Adult Surgical (and Other Interventional) Prophylaxis Guidelines
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Summary of changes in this version compared to previous version
- Advice regarding modifications with documented carriage of resistant gram negatives.
- Introduction of height based criteria for gentamicin dosing in surgical prophylaxis.
- Introduction of streptococcal and enterococcal cover in GI and gynaecological surgery prophylaxis.
- Switch to cefuroxime as prophylaxis for arthroplasty procedures other than total joint replacement.
- Change in dosage recommendation for teicoplanin in orthopaedic prophylaxis.
The goal of surgical prophylaxis is to reduce the incidence of surgical site infection (SSI), while reducing the risk of adverse effects from the antibiotics used.
All IV doses should be given within 60 minutes prior to skin incision and as close to time of incision as practically possible.
Single preoperative doses only to be prescribed unless otherwise stated.
Aim to give indicated prophylaxis before pre-operative urinary catheterisation where this is performed.
Further intraoperative doses are required in prolonged procedures or with blood loss as below
Blood loss > 1500 ml
Re-dose following fluid replacement giving same dose for all agents except
- Gentamicin* – give half initial prophylactic dose
- teicoplanin – give half original dose if ≥1.5L blood loss within first hour of operation
- clindamycin – give half original dose
Prolonged operation
- 4 hours - re-dose amoxicillin, cefuroxime, clindamycin, co-amoxiclav, flucloxacillin
- 8 hours – re-dose amoxicillin, cefuroxime, clarithromycin, clindamycin, co-amoxiclav, flucloxacillin, metronidazole and, if eGFR > 60 ml/min gentamicin* (at full prophylactic dose)
*For complex patients, discuss with microbiology in advance to ensure re-dosing is safe and appropriate
Contaminated or dirty, infected wounds require treatment courses not prophylaxis
Pregnant patients: Gentamicin should be avoided in pregnancy. Cefuroxime is suitable alternative.
Modifications related to carriage/colonisation with resistant bacteria
MRSA carriage
- Consider preoperative or perioperative decolonisation
- If prophylaxis indicated add Teicoplanin IV (400mg or 800mg/600mg for orthopaedic procedures) if not already included in regimen
Gentamicin resistant gram negatives
- Review microbiology results for available susceptibility information and discuss with microbiologist when feasible
- When prophylaxis is indicated and susceptibility information is unavailable consider use of meropenem as prophylactic agent.
Modifications related to allergy or other contra-indication to prophylactic antibiotics
Alternatives are generally provided for patients with penicillin allergy. For other circumstances when recommended agents cannot be given please contact microbiology or pharmacy for advice. Omitting agents will affect the cover offered.
Gentamicin dosing in surgical prophylaxis (based on GGC guideline)
Prophylactic gentamicin dosing is based on patient height and approximates to 3mg/kg ideal body weight capped at 300mg. This allows bolus administration in the anaesthetic room, as detailed in the table below.
Gentamicin surgical prophylaxis dosing table |
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Avoid gentamicin if eGFR <20 or renal transplant : seek advice on alternative from microbiology |
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Height ranges (Feet and inches) |
Height ranges (cm) |
Gentamicin dose (mg) |
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Males |
Females |
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4’ 8” – 4’ 10” |
142 - 147 |
160 |
140 |
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> 4’ 10 – 5’ 3” |
> 147 – 160 |
180 |
160 |
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> 5’ 3” – 5’ 10” |
> 160 - 178 |
240 |
200 |
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> 5’ 10” – 6’ 2” |
>178 - 188 |
300 |
260 |
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> 6’ 2” |
> 188 |
300 |
300 |
General Surgery |
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Appendectomy
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Amoxicillin 1g IV (or teicoplainin 400mg IV if beta-lactam allergy) plus Gentamicin IV(see gentamicin surgical prophylaxis dosing table above) plus Metronidazole 500mg IV |
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Colorectal surgery |
Amoxicillin 1g IV (or teicoplainin 400mg IV if beta-lactam allergy) plus Gentamicin IV (see gentamicin surgical prophylaxis dosing table above) plus Metronidazole 500mg IV |
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Upper GI Surgery |
Amoxicillin 1g IV (or teicoplainin 400mg IV if beta-lactam allergy) plus Gentamicin IV (see gentamicin surgical prophylaxis dosing table above) plus Metronidazole 500mg IV |
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Open cholecystectomy |
Amoxicillin 1g IV (or teicoplainin 400mg IV if beta-lactam allergy) plus Gentamicin IV (see gentamicin surgical prophylaxis dosing table above) plus Metronidazole 500mg IV |
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Laparoscopic cholecystectomy |
Prophylaxis not recommended unless high risk intraoperative cholangiogram, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, immunosuppression, insertion of prosthetic devices, pregnancy (if pregnant use cefuroxime prophylaxis) Amoxicillin 1g IV (or teicoplainin 400mg IV if beta-lactam allergy) plus Gentamicin IV (see gentamicin surgical prophylaxis dosing table above) plus Metronidazole 500mg IV |
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Endoscopic retrograde Cholangiopancreatography (ERCP)
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Prophylaxis not recommended unless high risk pancreatic pseudocyst, immunosuprression, incomplete biliary drainage Ciprofloxacin 500mg orally prior to procedure or if not given Gentamicin according to gentamicin surgical prophylaxis table above |
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Breast surgery Prophylaxis should be considered for procedures for breast cancer especially if extending towards the axilla. Prophylaxis should be considered for breast re-shaping procedures. Prophylaxis is advised for breast surgery involving the insertion of implants.
