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Issue 10: Special Edition

Antibiotics ABC July 2010, By Antimicrobial Subcommittee

KWC Antibiotic Guideline for Elective Orthopedic Surgery Prophylaxis


General principle:
1) Timing:
Antibiotics must be given so that good tissue levels are present at the time of procedure and for the first 3-4 hours after surgical
incision. Therefore, the first dose of IV antibiotics should be given within 30 – 60 minutes before surgical incision is made, i.e. with
induction of anesthesia. For those antibiotics requiring infusion (Ciprofloxacin, Clindamycin, Metronidazole, Vancomycin), infusion
should be completed 10 minutes before incision. If tourniquet is needed, iv antibiotics should be given 10 minutes before tourniquet
application.
2) Duration:
Single dose antibiotic given during induction provides adequate tissue level for most surgical procedures. For procedure lasting for
several hours, repeated doses of antibiotics may be necessary intraoperatively to maintain adequate tissue level.
KWC Antbiotic Regimen
Alternative
Type of operation Indication Recommendation (for patients with
beta-lactam allergy)
Non-traumatic No Foreign Body
Excluding: e.g Arthroscopy,
-Immunocompromised Tendon transfer, No antibiotics No antibiotics
-Open Intra-articular Procedure Posterior diskectomy
-Spine Surgery With Grafting
Non-traumatic No Foreign Body
-Immunocompromised e.g Arthrotomy,
-Open Intra-articular Procedure ASF
-Spine Surgery With Grafting iv Cefazolin4,5 1g (1-3 doses2)
e.g. Osteotomy, Note: Antimicrobial agents should iv VAN 1g (1-2 doses)
Non-traumatic Implants
Spinal instrumentation be completely infused before
Non-traumatic Prosthesis e.g Total joint replacement
inflating the tourniquet
Closed Traumatic No Foreign Body e.g. Repair of Tendo Achilles
Closed Traumatic Implants e.g. Malleolar fracture, DHS
Closed Traumatic Prosthesis e.g AMA
Soft Tissue Wound - No Fracture e.g Laceration of Tendo Achilles iv AUG1 1.2g (1 dose) iv CIP 400mg (1 dose)
Gustilo I, II & III Compound
Fracture iv AUG1 1.2g (1 dose) +/- GEN
1.5mg/kg (1 dose), followed by po
AUG1 375mg tds (when DAT)

- Duration: Individualized, 3 days iv CIP 400mg (1 dose) +


for Gustilo-Anderson grade I and II iv CLIN 600mg (1 dose)
-- open fractures and up to 5 days for on induction, followed by
Diabetic Foot grade III wound, or until 3 days after po CIP 500mg bd + po
acute inflammation disappears CLIN 300mg qid

- Antibiotics should be streamlined


according to the sensitvity result
when culture report comes back

iv AUG11.2g q8h + iv LVX 500mg


daily +/- iv CLIN3 600-900mg q8h if
Gm stain result shows Gm+ve cocci iv LVX 500mg daily
in chain
Necrotising Fasciitis -- + iv CLIN3 600-900mg
q8h
Note:
Switch iv LVX to po once patient is
hemodynamically stable

Remarks:
1
AUG has very good activities on anaerobes. There is no need to add MET when these drugs are being used
2
"3 doses" mean 1 dose during induction followed by 2 more doses postoperatively, i.e. 3 doses in total
3
iv CLIN 900mg q8h is required for cases with toxic shock syndrome
4
Give Cefazolin 2g for patients with body weight greater than 80kg
5
For hospitals or units with high incidence of postoperative wound infections by MRSA or MRSE, screening and additional preoperative measures for MRSA may
be indicated and / or use Vancomycin as preoperative prophylaxis

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KWC Antibiotic Guideline for Surgical Prophylaxis
General principle:
1) Timing:
Antibiotics must be given so that good tissue levels are present at the time of procedure and for the first 3-4 hours after surgical
incision. Therefore, the first dose of IV antibiotics should be given within 30 - 60 minutes before surgical incision is made, i.e.
with induction of anesthesia. For those antibiotics requiring infusion (Ciprofloxacin, Clindamycin, Metronidazole, Vancomycin),
infusion should be completed 10 minutes before incision.
2) Duration:
Single dose antibiotic given during induction provides adequate tissue level for most surgical procedures. For procedure lasting
for several hours, repeated doses of antibiotics may be necessary intraoperatively to maintain adequate tissue level.

