Title of Guideline (must include the word Guideline (not protocol, SURGICAL ANTIBIOTIC PROPHYLAXIS

policy, procedure etc) GUIDELINES WITHIN ORTHOPAEDIC SURGERY

FOR ADULT PATIENTS
Author: Contact Name and Job Title Mr Tim Hills (Lead Pharmacist Antimicrobials and
infection control ext 65940)
Dr Steve Holden (Consultant Microbiologist)
Mr Hunter (Consultant Orthopaedic Surgeon)
Directorate & Speciality Trauma/elective orthopaedics - MSKN

Date of submission June 2013. Minor update Jan. 2015.

Explicit definition of patient group to which it applies (e.g. inclusion Adult patients undergoing orthopaedic surgical
and exclusion criteria, diagnosis) procedures outlined within the guideline.
Version 3.0

Changes from previous guideline Increase in teicoplanin dose to 600mg on induction

rd th
Minor update Jan 15 - the 3 or 4 doses of fluclox
removed for day-case patients with simple fractures of
radius or ankle
If this version supersedes another clinical guideline please be Replaced Feb. 2011 version of guidance
explicit about which guideline it replaces including version
number.
- Statement of the evidence base of the guideline has the National SIGN guidelines on Surgical Antibiotic
guideline been peer reviewed by colleagues? Prophylaxis Guideline 104 available from
www.sign.ac.uk
Evidence base: (1-6)
1 NICE Guidance, Royal College Guideline, SIGN
(please state which source). British Orthopaedic association. Open fractures of the
2a meta analysis of randomised controlled trials lower limb a short guide. Sept 2009
2b at least one randomised controlled trial
3a at least one well-designed controlled study without Recommended best practice based on clinical
randomisation experience of guideline developers.
3b at least one other type of well-designed quasi-
experimental study
4 well designed non-experimental descriptive studies
(ie comparative / correlation and case studies)
5 expert committee reports or opinions and / or clinical
experiences of respected authorities
6 recommended best practise based on the clinical
experience of the guideline developer
Consultation Process Consultant Orthopaedic Surgeons (both campuses)
Members of the Antibiotic Guidelines Committee.

Ratified by: Antibiotic Guidelines Committee

Date: June 2013.

Target audience Prescribers, nurses and pharmacists caring for
patients undergoing orthopaedic operations.
Review Date: (to be applied by the Integrated Governance Team) June 2015
A review date of 5 years will be applied by the Trust. Directorates
can choose to apply a shorter review date, however this must be
managed through Directorate Governance processes.

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The
interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If
in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review
date.

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 SURGICAL ANTIBIOTIC PROPHYLAXIS GUIDELINES WITHIN
ORTHOPAEDIC SURGERY FOR ADULT PATIENTS

Contents Page
1. Introduction 3

3
2. Risk of infection

4
3. Antibiotic Prophylaxis - Principles
3.1 Timing for Administration

3.2 Additional Intra-operative doses

3.3 Post-operative antibiotic prophylaxis
5
4. Orthopaedic Surgery Antibiotic Prophylaxis Regimens

4.1 Standard regimen

4.2 Alternative regimen for patients with mild allergy to penicillins (i.e. no
angioedema / anaphylaxis)

4.3 Alternative regimen for patients with severe allergy to penicillins or

allergy to cephalosporins

5. Orthopaedic Antibiotic Guideline for Open Fractures 6

5.1 Standard regimen

5.2 Alternative regimen for patients with mild allergy to penicillins (i.e. no
angioedema / anaphylaxis)

5.3 Alternative regimen for patients with severe allergy to penicillins or

allergy to cephalosporins

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1.Introduction:

Surgical site infection (SSI) is one of the most common healthcare associated
infections resulting in an average additional hospital stay of 6.5 days per case.
In operations with a higher risk of infection (e.g. clean-contaminated surgery), peri-
operative antibiotic prophylaxis has been shown to lower the incidence of infection.
High antibiotic levels at the site of incision for the duration of the operation, are
essential for effective prophylaxis.
Studies have shown that the administration of prophylactic antibiotics after wound
closure do not reduce infection rates further and can result in harm (see below).
Administration of antibiotics also increases the prevalence of antibiotic-resistant
bacteria and predisposes the patient to infection with organisms such as Clostridium
difficile, a cause of antibiotic-associated colitis. This risk increases with the duration
that antibiotics are given for and is higher in the elderly, immunosuppressed, patients
who have a prolonged hospital stay or who have received gastro-intestinal surgery.

2. Risk of infection:

The risk of SSI depends on a number of factors; these can be related to the patient or the
operation and some of them are modifiable (see Table 1):
Patient Operation

Age Duration of surgical scrub / Skin antisepsis

Nutritional status Preoperative shaving/ preoperative skin prep.
Diabetes Length of operation
Smoking Appropriate antimicrobial prophylaxis
Obesity Operating room ventilation
Coexistent infections at a remote body site Inadequate sterilization of instruments
Colonisation with microorganisms Foreign material in the surgical site
(e.g. Staph. aureus) Surgical drains
Immunosuppression (inc. taking glucocorticoid Surgical technique inc. haemostasis, poor
steroids or immunosuppressant drugs) closure, tissue trauma
Length of preoperative stay Post-operative hypothermia
Co-existent severe disease that either limits activity
or is incapacitating.
Malignancy
Table 1 Risk factors that increase the rate of SSI

The risk is also related to the amount of contamination with microorganisms the so-called
class of the operation (see Table 2):
Class Definition
Clean Operations in which no inflammation is encountered and the respiratory, alimentary or
genitourinary tracts are not entered. There is no break in aseptic operating theatre technique.

