Surgical+Antimicrobial+Prophylaxis v2.0 23112017 PDF

Policy Classification: Public-I1-A2
Policy No.: CG269
Surgical Antimicrobial
Prophylaxis
Clinical Guideline
Version No: 2.0
Approval date: 2 November 2017
Contents
1. Guideline Statement.......................................................................................................................... 4
2. Roles and Responsibility ................................................................................................................. 4
2.1. Local Health Network (LHN) Chief Executive Officers will: .......................................................... 4
2.2. LHN AMS Committees are responsible for: ................................................................................... 4
2.3. Prescribers (including contracted staff) are responsible for: ...................................................... 4
2.4. Pharmacists (including contracted staff) are responsible for: .................................................... 5
2.5. Nurses are responsible for: ............................................................................................................. 5
3. Policy Requirements ......................................................................................................................... 5
3.1. Background ....................................................................................................................................... 5
3.2. Recommendations ............................................................................................................................ 5
3.2.1. Practice Points .................................................................................................................................. 5
3.2.2. Drug administration .......................................................................................................................... 6
3.2.3. MRSA risk .......................................................................................................................................... 6
3.2.4. Vancomycin administration ............................................................................................................. 6
3.2.5. Clindamycin administration ............................................................................................................. 6
3.2.6. Gentamicin administration ............................................................................................................... 6
3.2.7. Repeat doses ..................................................................................................................................... 6
3.2.8. Obese patients ................................................................................................................................... 6
4. Implementation and Monitoring....................................................................................................... 6
5. National Safety and Quality Health Service Standards ................................................................. 7
6. Definitions .......................................................................................................................................... 7
7. Associated Directives / Guidelines & Resources .......................................................................... 8
7.1. SA Policies and guidelines .............................................................................................................. 8
7.2. References ......................................................................................................................................... 8
7.3. Appendices ........................................................................................................................................ 8
Appendix 1 Breast procedures / Endocrine procedures / Abdominal procedures (including
Splenectomy) / Herniorrhaphy/ Insertion of infusaport / Clean excision procedures
Appendix 2 Cardiac Surgery
Appendix 3 CVIU / Cardiology Procedures
Appendix 4 Prevention of Endocarditis
Appendix 5 Endoscopic Gastrointestinal Surgery
Appendix 6 Gastrointestinal Surgery
Appendix 7 Head and Neck Surgery Prophylaxis
Appendix 8 Maxillofacial Surgery
Appendix 9 Neurosurgery Prophylaxis
INFORMAL COPY WHEN PRINTED Surgical Antimicrobial Prophylaxis Clinical Guideline v2.0 Page 2 of 9
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Appendix 10 Obstetrics and Gynaecology Surgery
Appendix 11 Ophthalmology
Appendix 12 Orthopaedic Surgery (Joint Replacement)
Appendix 13 Orthopaedic Surgery (Not Joint Replacement)
Appendix 14 Plastic and Reconstructive Surgery
Appendix 15 Thoracic Surgery
Appendix 16 Urology
Appendix 17 Vascular Surgery
8. Document Ownership & History ...................................................................................................... 9
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Surgical Antimicrobial Prophylaxis
Clinical Guideline
1. Guideline Statement
Surgical antimicrobial prophylaxis has become an accepted part of surgical practice to prevent
infections at the surgical site and optimise postoperative recovery. This Surgical Antimicrobial
Prophylaxis Guideline has been developed by SAAGAR to assist clinicians with recommendations
on appropriate antimicrobial dosage and administration, risks and contraindications, and
postoperative care for a range of surgical procedures.
The recommendations within this guideline are based on those published in the Australian
Therapeutic Guidelines, and are intended to allow for some variations for South Australian patient
demographics and resistance patterns.
2. Roles and Responsibility
The Surgical Antimicrobial Prophylaxis Clinical Guideline applies to surgery performed in all
South Australian public hospitals.
2.1. Local Health Network (LHN) Chief Executive Officers will:

> ensure clinicians have access to this guideline in electronic format
> ensure adequate resources and training are available for the implementation of this
guideline throughout the LHN
> maintain an effective mechanism for review of implementation of this guideline within the
LHN
> ensure the LHN meets standards for accreditation in relation to surgical antimicrobial
prophylaxis.
2.2. LHN AMS Committees are responsible for:

> providing governance over the use of prophylactic antimicrobial agents in surgery
> providing leadership for addressing requirements of the LHN relating to meeting the
surgical prophylaxis national standards for accreditation
> working collaboratively with departments of surgery, anesthesiology, or other relevant
hospital committees regarding development and implementation of surgical guidelines
> coordinating actions in response to results of audits of antimicrobial use in surgical
prophylaxis
> providing leadership for the training of clinical staff throughout the LHN in relation to AMS.
2.3. Prescribers (including contracted staff) are responsible for:

> safe and appropriate prescribing according to the general principles of antimicrobial surgical
prophylaxis
> ensuring antimicrobials are ordered so that they are administered within appropriate time
frames as specified in individual surgical prophylaxis guidelines
> prescribing according to the appropriate surgical prophylaxis guideline (see appendices) or
using the latest version of Therapeutic Guidelines: Antibiotic as part of their practice (1).
> where prescribing is not compliant with guidelines, documenting the reason on the
medication chart or case notes
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> provision of information to patients and their carers regarding their antimicrobial therapy
prior to surgery.
2.4. Pharmacists (including contracted staff) are responsible for:

> timely and accountable supply of antimicrobials used in surgical prophylaxis in accordance
with systems introduced by the LHN AMS Program, including mechanisms to control
access to restricted antimicrobials where restrictions exist
> safe, appropriate and timely advice to prescribers and nurses with regard to the selection,
dose, route, duration and monitoring of antimicrobials used in surgical prophylaxis
> where it is within their scope of practice, participation in providing evidence of monitoring
antimicrobial use in relation to surgical prophylaxis through auditing processes
> provision of information to patients and their carers regarding their antimicrobial therapy
prior to surgery.
2.5. Nurses are responsible for:

> being aware of the existence of surgical prophylaxis guidelines for a range of surgical
specialties, and able to assist prescribers to access electronic guidelines
> where it is within their scope of practice, ensuring safe and timely administration of
prescribed antimicrobials used in surgical prophylaxis
> where it is within their scope of practice, participation in providing evidence of monitoring
antimicrobial use in relation to surgical prophylaxis through auditing processes
> assisting patients and carers to obtain information and understanding of their antimicrobial
therapy.
3. Policy Requirements
3.1. Background
Prevention of surgical site infection accounts for between one-third and one-half of all
antimicrobial use in Australian hospitals. AURA 2016: First Australian report on antimicrobial
use and resistance in human health found that surgical prophylaxis was the most common
reason for antimicrobial use in hospitals in 2014 (2) . Of this use, 40% was deemed
inappropriate due to long duration, incorrect dose, or frequency (3). This guideline aims to
standardise the prescribing of surgical antimicrobial prophylaxis across the state.
3.2. Recommendations
Antimicrobial prophylaxis should be considered where there is a clear indication, a risk of
postoperative infection, or if postoperative infection will have serious consequences.
The recommended antimicrobial prophylaxis regimens for specific surgical procedures, along
with alternatives for patients with a high risk of penicillin/cephalosporin allergy, are available in
appendices 1 to 17.
3.2.1. Practice Points

Consider individual risk factors for every patient – need for prophylaxis, drug choice or dose
may alter (e.g. immune suppression, presence of prostheses, allergies, obesity, malnutrition,
diabetes, infection at another site, available pathology or malignancy).
Pre-existing infections at surgical site (known or suspected) – if present, use appropriate
treatment regimen instead of prophylactic regimen for procedure. Doses should be scheduled
to allow for re-dosing just prior to skin incision.
For patients with cardiac conditions that increase their risk of endocarditis following surgery,
refer to Antibiotic Prophylaxis Guidelines for Prevention of Endocarditis for further information
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3.2.2. Drug administration
> IV bolus – should be timed ≤ 60 minutes before skin incision (optimal 15-30 minutes).
Administration after skin incision or > 60 minutes before incision reduces effectiveness
> IV infusion – should be commenced 30-60 minutes prior to skin incision (e.g.
metronidazole). See below for vancomycin administration.
3.2.3. MRSA risk

Defined as history of MRSA colonisation or infection, OR inpatient of high risk hospital or unit
(where MRSA is endemic) for more than the last 5 days; add vancomycin (see vancomycin
administration below).
3.2.4. Vancomycin administration

Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion started 30-120
minutes before surgical incision and given at a recommended rate of 1g per hour (1.5g over 90
minutes). Note: infusion can be completed after skin incision.
3.2.5. Clindamycin administration

Give clindamycin 600mg (child: 15mg/kg up to 600mg) by IV infusion over at least 20 minutes
just before procedure. Repeat 4 hourly intra-operatively for prolonged procedures.
3.2.6. Gentamicin administration

Dosing should be based on ideal body weight, provided ideal body weight is less than actual
body weight. (See Aminoglycosides: Recommendations for use, dosing and monitoring clinical
guideline)
3.2.7. Repeat doses

A single pre-operative dose is sufficient for most procedures; however, repeat intra-operative
doses are advisable:
> for prolonged surgery (> 4 hours from the time of the first pre-operative dose) when a short-
acting agent is used (e.g. cefazolin); or
> if major blood loss occurs, following fluid resuscitation.
3.2.8. Obese patients

