Surgical

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Open Fracture prophylaxis

Grade 1

<1cm skin laceration, <8hrs since injury, no signs of infection and able to be adequately debrided/cleaned

Grade 2

As above but 1-10cm skin laceration

Grade 3

>10cm skin laceration or extensive soft tissue loss OR >8 hrs since injury OR infection established) Extreme high energy trauma Extensive soft tissue lost, extreme High energy trauma.

Antimicrobial 

Grade 1:

Cloxacillin 2g (child 50mg/kg) IV QID

Alternative:

Cefazolin 2g (child 50mg/kg) IV TID

OR

Clindamycin 600mg (child 15mg/kg) IV TID

Grade 2 and 3:

To Grade 1 prophylaxis, ADD:

Gentamicin 2mg/kg IV OD

For severe injuries that are heavily contaminated ADD:

Metronidazole 500mg (child 12.5mg/kg) PO/IV BID (adding metronidazole is not necessary if clindamycin is used).

For water exposed wounds ADD:

Ciprofloxacin 400mg (child 10mg/kg) TID IV OR Ciprofloxacin 750mg (child 20mg/kg) PO BID to above regimes (if ciprofloxacin is used, there is no need to add gentamicin).

Comments and Duration of Therapy 

All open fractures require debridement, washout, and fracture stabilisation. Antibiotics should be administered as soon as possible, ideally within 3 hours of injury.

Check Tetanus immunization status of all patients and give DTP vaccine if required (See Tetanus Prophylaxis in Chapter 1: Antibiotic Prophylaxis).

Duration:

Grade 1 and 2: Discontinue antibiotics at wound closure.
Grade 3: Do not continue antibiotics for more than 24 hours after wound closure.
For all grades stop antibiotics at 72 hours even without definitive closure.

If prosthetic material is placed into infected tissue, See Infected fracture fixation in Chapter 2: Bone and Joint Infections

Head injury prophylaxis

Antibiotic prophylaxis is not indicated for all soft tissue injuries. In wounds that are heavily contaminated see Traumatic Wound Prophylaxis in Chapter 13: Skin and Soft Tissues infections.

Antimicrobial 

Antibiotic prophylaxis is not indicated for base of skull fractures, linear closed skull fractures or other closed head injuries.

For elevated skull fractures, depressed skull fractures, or fractures associated with penetrating head injury use:

Ceftriaxone 2g (child 50mg/kg) IV BID

PLUS

Metronidazole 500mg (child 12.5mg/kg) IV TID

Comments and Duration of Therapy 

If infection is present see Meningitis following penetrating head trauma or neurosurgery in Chapter 4: Central Nervous System Infections

Duration:

If antibiotic prophylaxis is indicated, treat for 5 days then stop.

Surgical Prophylaxis

Surgical prophylaxis is the use of antibiotics to prevent infection as opposed to their use where infection is already established. Antibiotic choice is guided by the likely source of infective organisms. Most infections occur secondary to the patient’s own organisms which may include multiple drug resistant organisms secondary to previous antibiotic use. All pre-existing infections should be treated prior to any surgery if possible.

Antimicrobial 

Cephazolin is the antibiotic of choice for most surgical prophylaxis and has a relatively short half-life and therefore should be re-dosed if the procedure is 4 hours or longer. It should also be re-dosed if there is excessive (≥ 1.5L) blood loss intraoperatively.

For most procedures, use:

Cephazolin 2g (child: 50mg/kg) IV

Alternative:

Cloxacillin 2g (child 50mg/kg) IV

OR

Clindamycin 600mg IV (child 15mg/kg) IV

If patient is known to have MRSA, ADD:

Vancomycin 15 mg/kg IV, to cefazolin.

Comments and Duration of Therapy 

Give antibiotics within 1 hour before procedure (ideally 15-30 minutes before surgical incision).

Post-operative courses of antibiotics >24 hours are only necessary in established infection. Extended prophylaxis is not recommended, and is associated with increased rates of resistance and subsequent infection with resistant pathogens.

Ampicillin does not adequately cover Staphylococcus aureus and should not be used alone as surgical prophylaxis.
Ceftriaxone contributes to AMR and should be avoided as surgical prophylaxis.

Head and Neck Surgery Prophylaxis

Antimicrobial

Cefazolin 2 g (child: 50mg/kg) IV

For incisions through mucosal surfaces ADD:

Metronidazole 500mg (child 12.5mg/kg) IV

Alternative:

If cefazolin is not available replace this in the above regime with:

Cloxacillin 2g (child 50mg/kg) IV

OR

Cefuroxime 1.5g (child 50mg/kg) IV

OR

Clindamycin 600mg (child 15mg/kg) IV (if clindamycin is used, there is no need to add metronidazole)

OR

Vancomycin 15mg/kg IV

Comments and Duration of Therapy 

Antibiotic prophylaxis is NOT indicated for the following:

  • Uncomplicated ear, nose, or sinus surgery (including endoscopy)
  • Otoplasty
  • Stapedectomy
  • Tonsillectomy
  • Adenoidectomy

Antibiotic prophylaxis IS indicated for the following:

  • Major ear surgery
  • Complex septorhinoplasty
  • Revision sinus surgery
  • Laryngectomy
  • Tympanomastoid surgery
  • Hearing implant procedures

Duration:

Stop antibiotics after procedure. Do not continue prophylaxis beyond 24 hours.

