Gynaecology

SKIN

Skin grafting

Ö

Should be considered

Co-amoxiclav

Cefuroxime

Clindamycin

Consider addition of Teicoplanin if MRSA high risk/known colonisation

LIMB SURGERY

Lower limb amputation

A

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Clindamycin + Gentamicin

Vascular surgery (abdominal and lower limb arterial reconstruction)

A

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Teicoplanin + Gentamicin + Metronidazole

Varicose veins

Should be considered in patients undergoing groin surgery*

Co-amoxiclav

Cefuroxime + Metronidazole

Teicoplanin + Gentamicin + Metronidazole

Soft tissue surgery of the hand

Ö

Should be considered

Co-amoxiclav

Cefuroxime + Metronidazole

Clindamycin

*A recent study concluded that prophylactic antibiotics are beneficial in patients undergoing groin surgery for varicose veins especially if patients are obese or are current smokers. (8)

Consider addition of Teicoplanin if MRSA high risk/known colonisation

UROGENITAL SURGERY

Circumcision (routine elective)

Ö 

Not recommended

Hydrocoeles

C

Not recommended

Urethral catheterization

Should be considered **

Gentamicin stat dose as per renal function and wt

Gentamicin stat dose as per renal function and weight

Gentamicin stat dose as per renal function and weight

TURP

A

Recommended

Gentamicin + Amoxicillin

Gentamicin

Gentamicin

**The Irish “Guidelines for the Prevention of Catheter-associated Urinary Tract Infection” states that “There is no role for routine antimicrobial prophylaxis in patients with urinary catheters” and “Possible benefits of prophylaxis must be balanced against possible adverse effects.” However, “pending further evidence it seems reasonable to recommend a single dose of appropriate antimicrobial prophylaxis in a select group of high-risk patients” i.e. patients with bacteriuria at high risk of endocarditis or who are significantly immunocompromised (e.g. patients with neutropenia, haematological malignancy, post solid organ transplant). (21)

Consider addition of Teicoplanin if MRSA high risk/known colonisation

UPPER GASTROINTESTINAL

Oesophageal surgery

D

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

Stomach & duodenal surgery

A

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

Gastric bypass surgery

D

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

Small intestine surgery

D

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

Consider addition of Teicoplanin if MRSA high risk/known colonisation

HEPATOBILIARY

Bile duct surgery

A

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

Pancreatic surgery

B

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

Liver surgery

B

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

Gall bladder surgery (open)

A

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

Gall bladder surgery (laparoscopic)

A

Ö

Not recommended

Should be considered in high risk*** patients

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

***High risk: intraoperative cholangiogram, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, pregnancy, immunosuppression, insertion of prosthetic devices, extremes of age, diabetes, obesity, poor nutritional state, known co-existing bacterial colonization / infections at other sites.

Consider addition of Teicoplanin if MRSA high risk/known colonization

LOWER GASTROINTESTINAL

Appendicectomy

A

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole 

Gentamicin + Metronidazole

Colorectal surgery (incl. laparoscopic)

A

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

Haemorrhoidectomies

Should be considered

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

Consider addition of Teicoplanin if MRSA high risk/known colonisation.

ABDOMEN

Hernia repair – groin

(Inguinal/femoral  OR Laparoscopic with or without mesh)

A

Should be considered*

Co-amoxiclav

Cefuroxime + Metronidazole

Clindamycin

Hernia repair (incisional with or without mesh)

C

Should be considered*

Co-amoxiclav

Cefuroxime + Metronidazole

Clindamycin

Diagnostic endoscopic procedures

D

Not recommended

Therapeutic endoscopic procedures (ERCP and PEG)

D

Should be considered in high risk# patients

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

*Benefits of prophylaxis for clean surgical procedures is not clear. One analysis of inguinal hernia repair found prophylaxis to be beneficial in repairs with mesh⁹ while another analysis concluded that the data was not sufficiently strong to make firm recommendations for or against their use universally¹⁰

#High risk: intraoperative cholangiogram, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, pregnancy, immunosuppression, insertion of prosthetic devices, extremes of age, diabetes, obesity, poor nutritional state, known co-existing bacterial colonization / infections at other sites.

Consider addition of Teicoplanin if MRSA high risk/known colonisation

SPLEEN (NOTE: Please refer to Appendix 1 of long version of guidelines for post-splenectomy recommendations)

Splenectomy

Ö

Not recommended

Should be considered in high risk*patients

Co-amoxiclav

Cefuroxime + Metronidazole

Clindamycin + Gentamicin

• *High risk: intra-operative cholangiogram, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, pregnancy, immunosuppression, insertion of prosthetic devices.

• Consider addition of Teicoplanin if MRSA high risk/known colonization

GYNAECOLOGICAL SURGERY

Abdominal hysterectomy

A

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

Vaginal hysterectomy

A

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Gentamicin + Metronidazole

Caesarean section

A

Highly recommended

Co-amoxiclav

Cefuroxime 

Clindamycin

Assisted delivery

A

Not recommended

Perineal tear

D

Recommended for 3^rd/4^th degree perineal tears involving the anal sphincter/rectal mucosa

Co-amoxiclav

Cefuroxime + Metronidazole

Clindamycin + Gentamicin

Manual removal of the placenta

D

Should be considered

Recommended in proven chlamydia or gonorrhoea infection

Co-amoxiclav

Cefuroxime + Metronidazole

Clindamycin + Gentamicin

Evacuation of incomplete miscarriage

A

Not recommended

Intrauterine contraceptive device (IUCD) insertion

A

Not recommended – consider if known colonisation

Consider addition of Teicoplanin if MRSA high risk/known colonisation.

EAR, NOSE & THROAT SURGERY

Ear Surgery

A

Not recommended

Routine nose, sinus and endoscopic sinus surgery

A

Not recommended

Complex septoplasty

A

Recommended

Co-amoxiclav

Cefuroxime

Clindamycin

Tonsillectomy

Ö

Not recommended

Grommet insertion

B

A single dose of topical antibiotic isrecommended

Adenoidectomy

A

Not recommended

Thyroid lobectomy

Should be considered

Co-amoxiclav

Cefuroxime

Clindamycin

Consider addition of Teicoplanin if MRSA high risk/known colonization

HEAD AND NECK SURGERY

HEAD and neck surgery (clean, benign

D

Antibiotic prophylaxis is not recommended

Head and neck surgery (clean, malignant; neck dissection)

C

Antibiotic prophylaxis should be considered

Co-amoxiclav

Cefuroxime + Metronidazole

Clindamycin

Head and neck surgery (contaminated/clean-contaminated)

A

Antibiotic prophylaxis isrecommended*

Co-amoxiclav

Cefuroxime + Metronidazole

Clindamycin

  *Antibiotic prophylaxis should be considered in head and neck surgery that is clean, malignant or includes neck dissection.

The duration of prophylactic antibiotics should not be more than 24 hours

Consider addition of Teicoplanin if MRSA high risk/known colonization

NON-OPERATIVE INTERVENTIONS

Intravascular catheter insertion (Non-tunnelled & Tunnelled CVC)

D

A

Not recommended (14)

GENERAL (where procedure does not fit in categories above)

Clean-contaminated procedures

D

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Please discuss with Microbiology team.

Insertion of a prosthetic device or implant

D

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Please discuss with Microbiology team.

Dirty or infected procedures

Recommended

Co-amoxiclav

Cefuroxime + Metronidazole

Please discuss with Microbiology team.

Consider addition of Teicoplanin if MRSA high risk/known colonization