Consider increased dose of cefazolin if patient is obese (>120kg). Consult ID for advice.
4. Implementation and Monitoring
Where they exist, LHN AMS committees coordinate actions in response to results of audits of
antimicrobial use in surgical prophylaxis. The results of annual audits or KPI assessments should
be reported to LHN Chief Executive Officers and LHN Safety and Quality committees, together with
a plan for continuous (PDSA) improvement.
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5. National Safety and Quality Health Service Standards
National National National National National National National National National National
Standard 1 Standard 2 Standard 3 Standard 4 Standard 5 Standard 6 Standard 7 Standard 8 Standard 9 Standard 10
Governance Partnering Preventing Medication Patient Clinical Blood and Preventing Recognising & Preventing
for Safety with & Safety Identification Handover Blood & Responding to Falls &
and Quality Consumers Controlling & Procedure Products Managing Clinical Harm from
in Health Healthcare Matching Pressure Deterioration Falls
Care associated Injuries
infections
☐ ☐ ☒ ☒ ☐ ☐ ☐ ☐ ☐ ☐
The following National Safety and Quality Health Service Standard (NSQHSS) standards apply:
Standard 3 – Preventing & Controlling Healthcare Associated Infections
> Criterion 3.14 – Developing, implementing and regularly reviewing the effectiveness of the
antimicrobial stewardship system.
Standard 4 – Medication Safety

> Criterion 4.1 – Developing and implementing governance arrangements and organisational
policies, procedures and/or protocols for medication safety, which are consistent with national
and jurisdictional legislative requirements, policies and guidelines.
6. Definitions
In the context of this document:

> KPI Key Performance Indicators
> IBW Ideal Body Weight
> ID Infectious Disease Physician
> IV Intravenous
> MRSA Methicillin-resistant Staphylococcus aureus
> PDSA Plan-Do-Study-Act
> PO Per oral
> SAAGAR South Australian expert Advisory Group on Antimicrobial Resistance (SAAGAR)
> SSI Surgical site infection
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7. Associated Directives / Guidelines & Resources
7.1. SA Policies and guidelines

Antimicrobial Stewardship Policy Directive
Antimicrobial Prescribing Clinical Guideline
Peripartum Prophylactic Antibiotics Clinical Guideline
7.2. References
1. Antibiotic Expert Writing Group. Therapeutic Guidelines: Antibiotic (version 15). Melbourne;
2014.
2. Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2016: first
Australian report on antimicrobial use and resistance in human health. . Sydney; 2016.
3. National Centre for Antimicrobial Stewardship, Australian Commission on Safety and Quality
in Health Care. Antimicrobial prescribing practice in Australian hospitals: Results of the 2015
National Antimicrobial Prescribing Survey. Sydney; 2016.
7.3. Appendices
Appendix 1 Breast procedures / Endocrine procedures / Abdominal procedures (including
Splenectomy) / Herniorrhaphy / Insertion of infusaport / Clean excision
procedures
Appendix 2 Cardiac Surgery
Appendix 3 CVIU / Cardiology Procedures
Appendix 4 Prevention of Endocarditis
Appendix 5 Endoscopic Gastrointestinal Surgery
Appendix 6 Gastrointestinal Surgery
Appendix 7 Head and Neck Surgery Prophylaxis
Appendix 8 Maxillofacial Surgery
Appendix 9 Neurosurgery Prophylaxis
Appendix 10 Obstetrics and Gynaecology Surgery
Appendix 11 Ophthalmology
Appendix 12 Orthopaedic Surgery (Joint Replacement)
Appendix 13 Orthopaedic Surgery (Not Joint Replacement)
Appendix 14 Plastic and Reconstructive Surgery
Appendix 15 Thoracic Surgery
Appendix 16 Urology
Appendix 17 Vascular Surgery
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8. Document Ownership & History
Document developed by: South Australian expert Advisory Group on Antimicrobial

Resistance (SAAGAR
File / Objective No.: 2011-10137 | eA988353
Next review due: 2/11/2022
Policy history: Is this a new policy (V1)? N
Does this guideline amend or update and existing policy? Y
If so, which version? Version 1.1
Does this guideline replace another policy with a different title? N
If so, which guideline (title)?
Approval Who approved New/Revised

Version Reason for Change
Date Version
Safety & Quality Strategic Governance Formally reviewed in line with 1-5 year
2/11/2017 V2
Committee scheduled timeline for review.
Safety & Quality Strategic Governance Minor amendments to reflect current
12/08/14 V1.1
Committee practice.
Safety & Quality Strategic Governance
12/02/13 V1 Original approved version.
Committee
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Surgical Antibiotic Prophylaxis Guidelines
Breastprocedures/Endocrineprocedures/Abdominalprocedures(includingSplenectomy)/
Herniorrhaphy/Insertionofinfusaport/Cleanexcisionprocedures
Pre-Operative Considerations
Consider individual risk factors for every patient – need for prophylaxis, drug choice or dose may alter (e.g. immune suppression, presence of
prostheses, allergies, obesity, malnutrition, diabetes, infection at another site, available pathology or malignancy).
Pre-existing infections (known or suspected) – if present, use appropriate treatment regimen instead of prophylactic regimen for procedure. Doses
should be scheduled to allow for re-dosing just prior to skin incision.
*For patients with cardiac conditions refer to Antibiotic Prophylaxis Guidelines for Prevention of Endocarditis for further information.
Practice Points
Drug administration
> IV bolus – should be timed ≤ 60 minutes before skin incision (optimal 30 minutes). Administration after skin incision or > 60 minutes before
incision reduces effectiveness
> IV infusion – should be commenced 30-60 minutes prior to skin incision for metronidazole. See below for vancomycin administration.
MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of metropolitan or other high risk hospital for more than the last 5 days)
> Add vancomycin to cefazolin
Vancomycin administration
> Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion started 30-120 minutes before surgical incision and given at
a recommended rate of 1g per hour (1.5g over 90 minutes). Note: infusion can be completed after skin incision.
Repeat doses
A single pre-operative dose is sufficient for most procedures, however repeat intra-operative doses are advisable:
> for delayed or prolonged surgery (> 4 hours from the time of first preoperative dose) when a short-acting agent is used (e.g. amoxicillin,
cefazolin), OR
Obese patients
> Consider increased dose of cefazolin (3g) if patient is obese (>120kg) .Consult ID for advice.
Recommended Prophylaxis
*High risk
penicillin/cephalosporin allergy
Breast cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients > 80kg
actual body weight)
Clean contaminated procedures High risk of MRSA infection:
(microdochectomy, mastectomy, ADD vancomycin 1g IV infusion (1.5g for
reconstruction (incl. implants), patients > 80kg actual body weight)
reduction, sentinel node biopsy,
re-operative surgery <6wks prior.
Uncomplicated clean procedures