If infection is present, see Chapter 6: ENT / Respiratory Tract Infections.

Thoracic Surgery Prophylaxis

Antimicrobial 

Cefazolin 2 g (child: 50mg/kg) IV

Alternative:

Cloxacillin 2g (child: 50mg/kg) IV

OR

Cefuroxime 1.5g (child 50mg/kg) IV

OR

Clindamycin 600mg (child 15mg/kg) IV

OR

Vancomycin 15mg/kg

Comments and Duration of Therapy 

Duration:

Stop antibiotics after procedure. Do not continue prophylaxis beyond 24 hours.

If infection is present, see Chapter 3: Cardiovascular Infections and Chapter 6: ENT / Respiratory Tract Infections.

Chest drain insertion prophylaxis

Antimicrobial 

Antibiotic prophylaxis is not indicated when a chest drain is inserted for spontaneous pneumothorax, or in elective operations.

In patients who require chest drain insertion following trauma use:

Cefazolin 2 g (child: 50mg/kg) IV

Alternative:

Cloxacillin 2g (child: 50mg/kg) IV

OR

Cefuroxime 1.5g (child 50mg/kg) IV

Comments and Duration of Therapy 

Duration:

Stop antibiotics after procedure. Do not continue prophylaxis beyond 24 hours.

If infection is present, see Chapter 3: Cardiovascular Infections and Chapter 6: ENT / Respiratory Tract Infections.

Gastrointestinal Tract and Biliary Tree Surgery Prophylaxis

Antimicrobial 

Cefazolin 2 g (child: 50mg/kg) IV

Alternative:

Cloxacillin 2g (child: 50mg/kg) IV + Gentamicin 2mg/kg (adult and child) IV

OR

Clindamycin 600mg (child 15mg/kg) IV + Gentamicin 2mg/kg (adult and child) IV

OR

Vancomycin 15mg/kg IV + Gentamicin (adult and child) 2mg/kg IV

For colorectal surgery ADD:

Metronidazole 500mg (child 12.5mg/kg) IV

(No need to add metronidazole if clindamycin is used).

Comments and Duration of Therapy 

Duration:

Stop antibiotics after procedure. Do not continue prophylaxis beyond 24 hours.

If infection is present, see Chapter 15: Surgical Gastrointestinal Infections.

Urological procedure prophylaxis

The risk of post-operative infection is increased in patients with bacteriuria. Urine should be sent for culture and bacteriuria treated prior to urological procedures where possible.

Use recent culture results where available to direct prophylaxis.

Antimicrobial 

Endoscopic procedures and transurethral resection of the prostate:

Gentamicin (adult and child) 2mg/kg IV

Alternative:

Cefazolin 2g (child 50mg/kg) IV

Open or laparoscopic urological procedures:

Cefazolin 2g (child: 50mg/kg) IV

PLUS

Gentamicin 2mg/kg (adult and child) IV

Alternative:

Cloxacillin 2g (child: 50mg/kg) IV + Gentamicin 2mg/kg IV

OR

Clindamycin 600mg (child 15mg/kg) IV + Gentamicin 2mg/kg IV

OR

Vancomycin 15mg/kg IV + Gentamicin 2mg/ kg IV

If there is accidental rectal / bowel injury ADD:

Metronidazole 500mg (child 12.5mg/kg) IV

Transrectal prostate biopsy:

Ciprofloxacin 500mg PO 120 minutes prior to procedure

Transperineal prostate biopsy:

Cefazolin 2g IV

Alternative:

Cloxacillin 2g IV + Gentamicin 2mg/kg

Comments and Duration of Therapy

Send urine culture 3-5 days prior to procedure.

Duration:

Stop antibiotics after procedure. Do not continue prophylaxis beyond 24 hours.

If infection is present, see Chapter 16: Urinary Tract Infections.

Internal fixation of long bones and joint replacement surgery prophylaxis

Antimicrobial 

Cefazolin 2 g (child: 50mg/kg) IV

Alternative:

Cloxacillin 2g (child: 50mg/kg) IV

OR

Clindamycin 600mg (child 15mg/kg) IV

OR

Vancomycin 15mg/kg

If patient is colonised or suspected to be colonised with MRSA ADD:

Vancomycin 15mg/kg IV, to cefazolin.

Comments and Duration of Therapy

Duration:

Stop antibiotics after procedure. Do not continue prophylaxis beyond 24 hours.

If infection is present, see Chapter 2: Bone and Joint Infections.