Paediatric Cardiac Surgical Antibiotic Prophylaxis

Document ID CHQ-GDL-01070 Version no. 2.0 Approval date 08/07/2019

Executive sponsor Executive Director Medical Services Effective date 08/07/2019
Author/custodian Director, Infection Management and Prevention Service, Review date 08/07/2020
Immunology and Rheumatology
Supercedes 1.0
Applicable to All Children’s Health Queensland (CHQ) Staff
Authorisation Executive Director Clinical Services (QCH)

Purpose
This guideline provides a standardised approach to the appropriate use and prescribing of surgical antibiotic
prophylaxis to minimise surgical site infections.

The objective of this guideline is to minimise the selection of antibiotic-resistant organisms and promote safe
and effective antibiotic prescribing.

Scope
This guideline applies to all staff working within the Children’s Health Queensland Hospital and Health
Service relating to paediatric cardiac patients who require surgical antibiotic prophylaxis.

Related documents
Procedures, Guidelines, Protocols
• CHQ-GDL-01064 Children’s Health Queensland (CHQ) Paediatric Surgical Antibiotic prophylaxis
guideline
• CHQ-GDL-01202 CHQ Paediatric Antibiocard: Empirical Antibiotic Guidelines
• CHQ-GDL-01066: Empiric Antibiotic Guidelines for Paediatric Intensive Care Unit
• CHQ Guideline for Therapeutic Drug monitoring of Vancomycin
• CHQ Guideline for Therapeutic Drug monitoring of Tobramycin and Gentamicin
• CHQ-PROC-01035 Antimicrobial Restrictions
• CHQ Antimicrobial Restriction list

CHQ-GDL-01070 – Paediatric Cardiac Surgical Antibiotic Prophylaxis

-1-
1 List of Abbreviations

Term Definition
AMS Antimicrobial Stewardship
CHQ Children’s Health Queensland
CVL Central Venous Line
ECMO Extra corporeal membrane oxygenation
ESBL Extended spectrum beta-lactamase

ID Infectious Diseases
IDC Indwelling catheter
IV Intravenous
MCS Microscopy and culture
MRSA Methicillin resistant Staphylococcal aureus
TDM Therapeutic drug monitoring

2 Guideline for Paediatric Cardiac Surgical Antibiotic prophylaxis

2.1 General information

A. The process for administration of antibiotic prophylaxis should be standardised to ensure consistent,
timely administration. Antibiotics must be administered within 60 minutes prior to first incision. There
is evidence that the period of 15 to 60 minutes prior to first incision is ideal so therefore this is the
recommended timing for high risk procedures and wherever practically possible.
B. The choice of antibiotic should be in accordance with CHQ-GDL-01064 - Paediatric Surgical Antibiotic
prophylaxis guideline and be guided by previous microbiological results and known colonisations. For
further advice please contact Infectious Diseases.
C. Implementation of these recommendations will mean that the health service has taken responsible
steps to respond to the legal duty to improve the quality of care provided with regard to the surgical
antibiotic prophylaxis standard.
D. The current CHQ Paediatric Cardiac Surgical Antibiotic prophylaxis recommendations are available
via the CHQ AMS website and the CHQ eGovernance catalogue.
E. Compliance with surgical antibiotic prophylaxis will be monitored via the CHQ Surgical Antibiotic
prophylaxis dashboard and results reported to the CHQ Antimicrobial Stewardship Steering
committee, Infection Control Committee and the Patient Safety and Quality Committee.
F. Antibiotic dose and timing must be clearly and accurately documented in the electronic medical
record (via SA Anaesthesia or iEMR Medication administration record).