(wound revision, excision scar tissue, Prophylaxis NOT recommended
local excision, lumpectomy).
Endocrine
Prophylaxis NOT recommended
Thyroidectomy (or similar)
Abdominal metronidazole 500mg IV infusion (child: metronidazole 500mg IV infusion (child: 12.5mg/kg),
12.5mg/kg),
Procedures involving viscera PLUS
(e.g. appendicectomy, division of PLUS either gentamicin 2mg/kg IV
adhesions, resection) cefazolin 2g IV (child: 30mg/kg up to 2g)
High risk of MRSA infection:
OR ADD vancomycin 1g IV infusion (1.5g for patients
gentamicin 2mg/kg IV > 80kg actual body weight)
ADD vancomycin 1g IV infusion (1.5g for
patients > 80kg actual body weight)
Procedures not involving viscera cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients > 80kg
(e.g. abdominoplasty) High risk of MRSA infection: actual body weight)
Splenectomy cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients > 80kg
High risk of MRSA infection: actual body weight)
(Vaccination and post-splenectomy
antibiotic prophylaxis required in all ADD vancomycin 1g IV infusion (1.5g for
cases) patients > 80kg actual body weight)
SA Health Clinical Guideline for Vaccination and Antimicrobial Prophylaxis for Adult Asplenic
(Splenectomy) and Hyposplenic Patients available here.
*High risk
Herniorrhaphy cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients >80kg
> with mesh insert High risk of MRSA infection: actual body weight)
> without mesh insert Prophylaxis NOT recommended
Other cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients > 80kg
High risk of MRSA infection: actual body weight)
Insertion of infusaport/other devices
Clean excision procedures Prophylaxis NOT recommended
Post-Operative Care
Except where included above, post-operative antibiotics are NOT indicated unless infection is confirmed or suspected, regardless of the presence of
surgical drains.
If infection is suspected, consider modification of antibiotic regimen according to clinical condition and microbiology results.
Definitions / Acronyms
DRESS Drug rash with eosinophilia and systemic symptoms
ID Infectious Diseases
IV Intravenous
MRSA Methicillin-resistant Staphylococcus aureus
SJS / TEN Stevens-Johnson syndrome / Toxic epidermal necrolysis
* High Risk penicillin/cephalosporin allergy: History suggestive of high risk (eg. anaphylaxis, angioedema, bronchospasm, urticaria,
DRESS/SJS/TEN)
References
Antibiotic Expert Groups (2014). Therapeutic Guidelines: Antibiotic. Version 15. Melbourne, Therapeutic Guidelines Limited.
Bratzler, D, et al (2013). "Clinical practice guidelines for antimicrobial prophylaxis in surgery." Am J Health Syst Pharm 70 (3): 195-283.
Berrios-Torres, S., et al. (2017). "Centres for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection " JAMA Surgery
May 3. doi: 10.1001/jamasurg.2017.0904. [Epub ahead of print].
Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) March 2012, Last reviewed and amended August 2017
SAAGAR has endeavored to ensure that the information in this publication is accurate; however it makes no representation or warranty to this effect.
You rely on this publication at your own risk. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or incurred
as a result of reliance on this publication. As the information in this publication is subject to review, please contact a medical or health professional
before using this publication.s / Acronyms
October 2017
© Department for Health and Ageing, Government of South Australia.
All rights reserved.
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Cardiac Surgery (adult)
prostheses, allergies, obesity, diabetes, remote infection, available pathology or malignancy).
Local epidemiology - modify prophylaxis if there is a high local incidence of specific infections.
Practice Points
Drug administration
> IV bolus – should be timed ≤ 60 minutes before skin incision (optimal 15 to 30 minutes). Commencing administration of any antibiotic after
skin incision or completing administration of antibiotics > 60 minutes before incision reduces effectiveness.
> IV infusion – should be commenced 30-60 minutes prior to incision (e.g. gentamicin). See below for vancomycin administration.
MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of metropolitan or other high risk hospital for more than the last
five days)
> Add vancomycin to cefazolin (see vancomycin administration below).
> Give vancomycin 1g (1.5g for patients > 80kg actual body weight) started 30 to 120 minutes before surgical incision and given at a
recommended rate of 1g per hour (1.5g over 90 minutes).
Gentamicin administration
Dosing should be based on ideal body weight, provided ideal body weight is less than actual body weight.
Repeat doses
A single pre-operative dose is sufficient for most procedures however repeat intra-operative doses (2g cefazolin) are advisable:
> for delayed or prolonged surgery (> 4 hours from the time of first preoperative dose) when a short-acting agent is used (e.g. cefazolin); OR
> if major blood loss occurs requiring fluid resuscitation.
Obese patients
> Consider increased dose of cefazolin (3g) if patient is obese (>120kg). Consult ID for advice.
*High risk
Coronary Artery Bypass Surgery cefazolin 2g IV before skin incision
(CABG) vancomycin 1g IV infusion (1.5g for patients > 80kg
THEN (post-operative) actual body weight)
cefazolin 2g IV 8-hourly for a further 2 doses PLUS
gentamicin 5mg/kg IV (based on ideal body
High risk of MRSA weight)
ADD vancomycin 1g IV infusion (1.5g for THEN (post-operative)
patients > 80kg actual body weight) vancomycin 1g IV infusion (1.5g for patients >
80kg actual body weight) 12 hours after first dose
Routine Cardiac Valve Surgery cefazolin 2g IV before skin incision vancomycin 1g IV infusion (1.5g for patients > 80kg
actual body weight)
PLUS
vancomycin 1 g IV infusion (1.5g for patients > PLUS
80kg actual body weight) gentamicin 5mg/kg IV (based on ideal body
weight)
THEN (post-operative) THEN (post-operative)
cefazolin 2g IV 8-hourly for a further 2 doses vancomycin 1g IV infusion (1.5g for patients > 80kg
actual body weight) 12 hours after first dose
*High risk
High Risk Cardiac Valve Surgery cefazolin 2g IV before skin incision vancomycin 1g IV infusion (1.5g for patients > 80kg
actual body weight)
Trans-catheter Aortic Valve
Implantation (TAVI) PLUS depending on local epidemiology PLUS
consider additional
gentamicin 5mg/kg IV (based on ideal body
gentamicin 5mg/kg IV (based on ideal weight)
body weight)
THEN (post-operative)
vancomycin 1g IV infusion (1.5g for patients > 80kg
PLUS vancomycin 1 g IV infusion (1.5g for actual body weight) 12 hours after first dose
THEN (post-operative)
cefazolin 2g IV 8-hourly for 3 further doses
(24 hours post-operatively)
vancomycin 1g IV infusion (1.5g for patients
> 80kg actual body weight) 12 hours after
first dose
Post-Operative Care
Post-operative antibiotics (> 48 hours from first dose) are NOT indicated unless infection is confirmed or suspected, regardless of the presence of
surgical drains.
CABG Coronary Artery Bypass Graft
IV Intravenous
TAVI Trans-catheter Aortic Valve Implantation
* High Risk penicillin/cephalosporin allergy: History suggestive of high risk (e.g. anaphylaxis, angioedema, bronchospasm, urticaria,
DRESS/SJS/TEN)
References
Australian Injectable Drugs Handbook (2017) 7th ed. Collingwood, VIC. (online)
Australian Medicines Handbook (2017). Adelaide, SA. (online)
Bratzler, D., E. P. Dellinger, K. M. Olsen, T. M. et al (2013). "Clinical practice guidelines for antimicrobial prophylaxis in surgery." Am J Health Syst
Pharm 70: 195-283.
Edwards, F., R. Engelman, P. Houck, D. Shahian and C. Bridges (2006). "The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic
Prophylaxis in Cardiac Surgery, Part 1: Duration." Ann Thorac Surg 81: 397-404.
Engelman, R. M., D. Shahian, R. Shemin, T. S. Guy, D. Bratzler, F. H. Edwards, M. Jacobs, H. Fernando and C. Bridges (2007). "The Society of
Thoracic Surgeons Practice Guideline Series: Antibiotic Prophylaxis in Cardiac Surgery, Part 2: Antibiotic Choice." Ann Thorac Surg 83: 1569-1576.
Garcia, M. P. O., E. Marti-Bonmarti, J. G. Serrano and I. G. Gomez (2003). "Alteration of vancomycin pharmacokinetics during cardiopulmonary
bypass in patients undergoing cardiac surgery." Am J Health Syst Pharm 60(Feb 1): 260-265.
Garey, K. W., T. Dao, H. Chen, P. Amritkar, N. Kumar, M. Reiter and L. O. Gentry (2006). "Timing of vancomycin prophylaxis for cardiac surgery
patients and the risk of surgical site infections." Journal of Antimicrobial Chemotherapy 58: 645-650.
Haydon, TP., Presneill, JJ, Robertson, MS. (2010). "Antibiotic prophylaxis for cardiac surgery in Australia". Medical Journal of Australia 192 (3): 141-3
Frank, UK, Schmidt-Eisenlohr E, Mlangeni D, et al (1997). "Penetration of teicoplanin into heart valves and subcutaneous and muscle tissues of
patients undergoing open-heart surgery". Antimicrobial Agents and Chemotherapy 41 (11): 2559-61.
Lador, A., Nasir, H, Mansur, N, Sharoni, E, Biderman, P, Leibovici, L, Paul, M. (2012). "Antibiotic prophylaxis in cardiac surgery: systematic review
and meta-analysis. J Antimicrob Chemother 67: 541-50
Endorsed by South Australian expert Advisory Group on Antimicrobial Resistance (SAAGAR) March 2012, Last reviewed and amended August 2017.
SAAGAR has endeavoured to ensure that the information in this publication is accurate; however it makes no representation or warranty to this effect.
You rely on this publication at your own risk. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or incurred as a result of
reliance on this publication. As the information in this publication is subject to review, please contact a medical or health professional before using this publication
October 2017
Public – I1-A2
CVIU / Cardiology Procedures
Practice Points
Drug administration
> IV infusion – should be commenced 30-120 minutes prior to incision (e.g.vancomycin). See vancomycin administration below.
MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of high risk hospital or unit (where MRSA is endemic) for more than the
last 5 days)
> Add vancomycin to cefazolin (see vancomycin administration below)
> Give vancomycin 1g (1.5g for patients > 80kg actual body weight) starting the infusion 30 to 120 minutes before surgical incision and given
at a recommended rate of 1g per hour (1.5g over 90 minutes)
Repeat doses
A single pre-operative dose is sufficient for most procedures; however, repeat intra-operative doses (2 g cefazolin) are advisable:
> for prolonged surgery (> 4 hours from the time of first preoperative dose) when a short-acting agent is used (e.g. cefazolin), OR
> if major blood loss occurs, following fluid resuscitation
Obese patients
Consider higher doses of cefazolin (3g) if patient morbidly obese (>120kg). Consult ID for advice.
*High risk
Permanent pacemaker/defibrillator cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients > 80kg
insertion actual body weight)
PLUS
In patients with high MRSA risk, repeat PLUS
procedures, poor skin integrity, anticipated gentamicin 2mg/kg IV
difficult procedure, or recent (within last 3
months) antibiotic treatment:
ADD
vancomycin 1g IV infusion (1.5g for patients
> 80kg actual body weight)
Routine angioplasty, stent

insertion
Valvuloplasty, septal cefazolin 2g IV, then 8 hourly for up to 2 further vancomycin 1g IV infusion (1.5g for patients > 80kg
occlusion for high risk doses actual body weight)
patients only PLUS PLUS
(e.g. femoral catheter > 6hrs,
prosthetic valves, past history of vancomycin 1g IV infusion (1.5g for patients gentamicin 5mg/kg IV
endocarditis, atrial septal defect > 80kg actual body weight)
closure device insertion)
Post-Operative Care
surgical drains.
CVIU Cardiovascular investigational unit
IV Intravenous
* High Risk penicillin/cephalosporin allergy: History suggestive of high risk (eg. anaphylaxis, angioedema, bronchospasm, urticaria, DRESS/SJS/TEN)
References
Antibiotic Expert Group. Therapeutic Guidelines: Antibiotic, Version 15. Melbourne: Therapeutic Guidelines Limited; 2014
Baddour, LM et al. (2010). “AHA Scientific Statement: Update on Cardiovascular Implantable Electronic Device Infections and Their Management.”
Circulation. 121:458-477.
Bratzler, D., E. P. Dellinger, K. M. Olsen, T. M. Perl, P. G. Auwaerter, M. K. Bolon, et al (2013). "Clinical practice guidelines for antimicrobial
prophylaxis in surgery." Am J Health Syst Pharm 70: 195-283.
Darouiche, R., Mosier, M, Voigt, J. (2012). “Antibiotics and antiseptics to prevent infection in cardiac rhythm management device implantation
surgery”. Pacing Clin Electrophysiol 35: 1348-60.
Karchmer, AW (2017). “Infections involving cardiac implantable electronic devices”..In: Calderwood, SB., and Ganz, LI (Eds), UpToDate, Waltham, MA.
[www.uptodate.com]. Accessed Aug 2017
Korantzopoulos, P., Sideris, S, Dilaveris, P, Gatzoulis, K, Goudevenos, JA. (2016). “Infection control in implantation of cardiac implantable electronic
devices: current evidence, controversial points, and unresolved issues”. Europace 18: 473-8.
Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) March 2012, Last reviewed and amended August 2017.
SAAGAR has endeavored to ensure that the information in this publication is accurate; however it makes no representation or warranty to this effect.
October 2017
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Prevention of Endocarditis or Infection of Prosthetic Implants or Grafts
Antibiotic prophylaxis to prevent endocarditis is ONLY recommended for patients with cardiac conditions associated with the HIGHEST RISK of
adverse outcomes from endocarditis (See Box 1) and only for certain conditions (See Box 2).
Box 1: Cardiac conditions for which antibiotic prophylaxis to prevent endocarditis is recommended.
> Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
> Previous infective endocarditis
> Cardiac transplantation with the subsequent development of cardiac valvulopathy
> Rheumatic heart disease in Indigenous Australians and individuals at significant socioeconomic disadvantage
> Congenital heart disease, only if it involves:
i) unrepaired cyanotic defects, including palliative shunts and conduits;
ii) completely repaired defects with prosthetic material or devices, whether placed by surgery or catheter intervention, during the first six
months after the procedure (after which the prosthetic material is likely to have endothelialised);
OR
iii) repaired defects with residual defects at, or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation).
Antibiotic prophylaxis for endocarditis Does the patient have any of the Antibiotic prophylaxis for
MAY be required. See Box 2. YES conditions listed in Box 1? NO endocarditis NOT required.
Box 2 Procedures where antibiotic prophylaxis for endocarditis may or may not be required
Prophylaxis ALWAYS REQUIRED CONSIDER prophylaxis Prophylaxis IS NOT REQUIRED
DENTAL PROCEDURES: DENTAL PROCEDURES: DENTAL PROCEDURES:

