Antibiotic Prophylaxis

Jennifer Perera
Infection 2 - Wayamba
Antimicrobial prophylaxis – learning outcomes

At the end of the session, the student should be able to;

1.define prophylactic antibiotic therapy giving examples
2.list the Importance of antibiotic prophylaxis.
3.list the patient categories requiring antibiotic prophylaxis
4.outline the risks of antibiotic prophylaxis
Antibiotic Proiphylaxis is indicated in several
instances in the management of medical and
surgical conditions and following trauma

• It is prevention
• If there is an infection it cannot be called prophylaxis
Medical conditions that require prophylaxis
• Splenectomy
• Rheumatic fever
• Infective Endocarditis
• Bacterial meningitis
• Cirrhotic patients with GI bleeding
• Spontaneous bacterial peritonitis
• Recurrent cellulitis
Splenectomy

• Post splenectomised patients – elective or following trauma

• Antibiotcis (oral penicillin (250mg bd) or amoxicillin (250mg daily) for
2 years
• More importantly vaccination is important against capsulated
organisms 2 weeks prior to surgery and all 3 vaccines can be given on
the same day
• Pneumococcal vaccine
• Meningococcal Vaccine
• Hib vaccine
Rheumatic fever
Primary prevention
• Oral penicillin remains the drug of choice for treatment of GABHS pharyngitis,
but ampicillin and amoxicillin are equally effective.
• When PO penicillin is not feasible or dependable, a single dose of intramuscular
benzathine penicillin G, or benzathine/procaine penicillin combination is
therapeutic.
Secondary prevention
• patients with rheumatic fever without carditis receive prophylactic antibiotics for
5 years or until aged 21 years, whichever is longer
• Patients with RF with carditis but no valve disease should receive prophylactic
antibiotics for 10 years or well into adulthood, whichever is longer.
• Patients with RF with carditis and valve disease should receive antibiotics at least
10 years or until aged 40 years. They also need a single dose of antibiotics 1 hour
before surgical and dental procedures to help prevent bacterial endocarditis.
Infective endocarditis
To whom?
• Cardiac conditions
• Past infective enfdocarditis
• Prosthetic valve surgery or repair using prosthetic material
• Cardiac transplantations
• Certain congenital heart diseases (Cyanotic)
When?
üDental procedures – gum manipulation or penetration of oral mucosa
üInvasive respiratory procedures which requires incision fo resp mucosa
üGU and GI procedures which – to prevent enterococcal carditis
üInfected skin and soft tissue procedures – cover and staphylococcal or
Beta haemolytic streptococci
Bacterial meningitis – prophylaxis for contacts
Contacts of meningitis caused by
• 1) Meningococci – Ciprofloxacin
• 2) Hib – rifampicin and Index case children below 5 y, give vaccine to
orevent future repeated episodes
Cirrhotic patients with GI bleeding &

• Prior to endoscopy – e.g. Fluroquinolone (Norfloxacin) – prior to

procedure and for 24 hours

Recurrent cellulitis
PO penicillin 250m bd daily
When is not feasible or dependable, a single dose of intramuscular benzathine
penicillin G, or benzathine/procaine penicillin combination every 4 weeks
Surgical prohylaxis
Patient care for reducing Surgical Site Infections
• A good shower on the day of surgery with soap
• If hair removal is needed,razors should not be used – depilatory
creams or hair clippers
• Treat any existing infection before surgery – UTI
• Nasal / skin screening for S aureus if high risk surgery (implants,
orthopaedic, cardiac etc)
• Good glycaemic control
• During surgery adequate oxygenation and body temp maintenance
General recommendations
• Indicated in some clean and all clean-contaminated surgeries
• In dirty surgery antibiotic antibiotic treatment rather than prophylaxis
is needed because there may be already infection established
• Clean surgery –
• Use of prosthetic material in surgery
• If infection occurs the conseuence will be catastrophic – Neuro, open Ht,
orthopaedic, ophthalmic
• In those with impaired host defence
 Surgical Prophylaxis
1) All surgical procedures carry a risk of infection. However, the benefit of
prescribing prophylaxis must be balanced against the potential risks of
antimicrobial use.
E.g.
• allergic reactions
• antibiotic-associated C. difficile
• antibiotic resistance.

2) Prophylaxis is not indicated for

• clean surgery
• non-prosthetic- associated procedures
Site of surgery and prophylactic antibiotics

When - How is the decision made?

• Surgical site infections tends to be high, for example, colorectal surgery - Many
microorganisms
• The consequences are bad if surgery with implanted material such as
Arthroplasty/ Prosthetic joints/ Cardiac valve surgery.
Right Antimicrobial agent
• The choice of antimicrobial is ultimately influenced by the surgical
procedure and associated risk factors.
• Should cover the expected microbiological flora at the incision site.
• This is further influenced by multiple patient-specific risk factors
including:
• pre-existing infection
• Recent antimicrobial use
• Known colonisation with a resistant organism prolonged hospitalisation
• Prostheses
• Obesity
• Renal function
• Comorbidities
• Immunosuppression
Duration & Dose

• Generally a single dose and not more than 24 hours or maximum of 3

doses
• If the operation is longer than half life of antibiotic, a repeat dose is
needed. Eg Beta lactamns 3-4 hrs, Clindamycin 3-6 hrs, Vancomycin 6-
12hrs
• If there is much blood loss during surgery (> 25% of TBV) a repeat dose
• No need to continue until surgical drains ar eremoved
• If obese patients – higher doses need to be given
Right route of administration

• Parenteral administration (intravenous or intramuscular) is the

preferred route for surgical antimicrobial prophylaxis.
• However, there are exceptions, including topical use for ophthalmic
procedures,
• oral antibiotics for transurethral resections of the prostate
• oral amoxicillin before certain dental procedures for endocarditis
prophylaxis
Right timing of Administration

• IV antibiotics should ideally be given 30 min prior to incision.

• If antibiotic is given as an infusion, e.g. Vancomycin it should be started
2hr prior to surgery timing so that infusion should finish 15 – 30 mins prior
to incision.
• Other antibiotics that are given as infusions include ciprofloxacin,
Gentamicin etc so time has to be adjusted accordingly
• For caesarean sections, evidence supports antimicrobial prophylaxis
before cord clamping rather than afterwards.
Topical prophylaxis

• Despite insufficient evidence, antibiotic ointments and creams are

frequently used for topical prophylaxis.
• Antimicrobial prophylaxis should not be used as a stopgap for
inadequate infection prevention measures during surgery
• .Similarly, topical prophylaxis should not be a substitute for good
surgical closure technique and dressing management,
• High use of topical prophylaxis may increase the risk of antimicrobial
resistance.
• Studies have correlated increasing use of topical fusidic acid with an
increase of fusidic acid-resistant Staphylococcus aureus.
Right duration

• A single preoperative dose is adequate for the majority of

procedures.
• Post-procedural doses of intravenous antibiotics (up to 24
hours) are only required in defined circumstances, such as
some cardiac and vascular surgeries, and lower limb
amputation.
• Intravenous and oral antibiotic prophylaxis offer no benefit
beyond this period
Dental procedures
For dental procedures, guidelines recommend that
antimicrobial prophylaxis may be appropriate in

• immunocompromised patients,
• surgical removal of a bone-impacted tooth
• periapical surgery in a patient with a history of
recurrent infections
• risk of endocarditis.
Antibiotics in Trauma
General guidelines for antibiotics and review regularly whether to
continue

• Head and neck trauma

• Open limb fractures
• Penetrating abdominal trauma
• Thoracic trauma