KWC Antibiotic Regimen


Alternative
Type of operation Indication Recommendation (for patients with
beta-lactam allergy)
-Pulmonary resection
Thoracic5 -Closed tube throacostomy for iv Cefazolin4 1g
chest trauma OR
iv Cefuroxime 1.5g
-Abdominal aortic operations OR iv VAN 1g (1 dose)
-Prosthesis
iv AUG 1.2g
Vascular -Groin incision
-Lower extremity amputation for
(1 dose)
ischaemia

-Tonsillectomy iv AUG 1.2g


-Maxillofacial OR iv CLIN 600mg + iv GEN 120mg
Oral Pharyngeal / Nasal
-Rhinoplasty iv CLIN 600mg + iv GEN 120mg (1 dose)
-Turbinate/Septoplasty (1 dose)

High Risk:
-Age > 70
-Acute Cholecystitis 6 / Pancreatitis
-Obstructive Jaundice
-Common Bile Duct Stones iv Cefuroxime 1.5g +/- iv MET 500mg
Hepatobiliary System
-Morbid obesity OR
-Intraoperative cholangiogram iv GEN 120mg (1 dose)
Laparoscopic Gall Bladder iv AUG1 1.2g
-Bile spillage
Surgery
-Pregnancy (1 dose)8
-Immunosuppression
-Insertion of prosthetic devices
-Laparoscopic converts to
laparotomy

iv AUG 1.2g +/- iv GEN 120mg


Endoscopic Retrograde OR po CIP 500 mg (1 dose)
Cholangiopancreatography Biliary obstruction iv TZC 4.5g
(ERCP) (1 dose) Timing: 2 hours prior to procedure
Timing: 1 hour prior to procedure
iv Cefuroxime 1.5g
Oesophageal surgery with OR iv VAN 1g + iv MET 500mg
manipulation of pharynx iv Cefazolin4 1g + iv MET 500mg (1 dose)
(1 dose)
Gastroduodenal surgery
(High Risk):
-Obstruction
-Haemorrhage
Upper GI
-Gastric ulcer iv Cefuroxime 1.5g
-Malignancy OR
iv GEN 120mg (1 dose)
-H2 blocker iv AUG 1.2g
-Proton pump inhibitor (1 dose)
-Morbid obesity
-Gastric bypass
-Percutaneous endoscopic
gastrostomy

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KWC Antibiotic Regimen
Alternative
Type of operation Indication Recommendation (for patients with
beta-lactam allergy)
iv Cefuroxime 1.5g (1 dose) followed by
750mg (2 doses) + iv MET 500mg (3
doses2)8 iv GEN 120mg + iv MET 500mg (q8h
Appendectomy
OR for 3 doses 2)8
iv AUG1 1.2g
(3 doses in total 2)8
Parenteral
iv Cefuroxime 1.5g (1 dose) followed by
Lower GI 750mg (2 doses) + iv MET 500mg (3
doses2)8
Colorectal surgery OR
iv GEN 120mg + iv MET 500mg
- Most procedures require iv AUG11.2g
(3 doses in total 2)8
parenteral +/- oral prophylaxis (3 doses in total 2)8
Oral
po Neomycin and Erythromycin base 1g
each three times a day the day before
operation