> extractions consider prophylaxis for > oral examination
> periodontal procedures including surgery, the following procedures if multiple > infiltration and block local
subgingival scaling and root planning procedures are being conducted, anaesthetic injection
> replanting avulsed teeth the procedure is prolonged, or > restorative dentistry
> other surgical procedures (e.g. implant periodontal disease is present: > supragingival rubber dam clamping
placement, apicoectomy). > full periodontal probing for and placement of rubber dam
> intracanal endodontic procedures
RESPIRATORY PROCEDURES: patients with periodontitis
> intraligamentary and > removal of sutures
Any invasive procedure involving incision or > impressions and construction of
intraosseous local and
biopsy of respiratory mucosa, for example: dentures
anaesthetic injection
> tonsillectomy/ adenoidectomy > supragingival calculus removal > orthodontic bracket placement and
> surgery involving bronchial, sinus, nasal or or cleaning adjustment of fixed appliances
middle ear mucosa, including tympanostomy > application of gels
> rubber dam placement with
tube insertion. clamps (where risk of > intraoral radiographs
damaging gingiva) > supragingival plaque removal
GENITOURINARY AND GASTROINTESTINAL
PROCEDURES: Any procedure where antibiotic > restorative matrix band/ RESPIRATORY PROCEDURES:
prophylaxis is indicated for surgical reasons > strip placement > endotracheal intubation
> endodontics beyond the apical > rigid or flexible bronchoscopy with or
> lithotripsy foramen without incision or biopsy
> any genitourinary procedure in the presence > placement of orthodontic
of a genitourinary infection unless already bands or interdental wedges GENITOURINARY AND
treating enterococci (for elective cystoscopy or > subgingival placement of GASTROINTESTINAL PROCEDURES:
urinary tract manipulations, obtain a urine retraction cords, antibiotic > urethral catheterisation, uterine
culture and treat any bacteruria beforehand) fibres or antibiotic strips dilatation and curettage, sterilization
> any gastrointestinal procedure in the presence procedures, insertion or removal of
of an intra- abdominal infection unless already intrauterine contraceptive device
treating enterococci > obstetric procedures
> sclerotherapy for oesophageal varices. > transoesophageal echocardiography
OTHER PROCEDURES: > endoscopy (with or without
gastrointestinal biopsy including
> Incision and drainage of local abscess: brain, colonoscopy)
boils and carbuncles, dacryocystitis, epidural,
lung, orbital, perirectal, pyogenic liver, tooth,
surgical procedures through infected skin.
> Percutaneous endoscopic gastrostomy
Practice Points
Clindamycin administration
> IV infusion – should be commenced 30-60 minutes prior to the procedure. Administer doses of 600mg over at least 20 minutes (maximum rate
is 30mg/min)
> Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion started 30-120 minutes before the procedure at a
recommended rate of 1g per hour (1.5g over 90 minutes).
*High risk
Dental procedures amoxicillin 2g PO 1 hour prior to procedure clindamycin 600mg PO 1 hour prior to procedure
All other procedures amoxicillin 2g IV prior to procedure clindamycin 600mg by IV infusion

OR
vancomycin 1g IV infusion (1.5g > actual body
weight 80kg)
IV Intravenous
PO Per oral
* High Risk penicillin/cephalosporin allergy: History suggestive of high risk (e.g. anaphylaxis, angioedema, bronchospasm, urticaria,
DRESS/SJS/TEN)
References
Australian Injectable Drugs Handbook (2017) 7th ed. Collingwood, VIC (online).
Glenny AM, Oliver R, Roberts GJ,et al (2013). "Antibiotics for the prophylaxis of bacterial endocarditis in dentistry". Cochrane Database of Systematic
Reviews, Issue 10. Art. No.: CD003813. DOI: 10.1002/14651858.CD003813.pub4.
Habib G., Lancelotti P, Antunes MJ, et al (2015). "ESC Guidelines for the management of infective endocarditis: The Task Force for the Management
of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the
European Association of Nuclear Medicine (EANM)". Eur Heart J. 36:3075-128
Nishimura, RA., Otto CM, Bonow RO, et al (2017). " AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With
Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am
Coll Cardiol 70 (2): 252-89.
Sexton DJ., Chu VH (2017). "Antimicrobial prophylaxis for bacterial endocarditis". In: Otto, C (ed), UpToDate, Waltham, WA. [www.uptodate.com]
Accessed Nov 2015
Wilson, W., Taubert KA, Gewitz M, et al (2007). " Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline
from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the
Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research
Interdisciplinary Working Group". Circulation 116 (15): 1736-54.
SAAGAR has endeavoured to ensure that the information in this publication is accurate; however, it makes no representation or warranty to this effect.
You rely on this publication at your own risk. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or incurred
as a result of reliance on this publication. As the information in this publication is subject to review, please contact a medical or health professional
before using this publication.s / Acronyms
October 2017
Public – I1-A2
Endoscopic Gastrointestinal Procedures
For patients with cardiac conditions refer to Antibiotic Prophylaxis Guidelines for Prevention of Endocarditis for further information.
Practice Points
Drug administration
> IV infusion – should be commenced 30-60 minutes prior to incision (e.g. metronidazole). See below for vancomycin administration.
five days)
> Dosing should be based on ideal body weight, provided ideal body weight is less than actual body weight.
Repeat doses
A single pre-operative dose is sufficient for most procedures; however, repeat intra-operative doses (2g cefazolin) are advisable:
Obese patients
> Consider increased dose (3g) of cefazolin if patient is obese (>120kg). Consult ID for advice
*High risk
Percutaneous Endoscopic cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients >
Gastrostomy/Jejunostomy High risk of MRSA : 80kg actual body weight)
(PEG/PEJ) insertion/revision
Endoscopic Retrograde gentamicin 2mg/kg IV gentamicin 2mg/kg IV

Cholangiopancreatography (ERCP)
OR PLUS consider adding
(For patients with a high risk of
infection, e.g. known or suspected cefazolin 2g IV (child: 30mg/kg up to 2g) metronidazole 500mg IV infusion (child:
biliary obstruction, biliary sepsis, PLUS consider adding 12.5mg/kg up to 500mg)
pancreatic pseudocyst) High risk of MRSA :
metronidazole 500mg IV infusion (child:
12.5mg/kg up to 500mg) ADD vancomycin 1g IV infusion (1.5g for patients >
80kg actual body weight)
High risk of MRSA :
Endoscopic ultrasound-guided metronidazole 500mg IV infusion (child: metronidazole 500mg IV infusion (child:
fine-needle aspiration 12.5mg/kg up to 500mg) 12.5mg/kg up to 500mg)
PLUS PLUS
cefazolin 2g IV (child: 30mg/kg up to 2g) gentamicin 2mg/kg IV
High risk of MRSA : High risk of MRSA :
ADD vancomycin 1g IV infusion (1.5g for ADD vancomycin 1g IV infusion (1.5g for patients
patients > 80kg actual body weight) > 80kg actual body weight)
All other procedures

(with or without biopsy), e.g.
> endoscopy > colonoscopy
> sigmoidoscopy > sclerotherapy
> oesophageal dilatation
Post-Operative Care
surgical drains
If infection is suspected, consider modification of antibiotic regimen accordingly to clinical condition and microbiological results.
ID Infectious diseases
IV Intravenous
* High Risk penicillin/cephalosporin allergy: History suggestive of high risk (eg. anaphylaxis, angioedema, bronchospasm, urticaria, DRESS/SJS/TEN)
References
ASGE Standards of Practice Committee, Khashab, MA, Chithadi, KV, et al (2015). “Antibiotic prophylaxis for GI endoscopy”. Gastrointestinal
Endoscopy 81(1): 81-9.
Bratzler, D., E. P. Dellinger, K. M. Olsen, T. M. Perl, P. G. Auwaerter, M. K. et al (2013). "Clinical practice guidelines for antimicrobial prophylaxis in
surgery." Am J Health Syst Pharm 70: 195-283.
Meyer GW. (2017). “Antibiotic prophylaxis for gastrointestinal endoscopic procedures”. In: Saltzman JR (Ed), UpToDate, Waltham, MA.
[www.uptodate.com]. Accessed Aug 2017.
Endorsed by South Australian expert Advisory Group on Antimicrobial Resistance (SAAGAR) March 2012, Last reviewed and amended August 2017.
SAAGAR has endeavoured to ensure that the information in this publication is accurate; however it makes no representation or warranty to this effect.
October 2017
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Gastrointestinal Surgery
Pre-existing infections (known or suspected) – if present, use appropriate treatment regimen instead of prophylactic regimen for procedure.
Doses should be scheduled to allow for re-dosing just prior to skin incision.
Practice Points
Drug administration
> IV infusion – should be commenced 30-60 minutes prior to incision (e.g. metronidazole). See below for vancomycin administration.
five days)
> Add vancomycin (see vancomycin administration below)
recommended rate of 1g per hour (1.5g over 90 minutes). Note: infusion can be completed after skin incision.
Repeat doses
Obese patients
> Consider increased dose of cefazolin (3g) if patient obese (>120kg). Consult ID for advice.
*High risk
Gastric / duodenal / oesophageal cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients > 80kg
(bypass, resection, ulcer oversew, actual body weight)
PLUS
oesophagectomy etc) PLUS
*metronidazole 500mg IV (child: 12.5mg/kg
Biliary (incl. laparoscopic up to 500mg) *metronidazole 500mg IV (child: 12.5mg/kg up to
procedures) 500mg)
High risk of MRSA :
*OMIT metronidazole if low risk as defined by:

