Antibiotic Prophylaxis in Surgery

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Antibiotic prophylaxis refers to the administration of antibiotics in patients to reduce the risk of perioperative sepsis. The main cause of morbidity and mortality in surgery is infectious complications.

Antibiotic prophylaxis is indicated in cases where sepsis is expected and could have disastrous local or generalised effects.

For prophylaxis to be effective, antibiotics must be given before contamination takes place or at the earliest possible time before infection is established. For surgery, therefore, it must be given IV about the time of induction of anaesthesia, so that tissues are saturated with the antibiotic before contamination occurs. 

Cause

  • Staphylococcus aureus
  • Streptococcus spp.
  • Enterobacteriaceae (GI)
  • Anaerobes (GI)
  • Coagulase negative staphylococci (especially cardiac surgery, and implantation surgery), etc.

Objectives

  • Prevent infections 
  • Prevent complications
Indications

Proven Indications

  • Acute appendicitis and intestinal obstruction
  • Surgery on the colon and rectum
  • Surgery on the biliary tract
  • Gastro-oesophageal and oro-pharyngeal surgery for carcinoma
  • Hysterectomy
  • Surgery in the presence of pus
  • Patients with rheumatic heart disease
  • Patients with congenital heart disease

Accepted Indications

  • Implant surgery where prosthesis and device implants are used
  • Cardiovascular surgery
  • Caesarean section

Possible Indications  

  • Thoracic surgery
  • Neurosurgery
  • Surgery on the genito-urinary tract
  • Trauma surgery

Choice of Antibiotics

The antibiotic chosen must:

  • Have antibacterial activity against the anticipated pathogens
  • Not easily induce antimicrobial resistance
  • Have a high concentration at the site of infection
  • Be safely metabolised and excreted
  • Have few toxic or adverse reactions
  • Be affordable

See sections below for antibiotic regimens: 

Appendicectomy/Uncomplicated Appendicitis

Regimen: 
  • Ampicillin, IV, 

Adults

1g 

Children

6-12 years; 500 mg 

< 5 years; 250 mg 

And

  • Metronidazole, IV,

Adults

500 mg single dose at induction of anaesthesia

Children

7.5 mg/kg single dose at induction of anaesthesia

Or

  • Metronidazole, rectally,

Adults 

1g one hour before surgery

Children

125-250 mg one hour before surgery

Resection of the colon or rectum or obstructed bowel

Regimen: 
  • Gentamicin, IV, 

Adults and Children

5 mg/kg 

And

  • Metronidazole, IV,

Adults

500 mg

Children

7.5 mg/kg 

Or

  • Metronidazole, IV, (doses same as above)

And

  • Cefuroxime, IV,

Adults

1.5 g

Children

60 mg/kg as a single dose.


Or

  • Ciprofloxacin, IV, (to be administered over 60 minutes)

Adults

400 mg 8-12 hourly

Children

10 mg/kg 12 hourly (max. 400 mg)

And

  • Metronidazole, IV,

Adults

500 mg stat.

Children

7.5 mg/kg stat.

Biliary tract surgery

Regimen: 

Single dose of Gentamicin, IV, 

  • Gentamicin, IV, 

Adults and Children

5 mg/kg 

And

  • Cefuroxime, IV,

Adults

1.5 g

Children

60 mg/kg as a single dose.

Hysterectomy

Regimen: 

Single dose of Metronidazole, IV,
500 mg

 

Dental procedures for patients with heart valve prostheses, rheumatic heart disease, septal defect and patent ductus arteriosus

Under Local Anaesthesia:
  • Amoxicillin(Amoxycillin), oral,

Adults

3 g one hour before procedure

Children

6-12 years; 1.5 g

5 years; 750 mg

Patients with Penicillin allergy or who have received more than one dose Penicillin in the previous month;

  • Clindamycin, oral,

Adults

600 mg

Children

5-10 years; 300 mg

< 5 years; 150 mg

Patients who have had previous Endocarditis

Adults

  • Ampicillin, IV, 1g

And

  • Gentamicin, IV, 120mg at induction 

Then

  • Amoxicillin, oral, 500mg 6 hours later.

Children

  • Ampicillin,IV,

6-12 years; 500 mg

< 5 years; 250 mg

And

  • Gentamicin, IV, 2 mg/kg

Then (6 hours later)

  • Amoxicillin, oral,

6-12 years; 250 mg

< 5 years; 125 mg

Under General Anaesthesia:

  • Amoxicillin + Clavulanic Acid, IV,

Adults

1.2 g at induction

Then

  • Amoxicillin, oral, 500 mg 6 hours later.

Children

5-10 years; ½ of adult dose

< 5 years; ¼ of adult dose

If patient has a prosthetic valve or previously had endocarditis:

  • Ampicillin, IV

and

  • Gentamicin, IV (see doses under previous endocarditis above)

Patients who are allergic to penicillin or who have had more than a single dose of Penicillin In previous month:

  • Clindamycin, IV,

Adults

300 mg over at least 10 minutes at induction or 15 minutes before procedure,

then

  • Clindamycin, oral or IV, 150 mg 6 hours later

Children

6 mg/kg stat. 3 mg/kg 6 hours later