1st: po CIP 500mg


iv Cefuroxime 750mg q8h (3 doses 2)
(1 dose) given 2 hours before
Significant bacteriuria, TURP,
procedure
TURBT, TUR, stone operations, For cases with complication, followed by
nephrectomy, total cystectomy po AUG1 375mg tds until off foley 2nd: iv CIP 400mg (1 dose)
Urology
(maximum 5 days) followed by po 250mg bd (when DAT)

po CIP 500mg +/- po MET 400mg


Trans-rectal prostate biopsy / FNA (1 dose)
Timing: given 2 hours before procedure
iv Cefuroxime 1.5g + iv MET 500mg
OR
iv GEN 120mg + iv MET 500mg (q8h
Ruptured Viscus iv AUG1 1.2g
for 5-7 days)
Therapy is often continued for about 5-7
days
iv Cefazolin4 1g iv VAN 1g
OR OR
For treatment of established
iv Cefuroxime 1.5g iv CIP 400mg (1 dose) + iv CLIN
Traumatic Wound infection
OR 600mg (1 dose) on induction, followed
iv AUG1.2g by po CIP 500mg bd + po CLIN 300mg
(Duration of therapy: 5-7 days) qid for 5-7 days
iv CIP 400mg (1 dose) + iv CLIN
iv or po AUG 600mg (1 dose) on induction, followed
Bite Wound
(Duration of therapy: 5-7 days) by po CIP 500mg bd + po CLIN 300mg
qid for 5-7 days
Varicose vein surgery No antibiotics No antibiotics
Without implant:
7 Not indicated With implant / foreign body:
Mastectomy With implant / foreign body: iv VAN 1g (1 dose)
iv Cefazolin4 1g (1 dose)
Others
Thyroidectomy No antibiotics No antibiotics
iv Cefazolin4 1g
Hernioplasty7 OR
iv GEN 120mg (1 dose)
(with mesh) iv Cefuroxime 1.5g
(1 dose)
Remarks:
1
AUG has very good activities on anaerobes. There is no need to add MET when these drugs are being used
2
"3 doses" mean 1 dose during induction followed by 2 more doses postoperatively, i.e. 3 doses in total
3
iv CLIN 900mg q8h is required for cases with toxic shock syndrome
4
Give Cefazolin 2g for patients with body weight greater than 80kg
5
For hospitals or units with high incidence of postoperative wound infections by MRSA or MRSE, screening and additional preoperative measures
for MRSA may be indicated and / or use Vancomycin as preoperative prophylaxis
6
History of acute cholecystitis requires prophylaxis instead of treatment unless there is evidence of bacterial infection such as prescence of pus,
gangrane, perforation or cholangitis.
7
AUG may be used if operation is such that anaerobic coverage is needed, such as in hernia repair with bowel strangulation or incarcerated/
strangulated hernia or mastectomy with implant or foreign body
8
Antimicrobial agents should be considered postoperatively for operations with suppurative, ruptured and gangrenous conditions

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Abbreviations for anti-infective agents

AG= Aminoglycoside; AMK= Amikacin; AMOX= Amoxicillin; AMP= Ampicillin; AUG= Augmentin
(Amoxicillin&Clavulanic acid); CIP= Ciprofloxacin; CLIN= Clindamycin; CLR= Clarithromycin;
CLOX= Cloxacillin, ERY= Erythromycin; EMB= Ethambutol; FQ= Fluoroquinolone;
GEN= Gentamicin; INH= Isoniazid; LIN= Linezolid; LVX= Levofloxacin; MER= Meropenem;
MET= Metronidazole; NIT= Nitrofurantoin; PEN=Penicillin; PIP= Piperacillin; PZA= Pyrazinamide;
RIF= Rifampicin; SUL= Sulperazon, SXT= Septrin(Cotrimoxazole); TEIC= Teicoplanin;
TIEN= Tienam; TIM= Timentin (ticarcillin - clavulanate); TZC= Tazocin(piperacillin -tazobactam);
UNA = Unasyn (Ampicillin- sulbactam); VAN= Vancomycin

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