> Upper GI surgery: normal gastric acidity/mobility; no obstruction, bleeding, or malignancy; no previous
gastric surgery
> Biliary tract surgery: patient < 60yrs of age; no diabetes; elective cholecystectomy with low risk of
exploration of common bile duct
Colorectal (colon/small bowel metronidazole 500mg IV infusion (child: metronidazole 500mg IV infusion (child: 12.5mg/kg
resection, revision of 12.5mg/kg up to 500mg) up to 500mg)
anastomosis/stoma, PLUS PLUS
appendectomy etc.)
cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients >
Pancreatic (Whipple’s etc.) 80kg actual body weight)
PLUS
Liver resection PLUS
gentamicin 2mg/kg IV
Exploratory laparotomy/division gentamicin 2mg/kg IV
of adhesions High risk of MRSA :
Hernia repair Prophylaxis NOT recommended when mesh is not inserted
cefazolin 2g (child: 30mg/kg up to 2g) IV vancomycin 1g IV(1.5mg for patients > 80kg actual
Hernia repair with mesh insertion body weight)
High risk of MRSA :
Post-Operative Care
surgical drains.
IV Intravenous
DRESS/SJS/TEN)
References
Antibiotic Expert Group (2014). Therapeutic Guidelines: Antibiotic, Version 15. Melbourne: Therapeutic Guidelines Limited.
Anderson DJ., Sexton DJ. (2017). “Control measures to prevent surgical site infection following gastrointestinal procedure in adults”. In: Harris A (Ed),
UpToDate. Waltham, MA. [www.uptodate.com]. Accessed Aug 2017
Jafri, NS., Mahid, SS, Minor, KS, et al. (2007). “Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous
endoscopic gastrostomy”. Aliment Pharmacol Ther 25 (6): 647.
SAAGAR has endeavoured to ensure that the information in this publication is accurate; however, it makes no representation or warranty to this
effect.
You rely on this publication at your own risk. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or
incurred as a result of reliance on this publication. As the information in this publication is subject to review, please contact a medical or health
professional before using this publication.s / Acronyms
October 2017
Public – I1-A2
Otorhinolaryngology / Head & Neck Surgery
Prophylaxis is not indicated for intra-oral procedures: dentoalveolar surgery (extractions, impactions, exposures); minor pathology (soft tissue,
cysts).
*For patients with cardiac conditions refer to Antibiotic Prophylaxis Guidelines for Prevention of Endocarditis for further information
Practice Points
Drug administration
> IV bolus – should be timed ≤ 60 minutes before skin incision (optimal 30 minutes) [1]. Administration after skin incision or > 60 minutes before
incision reduces effectiveness.
> IV infusion – should be timed to end ≤ 30 minutes before skin incision (e.g. see clindamycin below)
last five days)
> Add vancomycin to cefazolin (see vancomycin administration below).
> Give clindamycin 600mg (child: 15 mg/kg up to 600mg) by IV infusion over at least 20 minutes, timed to end just before procedure. Repeat 4
hourly intra-operatively for prolonged procedures.
Repeat doses
Obese patients
*High risk
No incision through mucosal (oral, cefazolin 2g IV (child: 30mg/kg up to 2g) clindamycin 600mg IV infusion (child: 15mg/kg up to
nasal, pharyngeal, oesophageal) High risk of MRSA : 600mg)
surface ADD vancomycin 1g IV infusion (1.5g for High risk of MRSA :
patients > 80kg actual body weight) ADD vancomycin 1g IV infusion (1.5g for patients >
With incision through mucosal (oral, cefazolin 2g IV (child: 30mg/kg up to 2g) clindamycin 600mg IV infusion (child: 15mg/kg up
nasal, pharyngeal, oesophageal) PLUS to 600mg
surface High risk of MRSA :
12.5mg/kg up to 500mg) ADD vancomycin 1g IV infusion (1.5g for patients >
High risk of MRSA :
Other uncomplicated or minor clean

procedures (e.g. tonsillectomy,
adenoidectomy, typanostomy, nasal
septoplasty, endoscopic sinus
surgery, uncontaminated neck
dissection)
Post-Operative Care
surgical drains
IV Intravenous
DRESS/SJS/TEN)
References
Anderson DJ., Sexton DJ.(2017). “Antimicrobial prophylaxis for prevention of surgical site infection in adults”. In: Harris A (Ed), UpToDate,
Waltham, MA. [www.uptodate.com]. Accessed Aug 2017
Expert Group Antibiotics. Therapeutic Guidelines: Antibiotic (2014)
Ottoline, ACX., Tomita, S., et al. (2013). “Antibiotic prophylaxis in otolaryngologic surgery”. Otorhinolaryngol 17(1):85-91.
SAAGAR has endeavored to ensure that the information in this publication is accurate; however, it makes no representation or warranty to this
effect.
October 2017
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Oral and Maxillofacial Surgery
Prophylaxis is not indicated for intra-oral procedures: dentoalveolar surgery (extractions, impactions, exposures); minor pathology (soft tissue, cysts).
Practice Points
Drug administration
> IV infusion – should be commenced 30-60 minutes prior to skin incision (e.g. metronidazole, clindamycin). See below for vancomycin
administration.
MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of metropolitan or other high risk hospital for more than the last five days)
> Add vancomycin (see vancomycin administration below).
recommended rate of 1g per hour (1.5g over 90 minutes). Note: Infusion can be completed after skin incision.
> Give clindamycin 600mg (child: 15 mg/kg up to 600mg) by IV infusion over at least 20 minutes just before procedure. Repeat 4 hourly intra-
operatively for prolonged procedures.
Repeat doses
Obese patients
*High risk
Orthognathic surgery benzylpenicillin 1.2g IV (child < 12 years: clindamycin 600mg IV infusion (child: 15mg/kg up to
30mg/kg up to 1.2g) 600mg)
THEN (for procedures greater than 2 hours
duration)
Repeat dose 2-hourly intra-operatively
Skin approach procedures cefazolin 2g IV (child < 12 years: 30mg/kg up clindamycin 600mg (child: 15mg/kg up to 600mg) by
(oral cavity not involved) to 2g) IV infusion, then 8-hourly for 24 hours
Skin approach procedures cefazolin 2g IV (child < 12 years: 30mg/kg up clindamycin 600mg (child: 15mg/kg up to 600mg) by
(with concurrent oral cavity to 2g) IV infusion, then 8-hourly for 24 hours
involvement) PLUS
metronidazole 500mg IV infusion (child < 12
years:12.5mg/kg up to 500mg) before incision,
then 12-hourly for 24 hours
Implants (1st stage) benzylpenicillin 1.2g IV (child < 12 years: clindamycin 600mg (child: 15mg/kg up to 600mg)
30mg/kg up to 1.2g) before incision by IV infusion
THEN 2-hourly intra-operatively (for procedures
greater than 2 hours duration)
*High risk
Trauma
Intraoral compound operation benzylpenicillin 1.2g IV infusion (child < 12 clindamycin 600mg (child: 15mg/kg up to 600mg) by
(injury of any age, compound to years: 30mg/kg up to 1.2g) at presentation, then IV infusion, then 8-hourly for 48 hours
nose/skin/sinuses) 4-hourly for 48 hours
PLUS
12.5mg/kg up to 500mg) at presentation, then
12-hourly for 48 hours
Skin approach with concurrent cefazolin 2g IV (child < 12 years: 30mg/kg up clindamycin 600mg (child: 15mg/kg up to 600mg) by
oral cavity involvement to 1g), then 8-hourly for 24 hours IV infusion, then 8-hourly for 24 hours
(reconstructive surgery with ORIF
PLUS
or bone graft placement)
12.5mg/kg up to 500mg), then 12-hourly for
24 hours
Post-Operative Care
surgical drains
If infection is suspected, consider modification of antibiotic regimen according to clinical condition and microbiological results.
IV Intravenous
DRESS/SJS/TEN)
References
Anderson, DJ., Sexton,DJ. (2017). "Antimicrobial prophylaxis for prevention of surgical site infection in adults." In: Harris, A (ed). UptoDate. Waltham,
MA.[www.uptodate.com]. Accessed Aug2017.
Antibiotic Expert Group. (2014). Therapeutic Guidelines: Antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited
effect.
professional before using this publication. Acronyms
October 2017
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Neurosurgery
Practice Points
Wound irrigation
> Antibiotic solutions should NOT be used to irrigate the wound during surgery
Drug administration
> IV infusion – vancomycin infusion should be commenced 30-120 minutes prior to incision. See vancomycin administration below.
five days)
> Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion started 30-120 minutes before surgical incision and given
at a recommended rate of 1g per hour (1.5g over 90 minutes). Note: Infusion can be completed after skin incision.
Repeat doses
A single pre-operative dose is sufficient for most procedures; however, repeat intra-operative doses are advisable:
Obese patients
*High risk
Craniotomy procedures
cefazolin 2g IV(child: 30mg/kg up to 2g)
Trans-sphenoidal procedures
vancomycin 1g IV infusion (1.5g for patients > 80kg
Spinal procedures (laminectomy) High risk of MRSA : actual body weight)
CSF shunt / drain procedures ADD vancomycin 1g IV infusion (1.5g for
External ventricular drain shunt
Other minor clean procedures Prophylaxis NOT recommended
Post-Operative Care
surgical drains
CSF Cerebrospinal fluid
IV Intravenous
DRESS/SJS/TEN)
References
Anderson, DJ., Sexton, DJ. (2017). “Antimicrobial prophylaxis for prevention of surgical site infection in adults”. In: Harris, A (ed). UptoDate. Waltham, MA.
Antibiotic Expert Group (2014). Therapeutic Guidelines: Antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited.
Bratzler, D., E. P. Dellinger, K. M. Olsen, T. M. Perl, P. G. Auwaerter, M. K. et al. “Clinical practice guidelines for antimicrobial prophylaxis in surgery”. Am J Health
Syst Pharm 2013; 70: 195-283.
effect.
October 2017
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Obstetrics / Gynaecology
Before hysterectomy – screening for and treating bacterial vaginosis (BV) reduces BV-associated cuff infection.
Before surgical termination of pregnancy – screening for and treating Chlamydia trachomatis and BV reduces infectious complications.
Practice Points
Drug administration
> IV infusion – should be commenced 30-60 minutes prior to skin incision (e.g. metronidazole, clindamycin). See below for vancomycin
administration.
five days)
> Give clindamycin 600mg (child: 15mg/kg up to 600mg) by IV infusion over at least 20 minutes just before procedure. Repeat 4 hourly intra-
operatively for prolonged procedures.
Repeat doses
Obese patients
*High risk
Hysterectomy, laparotomy cefazolin 2g IV 15-30 mins prior to incision clindamycin 600mg IV infusion
procedures, vaginal repair PLUS either (for vaginal hysterectomy) PLUS
metronidazole 500mg IV infusion gentamicin 2 mg/kg IV
OR
High risk of MRSA:
tinidazole 2g PO as a single dose (6-12hrs
Replace clindamycin with vancomycin 1g IV infusion
prior to incision)
(1.5g for patients > 80kg actual body weight)
High risk of MRSA:

