ANTIBIOTIC PROPHYLAXIS IN ORTHOPAEDIC SURGERY

The aim of surgical prophylaxis is to reduce rates of surgical site and healthcare-associated infections and so reduce surgical morbidity and mor tality. There is however growing evidence that
aspects of prescribing practice may themselves be associated with health-care associated infections and antimicrobial resistance. The Scottish Antimicrobial Prescribing Group (SAPG), along
with the Scottish Government, monitors antimicrobial prescribing including surgical prophylaxis in order to reduce the rates of resistance and C.difficile. SIGN guideline 104 published in July
2008, and updated in April 2014, has outlined which surgical procedures require prophylactic antibiotics based on a review of the available ev idence. Principles of prophylaxis have also been
outlined, including timing and duration of antibiotic administration. In conjunction with the surgical specialties within NHS Tayside the Antimicrobial Management Group has under taken to
review local prophylaxis policy and to for mulate a uniform policy.

Principles of Antibiotic Prophylaxis Policy

1. Indication for prophylaxis should comply with SIGN 104 guideline i.e. when ‘highly recommended’, ‘recommended’ or ‘considered’ w ithin guideline.
2. Timing of antibiotic(s):
• Optimum timing is intravenous dose given or infusion completed ≤ 60 minutes prior to skin incision
• Sub-optimal if >1 hour prior to skin incision or post-skin incision
• The exception is co- trimoxazole which is a one hour infusion. The window for this is within 2 hours of knife to skin (or the application of a tour niquet where used).
3. Recording of antibiotic prescription in ‘once only’ section of medicine char t to avoid multiple dosing
4. Frequency of administration should be single dose only unless:
• > 1.5 litres intra-operative blood loss - re-dose following fluid replacement (see administration guidance table)
• operation prolonged (see administration guidance table)
• specifically stated in follow ing guidelines
5. Documentation in medical notes of reason for antibiotic administration beyond single dose or state intention for antibiotic treatment cour se
6. Choice of agent should:
• Avoid cephalosporins and quinolones wherever possible
• Use narrow spectrum agents when possible to minimise impact on resistance and CDI
• Take into account local resistance patterns
• Provision of alternatives for beta-lactam allergy
7. De-colonisation therapy/MRSA patients
• If a patient is identified as MRSA positive from screening swabs within 3 weeks of anticipated date of elective surgery then a decolonisation program
should be star ted as per MRSA protocol. For surgical prophylaxis for primary operations vancomycin infusion should be used. If they have an MRSA infection prior to
elective surgery the approach is the same as for any other infection. Fur ther advice is available from Infection Control and Microbiology.
8. Complex individual prophylaxis issues e.g. where patient has had an ESBL previously should be discussed with Microbiology or Infectious Diseases pre-operatively and recorded
in medical notes.
9. Compliance with local policy is required and monitored by NHS Tayside. Any deviation from policy must be recorded in the appropriate medical records.

For details of administration of antibiotics see last page.