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Flucloxacillin 1g IV or, if penicillin allergy, Teicoplanin 400 mg IV
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Hernia repair with or without mesh |
Prophylaxis not routinely recommended Consider in patients with mesh insertion if: obesity, diabetes, or other risk factors for SSI)
Teicoplanin 400 mg IV plus Gentamicin IV (see gentamicin surgical prophylaxis dosing table above) plus Metronidazole 500mg IV
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Haemorrhoidectomy, including stapled haemorrhoidopexy |
Amoxicillin 1g IV (or teicoplainin 400mg IV if beta-lactam allergy) plus Gentamicin IV (see gentamicin surgical prophylaxis dosing table above) plus Metronidazole 500mg IV |
Urology |
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Transrectal prostate biopsy |
Ciprofloxacin 500mg oral 60 minutes before procedure |
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Transurethral resection of prostate |
Gentamicin 160mg IV
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TURBT (Local practice) |
Gentamicin 160mg IV |
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Obstetrics and Gynaecology |
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Caesarean Section |
Cefuroxime 1.5g IV + metronidazole 500mg IV.
Or, in immediate (type 1) beta-lactam sensitivity Clindamycin 900mg IV as a single agent |
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Gynaecology majors, including PFRs |
Amoxicillin 1g IV (or teicoplainin 400mg IV if beta-lactam allergy) plus Gentamicin IV (see gentamicin surgical prophylaxis dosing table above) plus Metronidazole 500mg IV |
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Termination of pregnancy |
Metronidazole 1g oral or PR 2 hours before surgery followed by Azithromycin 1g oral single dose (unless pre-operative screening has ruled out chlamydial infection) with administration of Misoprostol |
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Transvaginal tapes |
Amoxicillin 1g IV (or teicoplainin 400mg IV if beta-lactam allergy) plus Gentamicin IV (see gentamicin surgical prophylaxis dosing table above) plus Metronidazole 500mg IV |
Orthopaedic Surgery |
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Total Joint Arthroplasty (antibiotic loaded cement is also recommended in addition to IV antibiotics)
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Cefuroxime 1.5g IV at induction as a single agent, followed by 2 doses of 750mg IV at 8 hourly intervals
Or, in immediate (type 1) beta-lactam sensitivity
Teicoplanin IV 800mg (600mg if weight ≤ 60kg) single dose plus Gentamicin IV according to gentamicin surgical prophylaxis table above) single dose |
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Other arthroplasty procedures
All intramedullary nails
Other internal fixations |
Cefuroxime 1.5g IV as a single agent
Or, in immediate (type 1) beta-lactam sensitivity
Teicoplanin IV 800mg (600mg if weight ≤ 60kg) single dose
plus Gentamicin IV according to gentamicin surgical prophylaxis table above, single dose |
Oral Surgery |
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Wisdom teeth extraction High risk patients (at discretion of oral surgeon) |
Preferred choice: Co-amoxiclav 1.2g IV Alternative: clindamycin 600mg IV |
Gastrointestinal Endoscopy |
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PEG insertion |
Co-amoxiclav 1.2g IV
Or, in penicillin allergy, teicoplanin 400mg IV |
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Variceal banding in presence of ascites |
Ceftriaxone 2g as a single agent or in immediate (type 1 ) beta-lactam sensitivity Teicoplainin 6mg/kg plus gentamicin IV (see gentamicin surgical prophylaxis dosing table above) |
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Variceal bleeding |
Ceftriaxone 2g as a single agent daily for 5 days or in immmediate (type 1 ) beta-lactam sensitivity Teicoplainin 6mg/kg mg twice daily for 3 doses then 6 mg/kg daily plus gentamicin IV (divided dose regimen see Appendix i ) |
Scottish Antimicrobial Prescribing Group. Good practice recommendations for surgical prophylaxis 2014.
SAPG recommendations for re-dosing antibiotics for surgical prophylaxis
https://www.sapg.scot/media/4105/gprs-for-re-dosing-antibiotics-for-surgical-prophylaxis.pdf
British Society of Gastroenterology.Antibiotic prophylaxis in gastrointestinal endoscopy. Gut 2009; 58: 869-880.
https://gut.bmj.com/content/58/6/869
Antibiotic prophylaxis in surgery, general principles NHS GGC