Add cefazolin with vancomycin 1g IV infusion
Caesarean section cefazolin 2g IV 15-30 mins prior to incision clindamycin 600mg IV infusion
PLUS
High risk of MRSA:
gentamicin 2mg/kg IV
Add cefazolin with vancomycin 1g IV infusion
High risk of MRSA:
Replace clindamycin with vancomycin 1g IV infusion
Endoscopic procedures, IUD

insertion, early suction termination, Prophylaxis NOT recommended
other minor procedures
*High risk penicillin/cephalosporin
allergy
Surgical termination of doxycycline 400mg PO as a single dose (1hr prior to procedure
pregnancy OR
azithromycin 1g PO (1hr prior to procedure)
Later term termination As for hysterectomy (see on previous page)
Post-Operative Care
surgical drains
Additional notes
Caesarian section: Traditionally administration of antibiotics after the cord is clamped has been common practice to avoid exposing the neonate to
antibiotics. However, recent studies have shown lower surgical site infection rates, without compromising neonatal outcome, if prophylaxis is
administered before skin incision.
IV Intravenous
DRESS/SJS/TEN)
References
Antibiotic Expert Group. (2014). Therapeutic Guidelines: Antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited.
Berghella V. Cesarean delivery: Preoperative issues. In: Lockwood C (Ed), UpToDate, Waltham, MA. [www.uptodate.com] Accessed Nov 2015
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2016). “Prophylactic antibiotics in obstetrics and
gynaecology” [https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-
MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical%20-%20General/Prophylactic-antibiotics-in-obstetrics-and-gynaecology-
(C-Gen-17)-Review-July-2016.pdf?ext=.pdf]
South Australian Perinatal Practice Guidelines Workgroup (2015). “South Australian Perinatal Practice Guidelines: Peripartum prophylactic
antibiotics”. Adelaide: SA Health. [Available at:
www.sahealth.sa.gov.au/wps/wcm/connect/84d20f804ee559c1a8baadd150ce4f37/Peripartum+prophylactic+antibiotics_June2014.pdf?MOD=AJPE
RES&CACHEID=84d20f804ee559c1a8baadd150ce4f37]. Accessed Aug2017.
Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) May 2017, Last reviewed and amended August 2017
effect.
October 2017
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Ophthalmology
Practice Points
Drug administration
> IV bolus – should be timed ≤ 60 minutes before skin incision (optimal 30 minutes) [1]. Administration after skin incision or > 60 minutes
before incision reduces effectiveness [2].
> IV infusion – should be timed to end ≤ 30 minutes before skin incision (e.g. see clindamycin below)
five days)
> See recommended prophylaxis
> Give clindamycin 600mg (child: 10mg/kg up to 450mg) single dose IV infusion at a rate ≤ 30mg/minute. The IV infusion should be timed to
end ≤ 30 minutes before skin incision.
Obese patients
> Consider increased dose of cefazolin (3g) if patient is obese (>120kg) .
*High risk
All procedures Pre-operatively: Immediately prior to surgical incision, apply sterile povidone-iodine 5% swab to
conjunctival cul de sac, lid margins and periorbital skin and dry at 2 minutes. In patients with a povidone
iodine (Betadine®) allergy, use a sterile product containing chlorhexidine acetate 0.05% for 5 minutes
[3].
Extra-ocular procedures
Clean procedures There is no strong evidence that IV prophylactic antibiotics improve outcomes for clean extra-ocular
> conjunctival procedures procedures in otherwise healthy individuals. If required, use:
> rectus / oblique muscle
procedures cefazolin 2g IV (child: 30mg/kg up to 2g) clindamycin 600mg IV infusion (child: 10mg/kg up
> entropion / ectropion repair High risk of MRSA infection: to 450mg)
REPLACE cefazolin with clindamycin 600mg IV
infusion
Procedures where infection may No strong evidence for IV prophylaxis (as above).
be present
Chloramphenicol 0.5% eye drops four times a day post-operatively for 7 days. [4]
(e.g. Dacryocystorhinostomy)
Intra-ocular procedures
Anterior procedures cefazolin 1mg/0.1ml intracameral injection at

> phacoemulsification / lens the end of the procedure
implant PLUS
> keratoplasty chloramphenicol 0.5% eye drops four times
> trabeculectomy / tube implant
a day post-operatively for one week Seek ID advice:
> corneal graft
OR, if chloramphenicol contraindicated then: Intracameral moxifloxacin 0.5% (available by SAS
tobramycin 0.3% eye drops four times a day only) may be considered as an alternative to
post-operatively for one week ceftazidime / cephazolin based on evidence
presented in a meta-analysis of non-randomised
studies [5, 6].
Vitreous procedures ceftazidime 2.25 mg/0.1 mL subconjunctival Intracameral vancomycin is not recommended due to
> retinal detachment repair injection at the end of the procedure the risk of haemorrhagic occlusive retinal vasculitis
> scleral buckle PLUS [7].
> cryotherapy chloramphenicol 0.5% eye drops four times
a day post-operatively for one week
OR if chloramphenicol contraindicated then:
tobramycin 0.3% eye drops four times a day
post-operatively for one week
Post-Operative Care
There is a lack of strong evidence to support the use of post-operative topical antibiotics [4]. Prolonged treatment with antibiotic ointment or drops is
not indicated unless there is confirmed or suspected infection. For patients who are treated with extended periods of topical steroids or who have
been treated with systemic steroids preoperatively, immunological defenses may be reduced and the risk of infection may be increased [9]. If post-
operative topical antibiotics are considered necessary due to higher risk of infection, chloramphenicol 0.5% eyedrops can be used four times daily
for 7 days [4]. Tobramycin eyedrops should only be used in patients hypersensitive to chloramphenicol due to an increased risk of resistance [4].
IV Intravenous
DRESS/SJS/TEN)
References
1. Bratzler, D., et al., Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm, 2013. 70(Feb 1): p. 195 -283.
2. Weber, W.P.M.D., et al., The Timing of Surgical Antimicrobial Prophylaxis. Annals of Surgery, 2008. 247(6): p. 918-926.
3. Merani, R., et al., Aqueous chlorhexidine for intravitreal injection antisepsis: a case series and review of the literature Ophthalmology 2016. 123:
p. 2588-94.
4. Therapeutic Guidelines: Antibiotic, Surgical prophylaxis for ophthalmic surgery. 2014: Melbourne [Available at: www.tg.org.au].
5. Kessel, L., et al., Antibiotic prevention of postcataract endophthalmitis: a systematic review and meta-analysis. Acta Ophthalmologica, 2015.
93(4): p. 303-317.
6. Zhou, A.X., et al., Safety of undiluted intracameral moxifloxacin without postoperative topical antibiotics in cataract surgery. International
Ophthalmology, 2016. 36(4): p. 493-8.
7. Miller, M.A., et al., Postoperative hemorrhagic occlusive retinal vasculitis associated with intracameral vancomycin prophylaxis during cataract
surgery. Journal of Cataract & Refractive Surgery, 2016. 42(11): p. 1676-1680.
8. Gurusamy, K.S., et al., Antibiotic prophylaxis for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) related complications in
surgical patients. Cochrane Database of Systematic Reviews, 2013(8): p. CD010268.
9. Aronson, J., Meyler's Side Effects of Drugs (16th edition). 2016, Elsevier Science & Technology: Oxford, UK.
Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) May 2017, Last reviewed and amended August 2017
SAAGAR has endeavored to ensure that the information in this publication is accurate; however it makes no representation or warranty to this
effect.
October 2017
Public – I1-A2
Orthopaedic Surgery (Joint Replacement)
prostheses, allergies, obesity, diabetes, remote infection, available pathology or malignancy)
should be scheduled to allow for re-dosing just prior to skin incision
Practice Points
Drug administration
> IV infusion – should be commenced 30-120 minutes prior to skin incision. See below for vancomycin administration.
last five days)
recommended rate of1g per hour (1.5g over 90 minutes). Note: Infusion can be completed after skin incision.
Repeat doses
Obese patients
Duration of prophylaxis should not exceed 24hrs, irrespective of presence of drains or catheters
*High risk
Primary Total Hip Replacement cefazolin 2g IV (child: 30mg/kg up to 2g) before vancomycin 1g IV infusion (1.5g for patients > 80kg
(THR) incision, then 8-hourly for 2 more doses actual body weight)
OR High risk of MRSA :
Total Knee Replacement (TKR) ADD vancomycin 1g IV infusion (1.5g for
Patients requiring revision / re- cefazolin 2g IV (child: 30mg/kg up to 2g) before vancomycin 1g IV infusion (1.5g for patients > 80kg
operation incision, then 8-hourly for 2 more doses actual body weight)
PLUS AND (if cement is used)
vancomycin 1g IV infusion (1.5g for patients vancomycin added to tobramycin or gentamicin
> 80kg actual body weight) bone cement (≤ 5% w:w) (add vancomycin 500mg
AND also (if cement is used) per 40g packet of bone cement)
vancomycin added to tobramycin or