Type of Surgery Procedure
Orthopaedic Arthroplasty (including revisions
where no infection is suspected)
Open fracture
(including open hand fractures)
Open surgery for closed fracture
Hip fracture
Orthopaedic surgery without implant
Lower limb amputation
Soft tissue surgery of the hand
(not trauma surgery)
Spinal surgery with implant
Spinal surgery without implant
SIGN 104 Recommendation
‘Highly Recommended’
Antibiotic loaded cement is
recommended in addition to IV
antibiotics
‘Highly Recommended’
‘Highly Recommended’
‘Highly Recommended’
‘Not Recommended’
See Vascular surgical prophylaxis
guidance
Locally not routinely recommended
Locally recommended
Locally recommended
Antibiotic(s) Comments
MRSA positive – add vancomycin to surgical
prophylaxis regime – see dosing in table on last
page
Previous ESBL – ask Micro for advice on
appropriate surgical prophylaxis
Co-amoxiclav 1.2g IV 2 additional doses of Co-amoxiclav 1.2g (regardless of BMI) should
be given at 8 hourly intervals ( i.e. at 8 hours and 16 hours post
Hip Arthroplasty induction)
and BMI ≥ 30:
Co-amoxiclav 1.2g IV In penicillin allergic patients use co- trimoxazole 960mg. 1 additional
+ dose should be given at 12 hours post induction.
Amoxicillin 1g IV
Co-amoxiclav 1.2g IV In penicillin allergic patients use co- trimoxazole 960mg 12 hourly and
every 8 hours metronidazole 500mg 8 hourly to ensure adequate cover.
Prophylaxis should be started as soon as possible after injury and
ideally within 3 hour s of trauma, and continued until soft tissue
closure or for a maximum of 72 hours, whichever is sooner.
(Ref BOA 2009)
Co-amoxiclav 1.2g IV All single doses only (no fur ther doses required)
In penicillin allergic patients use co- trimoxazole 960mg.
Co-amoxiclav 1.2g IV 2 additional doses of Co-amoxiclav 1.2g should be given at 8 hourly
intervals ( i.e. at 8 hours and 16 hours post induction)
In penicillin allergic patients use co- trimoxazole 960mg. 1 additional
dose should be given at 12 hours post induction
Co-amoxiclav 1.2g IV 2 additional doses of Co-amoxiclav 1.2g should be given at 8 hourly
intervals ( i.e. at 8 hours and 16 hours post induction)
In penicillin allergic patients use co- trimoxazole 960mg. 1 additional
dose should be given at 12 hours post induction
Co-amoxiclav 1.2g IV All single doses only (no fur ther doses required)
Type of Surgery Procedure
Orthopaedic Revision ar throplasty
DAIR procedure
Removal of other implant
Applies to procedures where
infection is suspected
SIGN 104 Antibiotic(s) Comments
Recommendation Previous ESBL – ask Micro for advice on
appropriate surgical prophylaxis
Locally recommended in THEATRE: Choice of antimicrobial is based on a number of factors:
Ciprofloxacin 400mg IV one dose • Locally increasing number of gram negative
+ infections
Vancomycin IV • Pseudomonas should be covered until microbiology
Give LOADING dose in theatre after results or indicators deter mine this is not required
• Locally a number of teicoplanin resistant but
samples taken: vancomycin sensitive coagulase negative
Based on actual body weight staphylococci infections
<40kg 750mg over 90 minutes
40-59kg 1g over 2 hours • It is essential that dosing of
60-90kg 1.5g over 3 hours vancomycin is sufficient to treat
>90kg 2g over 4 hours
infection
Antibiotics should not be given until samples have been taken
then continue on the WARD:
for culture and sensitivity.
IV Vancomycin MAINTENANCE dose 12- Aim for pre dose vancomy cin level of 15-20mg/L
24 hours after loading dose calculated as per
local vancomycin guidance or calculator
+
ORAL ciprofloxacin 500mg bd
(750mg bd only if Pseudomonas confir med)
STOP ciprofloxacin after 48 hours if no gram
negative bacteria on cultures. Continue
vancomycin alone until cultures available then
discuss with infection specialist.
 IV Antibiotic Administration Guidance:

Antibiotic Dose Administration Prolonged surgery >1.5L blood loss redose

(time from administration of initial dose) after fluid replacement
Co-amoxiclav 1.2g Bolus over 3-5 minutes 1.2g to be repeated every 4 hours* 1.2g

Co-trimoxazole 960mg Infusion over 60 minutes Redose 480mg after 8 hours ** 480mg
Dilute each 480mg/5ml vial in
125ml sodium chloride 0.9%
Metronidazole 500mg Infusion over 20 minutes Redose 500mg after 8 hours 500mg

Vancomycin*** 1g Infusion over 100 - 120 minutes Redose 1g after 12 hours 500mg
(FOR PRIMARY in 250ml sodium chloride 0.9%
SURGERY)
Ciprofloxacin 400mg Infusion over 60 minutes Redose 400mg after 8 hours 200mg
See Fluoroquinolones
warnings document
Vancomycin*** Treatment dose required to ensure sufficient levels Continue treatment dose as calculated from local 50% of dose given initially
(FOR REVISION vancomycin guidance after 12 hours
SURGERY) LOADING dose in THEATRE as per infor mation in table above

MAINTENANCE doses on WARD 12-24 hours after loading dose calculated as per
guidance or calculator

* Locally it has been agreed that if the routine practice of the surgeon is to re-dose co-amoxiclav IV 1.2g after 2 hours or, in the case of a bilateral hip procedure, prior to incision on the 2nd
side, this is acceptable. The 2 additional doses at 8 and 16 hours post induction should also be given where indicated for the procedures above.
** There is no requirement to re dose co- trimoxazole at 2 hours or before incision on second side because it has a very long half life (9-11 hours at least). Developed by: AMG/Orthopaedic s
Approv ed: Nov 2012
*** Note if vancomycin is being used to treat a presumed or known infection the dosing should be as per the vancomycin guideline to ensure sufficient levels Updated: March 2013, May 2014 , March
2015, July 2015, Sept 2017
Rev iew: Sept 2019
Amended as per SAPG updated guidance
May 2019
References:
• SAPG Good Practice Recommendations for Surgical and Procedural Antibiotic Prophylaxis in Adults in NHS Scotland. https://www.sapg.scot/media/4109/good-practice-
recommendations- for-surgical-and-procedural-antibiotic-prophylaxis-in-adults-in-nhs-scotland.pdf [Accessed May 2019]
• SAPG Recommendations for Re-dosing Antibiotics for Surgical Prophylaxis. https://www.sapg.scot/media/4105/good-practice-recommendations-for-re-dosing-antibiotics-for-surgical-
prophylaxis.pdf [Accessed May 2019]