hour before incision.
- Not continuing the antibiotic(s) after surgery (except for 24 hours for cardiac and selected vascular procedures).
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2024 Edition