gentamicin bone cement (≤ 5% w:w) (add
vancomycin 500mg per 40g packet of bone
cement)
Note: Pre-existing infections (known or suspected) – if present, use appropriate treatment regimen
instead of prophylactic regimen for procedure. Doses should be scheduled to allow for re-dosing just
prior to skin incision.
Morcellised allografting at joint Add approximately 250mg vancomycin to bone cement for first femoral head equivalent, and 500mg
replacement for more than one head, and no more than 500mg to graft
Routine arthroscopic No prophylaxis required

procedures
(unless prosthesis is being inserted or patient is immunocompromised)
Post-Operative Care
surgical drains
IV Intravenous
DRESS/SJS/TEN)
References
Australian Orthopaedic Association. (2014) "Cement in Hip & Knee Arthroplasty – Supplementary Report 2014". National Joint Replacement Registry
[online] https://aoanjrr.dmac.adelaide.edu.au/documents/10180/172288/Cement%20in%20Hip%20%26%20Knee%20Arthroplasty (Accessed Nov
2015)
Belden K, Silibovsky R, Vogt M. "Perioperative Antibiotics". Journal of Orthopaedic Research 2014; 32: S31–S59.
Berbari E, Baddour L. Epidemiology and prevention of prosthetic joint infections (2017). In: Sexton DJ (Ed), UpToDate, Waltham, MA.
[www.uptodate.com]. Accessed Aug 2017
Bratzler, D., E. P. Dellinger, K. M. Olsen, T. M. Perl, P. G. Auwaerter, M. K. et al. (2013) "Clinical practice guidelines for antimicrobial prophylaxis in
surgery". Am J Health Syst Pharm 70:195-283.
Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) March 2012, Last reviewed and amended May 2016.
effect.
October 2017
Public – I1-A2
Orthopaedic Surgery (Not Joint Replacement)
This guideline does not apply to open fractures.
prostheses, allergies, obesity, diabetes, remote infection, available pathology or malignancy)
should be scheduled to allow for re-dosing just prior to skin incision
Practice Points
Drug administration
> IV infusion – should be commenced 30-60 minutes prior to skin incision (e.g. metronidazole). See below for vancomycin administration
last five days)
Repeat doses
Obese patients
Duration of prophylaxis should not exceed 24hrs, irrespective of presence of drains or catheters.
*High risk
Internal fixation of large bones cefazolin 2g IV (child <12 years: 30mg/kg up to vancomycin 1g IV infusion (1.5g for patients > 80kg
2g) actual body weight), may be repeated 12 hours after
THEN initial dose
repeat 8-hourly for 2 further doses.

(Max 3 doses irrespective of the presence of
surgical drains)
High risk of MRSA :
Other (closed) internal fixation cefazolin 2g IV (child < 12 years: 30mg/kg up to vancomycin 1g IV infusion (1.5g for patients > 80kg
2g) actual body weight), may be repeated 12 hours after
High risk of MRSA : initial dose

Arthroscopic and other clean Prophylaxis NOT recommended

procedures not involving foreign
material (e.g. pins, plates)
Lower limb amputation cefazolin 2g IV (child < 12 years: 30mg/kg up to vancomycin 1g IV infusion (1.5g for patients > 80kg
2g) actual body weight), may be repeated after 12 hours
THEN PLUS
repeat 8-hourly for up to 2 further doses gentamicin 5mg/kg (adults and children) IV, 15-30
High risk of MRSA : minutes before surgical incision

If limb is ischaemic
ADD to above metronidazole 500mg IV infusion
(child < 12 years: 12.5mg/kg up to 500mg) , may be repeated after 12 hours
*High risk
Spinal procedures cefazolin 2g IV (child < 12 years: 30mg/kg up to vancomycin 1g IV infusion (1.5g for patients > 80kg
2g) actual body weight), may be repeated after 12 hours
High risk of MRSA :
Post-Operative Care
surgical drains
IV Intravenous
DRESS/SJS/TEN)
References
Berbari E, Baddour L.(2017). "Epidemiology and prevention of prosthetic joint infections". In: Sexton DJ (Ed), UpToDate, Waltham, MA.
Bratzler, D., E. P. Dellinger, K. M. Olsen, T. M. Perl, P. G. Auwaerter, M. K. et al. (2013). "Clinical practice guidelines for antimicrobial prophylaxis in
surgery." Am J Health Syst Pharm 70: 195-283.
Slobogean, GP, Kennedy, SA, Davidson, D, O'Brien, PJ. (2008). "Single versus multiple-dose antibiotic prophylaxis in the surgical treatment of closed
fractures: a meta-analysis". J Orthop Trauma 22:264-09
Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) March 2012, Last reviewed and amended November
2015
effect.
October 2017
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Plastic and Reconstructive Surgery
Practice Points
Unless otherwise stated, antibiotic prophylaxis is NOT required for the following plastic surgery indications:
> Clean elective surgery with no implants
> Clean trauma with no fracture and less than 24 hours since injury
Drug administration
> IV bolus – should be timed ≤ 60 minutes before skin incision (optimal 15-30 minutes). Administration after skin incision or > 60 minutes before
> IV infusion – vancomycin should be commenced 30-120 minutes prior to skin incision. See under vancomycin administration.
last five days)
Repeat doses
Obese patients
Topical antibiotics should NOT be applied to the wound during or after surgery
*High risk
Groin/axilla/neck dissections cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients > 80kg
actual body weight)
Open reduction and internal
fixation of fractures High risk of MRSA infection :
Insertion of implants, mesh, ADD vancomycin 1g IV infusion (1.5g for
prostheses, screws, plates etc. patients > 80kg actual body weight)
Clean bone or soft tissue injury

Hand surgery (without implants) Prophylaxis NOT recommended
Non-infected lesions & minor
excisions
Post-Operative Care
surgical drains.
IV Intravenous
DRESS/SJS/TEN)
References
Anderson, DJ., Sexton, DJ. (2017). "Antimicrobial prophylaxis for prevention of surgical site infection in adults". In: Harris, A (ed). UptoDate. Waltham,
MA. [www.uptodate.com] Accessed July 2017.
Antibiotic Expert Group.(2014) Therapeutic Guidelines: Antibiotic, Version 15. Melbourne: Therapeutic Guidelines Limited.
Endorsed by South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR) March 2012, Last reviewed and amended November
2015
effect.
October 2017
Public – I1-A2
Thoracic Surgery
Practice Points
Drug administration
> IV infusion – should be commenced 30-60 minutes prior to skin incision (e.g. metronidazole). See below for vancomycin administration.
MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of metropolitan or other high risk hospital for more than the last five days)
> Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion started 30-120 minutes before surgical incision and given at a
Repeat doses
> for delayed or prolonged surgery (> 4 hours from the time of first preoperative dose) when a short-acting agent is used (e.g. cefazolin), OR
Obese patients
*High risk
Pneumonectomy / Lobectomy cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients > 80kg
actual body weight)
THEN
cefazolin 2g IV (child: 30mg/kg up to 2g) 8- THEN
hourly for 2 more doses commencing 4 hours vancomycin 1g IV infusion (1.5g for patients >
after the initial dose 80kg actual body weight) 12 hourly for 2 more
If anaerobic cover required (empyema or doses commencing 8 hours after the initial dose
abscess) then ADD: If anaerobic cover required (empyema or abscess)
metronidazole 500mg IV infusion (child: then ADD:
12.5mg/kg), repeated 12 hourly for 2 more metronidazole 500mg IV infusion (child:
doses commencing 6 hours after initial dose 12.5mg/kg), repeated 12 hourly for 2 more doses
High risk of MRSA infection: commencing 6 hours after initial dose