CHQ-GDL-01070 – Paediatric Cardiac Surgical Antibiotic Prophylaxis

-2-
 2.2 Guideline for Paediatric Cardiac Surgical Antibiotic prophylaxis
Indication
Most cardiac surgery
If not on antibiotics with gram
negative and positive cover.
Including valve replacement.
Most cardiac surgery
If on antibiotics with gram
negative and positive cover
Known MRSA infection or
colonisation, currently or in the
past
ESBL infection or colonisation
Penicillin/Cephalosporin allergy
Chest opening or exploration
If not on antibiotics with gram
negative and positive cover
Chest opening or exploration
If on antibiotics with gram
negative and gram positive cover
ECMO (cannulation, reopen on
ECMO, decannulation)
If not on antibiotics with gram
negative and positive cover
ECMO (cannulation, reopen on
ECMO, decannulation)
If on antibiotics with gram
negative and gram positive cover
Postoperative open chest
Chest closure
If not on antibiotics with gram
positive and gram negative cover
Chest closure
If on antibiotics with gram
negative and gram positive cover
Eradication of Staph Aureus nasal
colonisation
CHQ-GDL-01070 – Paediatric Cardiac Surgical Antibiotic Prophylaxis
-3-
Prophylaxis
Cephazolin IV 50 mg/kg
(Maximum 2 g)
(If more than 120 kg, give 3 g)
No further prophylaxis required
Cephazolin IV 50 mg/kg
(Maximum 2 g)
(If more than 120 kg, give 3 g)
plus
Vancomycin IV
Neonate: 25mg/kg
Child less than 12 years:
30 mg/kg (Maximum 1.5 g)
More than 12 years: 25 mg/kg
(Maximum 1.5 g)
Meropenem IV 40 mg/kg
(Maximum 2 g)
Lincomycin IV 15 mg/kg
(Maximum 600mg)
Plus Gentamicin IV 5 mg/kg
1 month to 10yrs:
(Maximum 320 mg)
More than 10yrs:
(Maximum 560 mg)
As per prophylaxis for cardiac
surgery above
No further prophylaxis required
As per prophylaxis for ‘most cardiac
surgery’
No further prophylaxis required
As per ‘most cardiac surgery’
As per prophylaxis for ‘most cardiac
surgery’
No further prophylaxis required
Apply Mupirocin 2% (Bactroban
®) intranasally twice daily
Timing and Duration
Optimal timing for Beta-Lactams:
Administer between 30 to 60 minutes before
incision. Intraoperative doses 30 mg/kg/dose
(maximum 1 g) every 4 hours.
Total 3 postoperative doses at 30
mg/kg/dose (maximum 1 g) every 8 hours.
As per original indication.
Cephazolin:
Optimal timing for Beta-Lactams:
Administer between 30 to 60 minutes before
incision. Intraoperative doses 30 mg/kg/dose
(maximum 1 g) every 4 hours. Total 3
postoperative doses at 30 mg/kg/dose
(maximum 1 g) every 8 hours.
Vancomycin: Slow infusion starting at least
60 minutes before and finishing immediately
before incision; CVL not required.
No further doses of Vancomycin required
Total 2 postoperative doses of Meropenem
40 mg/kg/dose (Maximum 2 g) every 8
hours.
Lincomycin: Optimal timing: give over at
least 60 minutes, finish before incision, max
rate should not exceed 1 g/hour; CVL not
required.
Gentamicin: No further doses required
As per prophylaxis for ‘most cardiac
surgery’. Remember to cease after 24 hours
As per original indication
As per prophylaxis for ‘most cardiac surgery’
As per original indication
Duration: Continue as long as chest open
As per prophylaxis for ‘most cardiac
surgery’. Remember to cease after 24 hours
As per original indication
Ideally start 2 days prior to surgery.
Continue to a total of 5 days.
2.2 Guideline for Paediatric Cardiac Surgical Antibiotic prophylaxis (continued)

Choice of Antibiotics for Empiric Treatment of Infections

Pre-operative • Test should be offered to at-risk ethnic groups and patients with a personal
nasal swab for or family history of boils/furuncles.
MRSA • Appropriate sterile swab should be used for swabbing anterior nares, one
screening nostril followed by the other with same swab; prior to swabbing, the swab
should be moistened in the transport medium within the tube or by using
sterile saline.
• Request form (or iEMR Pathology order) should state ‘nasal swab for
MRSA screen’.
• Patients with MRSA grown from nasal swabs are given Cephazolin IV
plus Vancomycin IV for surgical prophylaxis.
• Patients with MRSA in nasal swabs are given peri-operative Mupirocin 2%
nasal ointment as for all cardiac surgery patients, and will require contact
precaution until cleared; they should wash daily with 2% Chlorhexidine
solution or soap (see CHQ procedure: Detection and Management of
MRSA (Methicillin resistant Staphylococcus aureus).
Postoperative Culture ‘head-to-toe’.
suspicion of Start Vancomycin IV (dose based on actual body weight)
bacterial Neonates 29 to 44 weeks post conceptional age:
infection • Week 1 and 2 of life: 15 mg/kg/dose every 12 hours.
without focus • Week 3 of life: 15 mg/kg/dose every 8 hours
Infants and children <18 years:
• General dosing: 15 mg/kg/dose (maximum initial dose 500 mg) every 6 hours.
• For critically ill patients/severe sepsis: 15 mg/kg/dose (maximum initial dose
750 mg) every 6 hours.
Seek pharmacist/ ID advice on appropriate therapeutic drug monitoring (TDM)

Plus Gentamicin IV (dose based on ideal body weight)

Premature neonates (younger than 35 weeks post menstrual age):
Please refer to Neonatal dosing recommendations on the CHQ AMS website –
link:
https://www.childrens.health.qld.gov.au/chq/healthprofessionals/antimicrobial-
stewardship/guidelines/neonatal-dosing
Term Neonates week 1 to 4 of life: 5mg/kg/day
Infants over 1 month of age and Children younger than 10 years old:
7.5 mg/kg/day (maximum 320mg initial dose)
Children >10 years old and adolescents: 6 mg/kg/day (maximum 560 mg initial
dose)
Septic/critically ill children >10 years old: 7 mg/kg/day (maximum 640 mg
initial dose)
Seek pharmacist/ ID advice on appropriate therapeutic drug monitoring (TDM).
Cease treatment if cultures are negative after 48hrs & consultation with ID.

CHQ-GDL-01070 – Paediatric Cardiac Surgical Antibiotic Prophylaxis

-4-
 2.2 Guideline for Paediatric Cardiac Surgical Antibiotic prophylaxis (continued)

Choice of Antibiotics for Empiric Treatment of Infections

Postoperative Wound: see ‘CVL/bloodstream’
suspicion of
bacterial CVL/bloodstream:
infection • See ‘postoperative infection without focus’
with focus • If life threatening staphylococcal infection suspected:
• Add Flucloxacillin IV 50 mg/kg/dose (maximum 2 g) every 6 hours to
Vancomycin IV
• Consider replacing CV
• Seek ID advice on duration of treatment

Respiratory tract:
Nasopharyngeal swab for respiratory viruses and deep tracheal aspirate for MCS
Start Piperacillin/Tazobactam IV 100 mg/kg/dose (Maximum 4 g Piperacillin
component) every 6 hours
plus
Vancomycin IV(dose based on actual body weight)
Neonates 29 to 44 weeks post conceptional age:
• Week 1 and 2 of life: 15 mg/kg/dose every 12 hours.
• Week 3 of life: 15 mg/kg/dose every 8 hours
Infants and children <18 years:
• General dosing: 15 mg/kg/dose (maximum initial dose 500 mg) every 6 hours.
• For critically ill patients/severe sepsis: 15 mg/kg/dose (maximum initial dose
750 mg) every 6 hours.
Seek pharmacist/ ID advice on appropriate therapeutic drug monitoring (TDM)
Cease Vancomycin after 48hrs if blood cultures negative.
Duration as per ID consult.

Urinary tract:
Replace IDC
Start Ampicillin IV 50 mg/kg/dose (maximum 2 g) IV every 6 hours
Plus Gentamicin IV (dose based on ideal body weight)
Premature neonates (younger than 35 weeks post menstrual age):
Please refer to Neonatal dosing recommendations on the CHQ AMS website
Term Neonates week 1 to 4 of life: 5 mg/kg/day
Infants over 1 month of age and Children younger than 10 years old:
7.5 mg/kg/day (maximum 320mg initial dose)
Children >10 years old and adolescents: 6 mg/kg/day (maximum 560 mg initial
dose)
Seek pharmacist/ ID advice on appropriate therapeutic drug monitoring (TDM).
Cease treatment if cultures are negative after 48hrs & consultation with ID.