Decortication / Pleurectomy cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients > 80kg
actual body weight)
If anaerobic cover required ADD:
metronidazole 500mg IV infusion (child: If anaerobic cover required ADD:
12.5mg/kg) metronidazole 500mg IV infusion (child:
High risk of MRSA infection: 12.5mg/kg)
Video-assisted thoracoscopic cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g by IV infusion (1.5g for patients >
surgery (VATS) 80kg actual body weight)
Post-Operative Care
surgical drains.
IV Intravenous
DRESS/SJS/TEN)
References
Anderson DJ, Sexton DJ (2017). "Antimicrobial prophylaxis for prevention of surgical site infection in adults ". In: Harris, A (ed), UpToDate, Waltham,
MA. [www.uptodate.com] Accessed Aug 2017
Chang, SH., Krupnick AS (2012). "Perioperative antibiotics in thoracic surgery". Thorac Surg Clin 22 (1):35-45.
effect.
October 2017
Public – I1-A2
Urology
prostheses, urinary catheters or stents, allergies, obesity, diabetes, remote infection, available pathology or malignancy).
Pre-operative urine screening: Where possible exclude or treat urinary infection prior to surgery. If surgery is urgent in the presence of confirmed
infection or bacteriuria, use gentamicin 3mg/kg IV as a single preoperative dose. Higher doses may be required if systemic symptoms are present.
Practice Points
Drug administration
> IV infusion – should be commenced 30-60 minutes prior to skin incision (e.g. metronidazole). See below for vancomycin administration.
MRSA risk (defined as history of MRSA colonisation or infection, OR inpatient of high risk hospital or unit (where MRSA is endemic) for more than
the last five days)
a recommended rate of 1g per hour (1.5g over 90 minutes). Note: Infusion can be completed after skin incision.
> Dosing should be based on ideal body weight, provided ideal body weight is less than actual body weight.
Repeat doses
Obese patients
*High risk
Open/laparoscopic procedures cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g for patients > 80kg
when: actual body weight)
PLUS
> urinary tract entered gentamicin 2mg/kg IV (adults and children) PLUS
> urinary tract not entered but: If risk of entry into bowel lumen then ADD: gentamicin 2mg/kg IV (adults and children)
• patient is at risk of post- metronidazole 500mg IV infusion (child: If risk of entry into bowel lumen then ADD:
operative infection (e.g. urinary 12.5mg/kg up to 500mg) metronidazole 500mg IV infusion (child: 12.5mg/kg
tract obstruction/ up to 500mg)
abnormalities);
High risk of MRSA :
• prosthetic material is inserted; ADD vancomycin 1g IV infusion (1.5g for
OR patients > 80kg actual body weight)
• bacteriuria cannot be
excluded.
Open/laparoscopic procedures
when urinary tract not entered and
urine is sterile (e.g. vasectomy,
scrotal surgery, varicocele ligation)
*High risk
Open prostatectomy / Robotic cefazolin 2g IV vancomycin 1g IV infusion (1.5g for patients > 80kg
prostatectomy actual body weight)
PLUS
gentamicin 2mg/kg IV PLUS
If risk of entry into bowel lumen then ADD: gentamicin 2mg/kg IV

metronidazole 500mg IV infusion (child: If risk of entry into bowel lumen then ADD:
12.5mg/kg up to 500mg) metronidazole 500mg IV infusion (child: 12.5mg/kg
High MRSA risk: up to 500mg)
Endoscopic procedures cefazolin 2g IV (child: 30mg/kg up to 2g) gentamicin 2mg/kg IV (adults and children)
> removal of calculi Known urinary MRSA colonisation:
> Extracorporeal Shock Wave ADD vancomycin 1g IV infusion (1.5g for Known urinary MRSA colonisation:
Lithotripsy only if high risk of patients > 80kg actual body weight) ADD vancomycin 1g IV infusion (1.5g for patients >
infection 80kg actual body weight)
> specific risk for postoperative
infection
Removal of calculi gentamicin 2mg/kg IV (adults and children) gentamicin 2mg/kg IV (adults and children)
Transurethral resection of OR (if gentamicin contraindicated) OR (if gentamicin contraindicated)
prostate (TURP)
cefazolin 2g IV (child: 30mg/kg up to 2g) trimethoprim 300mg PO 1hr prior to insertion
Stent insertion
Known urinary MRSA colonisation:
Ureteroscopy/instrumentation of ADD vancomycin 1g IV infusion (1.5g for Known urinary MRSA colonisation:
upper tract (incl. retrograde patients > 80kg actual body weight) ADD vancomycin 1g IV infusion (1.5g for patients >
pyelogram) 80kg actual body weight)
Transperineal prostatic biopsy cefazolin 2g IV vancomycin 1g IV infusion (1.5g for patients > 80kg
High MRSA risk: actual body weight)
Transrectal prostatic biopsy ciprofloxacin 500mg PO as a single dose, 1-2 hours before procedure. Dose may be repeated 12 hours
after the first dose if procedure delayed beyond 6 hours
If there is a history of overseas travel (India, South East Asia, Southern Europe) in the last 6 months, the
patient may be colonised with multi-resistant organisms. Contact ID/Clinical Microbiology for advice.
Other clean procedures /

diagnostic cystoscopy without Prophylaxis NOT recommended
manipulation of urinary tract
Post-Operative Care
surgical drains.
IV Intravenous
PO Per oral
DRESS/SJS/TEN)
References
Benway BM, Andriole GL (2017). "Prostate biopsy". In: Richie J (ed), UpToDate, Waltham, MA. [www.uptodate.com] Accessed Aug 2017
Mirmilstein G, Ferguson J (2015). "Stable post-TRUS biopsy sepsis rates and antibiotic resistance over 5 years in patients from Newcastle, New
South Wales". Med J Aust 202(5): 237.
Wagenlehner, FM., Van Oostrum E, Tenke P, et al (2013). "Infective complications after prostate biopsy: outcome of the Global Prevalence Study
of Infections in Urology (GPIU) 2010 and 2011, a prospective multinational prostate biopsy study." Eur Urology 63: 521-7.
effect.
October 2017
Public – I1-A2
Vascular Surgery
prostheses, urinary catheters or stents, allergies, obesity, diabetes, remote infection, available pathology or malignancy).
Practice Points
Drug administration
> IV infusion – should be commenced 30-60 30 minutes prior to skin incision (e.g. metronidazole). See below for vancomycin administration
last five days)
> Give vancomycin 1g (1.5g for patients >80kg actual body weight) by IV infusion, starting 30-120 minutes before surgical incision and given at
a recommended rate of 1g per hour (1.5g over 90 minutes). Note: Infusion can be completed after skin incision.
Repeat doses
Obese patients
*High risk
Vascular reconstruction cefazolin 2g IV (child: 30mg/kg up to 2g), vancomycin 1g IV infusion (1.5g > 80kg actual body
(e.g. abdominal aorta, graft/stent repeated 8-hourly for 2 further doses post- weight), may repeat 12 hours after initial dose
insertion, groin incision) operatively
High risk of MRSA :
Amputation of ischaemic limb cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g > 80kg actual body
repeated 8-hourly for 2 further doses post- weight), repeated 12 hours after initial dose
operatively PLUS
PLUS metronidazole 500mg IV infusion (child:
metronidazole 500mg IV infusion (child: 12.5mg/kg up to 500mg), repeated 12 hours after
12.5mg/kg up to 500mg), repeated 12 hours initial dose
after initial dose
High risk of MRSA :
Primary autogenous
arteriovenous fistula (AVF) No prophylaxis required
formation
AVF revision or AVF with cefazolin 2g IV (child: 30mg/kg up to 2g) vancomycin 1g IV infusion (1.5g > 80kg actual body
insertion of prosthetic material weight)
High risk of MRSA :
(e.g Dacron graft)
All other clean procedures Prophylaxis NOT recommended

(e.g. thoracoscopic
sympathectomy)
Post-Operative Care
surgical drains
IV Intravenous
DRESS/SJS/TEN)
References
Antibiotic Expert Group (2014). Therapeutic Guidelines: Antibiotic, Version 15. Melbourne: Therapeutic Guidelines Limited.
Kalapatapu V. (2017). "Lower extremity amputation". In: Mills JL Snr and Eidt JF (eds), UpToDate, Waltham, MA. [www.uptodate.com] Accessed Aug
2017
McIntosh, J., Earnshaw, JJ. (2009) "Antibiotic prophylaxis for the prevention of infection after major limb amputation". Eur J Vasc Endovasc Surg 37
(6): 696 - 703.
Salman, L., Asif, A. (2009) "Antibiotic Prophylaxis: Is it needed for dialysis access procedures?". Seminars in Dialysis 22(3): 297-9.
Stone, PA., AbuRahma, AF, Campbell, JR et al (2015). "Prospective randomized double-blinded trial comparing 2 anti-MRSA agents with
supplemental coverage of cefazolin before lower extremity revascularization". Ann Surg 262: 495-501.
effect.
professional before using this publication. / Acronyms
October 2017
Public – I1-A2

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Policy Classification: Public-I1-A2

Policy No.: CG269

2. Roles and Responsibility

2.1. Local Health Network (LHN) Chief Executive Officers will:

2.2. LHN AMS Committees are responsible for:

2.3. Prescribers (including contracted staff) are responsible for:

2.4. Pharmacists (including contracted staff) are responsible for:

2.5. Nurses are responsible for:

3.2.1. Practice Points

3.2.3. MRSA risk

3.2.4. Vancomycin administration

3.2.5. Clindamycin administration

3.2.6. Gentamicin administration

3.2.7. Repeat doses

3.2.8. Obese patients

4. Implementation and Monitoring

Standard 4 – Medication Safety

In the context of this document:

7.1. SA Policies and guidelines

Document developed by: South Australian expert Advisory Group on Antimicrobial

Approval Who approved New/Revised

Uncomplicated clean procedures

> without mesh insert Prophylaxis NOT recommended

Clean excision procedures Prophylaxis NOT recommended

Routine angioplasty, stent

DENTAL PROCEDURES: DENTAL PROCEDURES: DENTAL PROCEDURES:

All other procedures amoxicillin 2g IV prior to procedure clindamycin 600mg by IV infusion

Endoscopic Retrograde gentamicin 2mg/kg IV gentamicin 2mg/kg IV

All other procedures

*OMIT metronidazole if low risk as defined by:

Hernia repair Prophylaxis NOT recommended when mesh is not inserted

Other uncomplicated or minor clean

Expert Group Antibiotics. Therapeutic Guidelines: Antibiotic (2014)

Other minor clean procedures Prophylaxis NOT recommended

High risk of MRSA:

Endoscopic procedures, IUD

Later term termination As for hysterectomy (see on previous page)

Anterior procedures cefazolin 1mg/0.1ml intracameral injection at

vancomycin added to tobramycin or

Routine arthroscopic No prophylaxis required

repeat 8-hourly for 2 further doses.

ADD vancomycin 1g IV infusion (1.5g for

Arthroscopic and other clean Prophylaxis NOT recommended

ADD vancomycin 1g IV infusion (1.5g for

Clean bone or soft tissue injury

ADD vancomycin 1g IV infusion (1.5g for

If risk of entry into bowel lumen then ADD: gentamicin 2mg/kg IV

Other clean procedures /

All other clean procedures Prophylaxis NOT recommended

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