CHQ-GDL-01070 – Paediatric Cardiac Surgical Antibiotic Prophylaxis

-5-
2.3 Peri-operative Mupirocin nasal treatment for cardiac surgery patients
• The objective with mupirocin 2% nasal treatment is to eradicate Staphylococcus aureus nasal colonization
in cardiac surgery patients.
• Nasal mupirocin applied twice daily should be commenced at least the day before surgery but ideally 2
days prior to surgery and continued for a total of 5 days for all cardiac surgery patients.
• A parent information leaflet (see appendix A) and a prescription for nasal mupirocin 2 % ointment should
be given to parents at the pre-operative visit with instructions for application.
• All patients will also receive one dose of nasal mupirocin 2% ointment at induction of surgery.

CHQ-GDL-01070 – Paediatric Cardiac Surgical Antibiotic Prophylaxis

-6-
2.4 Appendix A

MUPIROCIN 2% (Bactroban®) NASAL OINTMENT

TO PREVENT SURGICAL SITE INFECTION
Information for Paediatric Cardiac Surgery patients and families

What causes infection at the site of recent heart surgery?

Staphylococcus aureus is a bacterium often carried by healthy people on the skin and in the nose.
This bacterium may not cause any problems but in some cases it can be responsible for infection at the site
of recent surgery. Following heart surgery, infection can occur in the skin at the surgical site and may involve
deeper structures such as bone.

What can help to prevent surgical site infection?

Treatment with mupirocin 2% nasal ointment (Bactroban®) clears Staphylococcus aureus from the nose and
will help to prevent surgical site infection.
A small amount of the ointment, placed on the end of a finger, is put into each nostril twice a day beginning
24 to 48 hours before surgery and continuing for a total of 5 days. Hands should be washed before and
after applying the ointment.
It is important to remember to apply the ointment at home twice a day for the 2 days before surgery.

Are there any side effects from using mupirocin treatment?

There are no significant side effects associated with this treatment.

If you have any questions, please do not hesitate to contact your child’s treating Doctor or
Infection Control staff at the Queensland Children’s Hospital via the hospital switchboard
(07) 3068 1111.

CHQ-GDL-01070 – Paediatric Cardiac Surgical Antibiotic Prophylaxis

-7-
Acknowledgement
Children’s Health Queensland would like to acknowledge the contribution made by:
• Dr Nelson Alphonso, Director Paediatric Cardiac Surgery
• Dr Christian Stocker, QPCS Quality Management
• Quyen Tu, PICU Pharmacist

Consultation
Key stakeholders who reviewed this version:
• Director – Paediatric Infectious Diseases, Rheumatology and Immunology
• Consultant. Infection Management and Prevention Services
• Pharmacist Advanced - Antimicrobial Stewardship

References and suggested reading

1. Therapeutic Guidelines: Antibiotic, 2010. Therapeutic Guidelines Ltd, Melbourne
2. Dellinger EP et al. Quality standard for antimicrobial prophylaxis in surgical procedures CID
1994;18:422-427
3. Engelman R et al. The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic Prophylaxis
in Cardiac Surgery, Part 1: Duration. Ann Thorac Surg 2006;81: 397-404. Part 2: Antibiotic Choice. Ann
Thorac Surg 2007;83:1569-1576
4. Alphonso N et al. Perioperative antibiotic prophylaxis in paediatric cardiac surgery. Cardiol Young
2007;17:12-25
5. Bratzler DW et al. Clinical Practice guidelines for antimicrobial prophylaxis in surgery. AJHSP. 2013;
70:195-283

CHQ-GDL-01070 – Paediatric Cardiac Surgical Antibiotic Prophylaxis

-8-
Guideline revision and approval history
Version No. Modified by Amendments authorised by Approved by
1.0 Antimicrobial Stewardship CHQ Medicines Advisory Executive Director Hospital
(06/10/2016) Pharmacist Committee Services

2.0 Pharmacist Advanced – CHQ Medicines Advisory Executive Director Clinical

(08/07/2019) Antimicrobial Stewardship Committee Services (QCH)
Director of Infection
Management and Prevention
Service, Immunology and
Rheumatology

Keywords Antimicrobial stewardship, antibiotics, cardiac, surgical, surgery, prophylaxis, medication,

mupirocin, cephazolin, Post operative suspicion of bacterial infection, 01070
Accreditation National Safety and Quality Health Service Standards (1-8):
references Standard 3: Preventing and Controlling Healthcare-Associated Infection

Standard 4: Medication Safety

CHQ-GDL-01070 – Paediatric Cardiac Surgical Antibiotic Prophylaxis

-9-