Clean-contaminated Operations in which the respiratory, alimentary or genitourinary tracts are entered but without
significant spillage.

Contaminated Operations where acute inflammation (without pus) is encountered, or where there is visible
contamination of the wound. Examples include gross spillage from a hollow viscus during the
operation or compound/open injuries operated on within four hours
Dirty Operations in the presence of pus, where there is a previously perforated hollow viscus, or
compound/open injuries more than four hours old.
Table 2 Definitions of operation class.

Peri-operative antibiotics are generally recommended for clean-contaminated or

contaminated operations. Dirty operations (e.g. open fracture>4 hours old) generally
require treatment with antibiotics (see section 5).

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3 Antibiotic Prophylaxis

3.1 Timing for Administration

Antibiotic prophylaxis administered too early or too late increases the risk of SSI.
Studies suggest that antibiotics are most effective when given 30 minutes before
skin is incised.
The pragmatic approach is to administer prophylaxis towards the end of
induction and ensure that surgery starts within 30 minutes of this time
wherever possible.
It is important that antibiotics are fully administered prior to tourniquet
inflation (if used).

3.2 Additional Intra-operative doses

Common Recommended re-dosing
High antibiotic levels, at the site of incision, Antibiotics interval/dose to give
for the duration of the operation, are Cefuroxime 4 hours, give 750mg IV
essential for effective prophylaxis. Flucloxacillin 3 hours, give 1g IV
Patients who experience major blood loss Gentamicin re-dosing not recommended
(greater than 1500ml) should have fluid Teicoplanin re-dosing not recommended
resuscitation, followed by re-dosing with the Table 3: Recommend re-dosing interval
recommend prophylaxis regimen for that
operation (see section 4 and 5).
For operations lasting > 4 hours re-dosing may be necessary (see table 3)

3.3 Post-operative antibiotic prophylaxis

Studies have shown that giving additional antibiotic prophylaxis after wound
closure does not reduce infection rates further. Post-operative antibiotics should
only be given to treat active/on-going infection (e.g. perforated appendectomy)
unless specifically recommended against the surgical procedure.

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4 Orthopaedic Antibiotic Prophylaxis Regimens

4.1 Standard regimens

Clean surgery without the insertion of prosthetic material

No antibiotic prophylaxis required

Insertion of joint prosthetics / internal fixation

Flucloxacillin 2g IV + Gentamicin 2mg/kg IV at induction
Plus
Flucloxacillin 1g IV at 3 hours post-induction if still intra-operative or 6 hours post-
induction if operation finished.
Plus
Flucloxacillin 1g IV, 12 hours post-induction*.
Plus
Flucloxacillin 1g IV 18 hours post-induction*.

*The doses of Flucloxacillin 1g IV at 12 and 18 hours post-induction are not required in

day-case patients with simple fractures of the radius or ankle.

4.2 Alternative regimen for patients with mild allergy to penicillins (i.e. no
angioedema / anaphylaxis)

Clean surgery without the insertion of prosthetic material

No antibiotic prophylaxis required

Insertion of joint prosthetics / internal fixation

Cefuroxime 1.5g IV + Gentamicin 2mg/kg IV at induction

Additional doses for prolonged procedures/ major blood loss (see 3.2):
Cefuroxime 750mg IV at 4 hours post-induction if still intra-operative or if there is
major blood loss (>1500mls).

No post-operative antibiotic prophylaxis is given.

4.3 Alternative regimen for patients with severe allergy to penicillins or allergy to
cephalosporins

Clean surgery without the insertion of prosthetic material

No antibiotic prophylaxis required

Insertion of joint prosthetics / internal fixation

Teicoplanin IV 600mg at induction.
No further post-operative doses required

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5 Orthopaedic Antibiotic Guideline for Open Fractures

5.1 Standard regimen

Start Co-amoxiclav IV 1.2g 8 hourly as soon as possible after the injury, and certainly
within three hours, continue until first debridement (excision).

At the time of first debridement give:

Co-amoxiclav IV 1.2g + Gentamicin (2mg/kg) at induction

Post first debridement:

Continue Co-amoxiclav IV 1.2g 8 hourly until soft tissue closure or for a maximum of 72
hours, whichever is sooner.

At time of Skeletal Stabilisation and definitive soft tissue closure:

Gentamicin IV 2 mg/kg + Teicoplanin IV 800mg at induction
These should not be continued post-operatively.

5.2 Alternative regimen for patients with mild allergy to penicillins (i.e. no
angioedema / anaphylaxis)
Start Cefuroxime IV 1.5g 8 hourly as soon as possible after the injury, and certainly within
three hours (Add Metronidazole IV 500mg 8 hourly if there is gross contamination of the
wound). Continue until first debridement (excision).

At the time of first debridement give:

Cefuroxime IV 1.5g + Gentamicin (2mg/kg) at induction. Add Metronidazole IV 500mg at
induction if there is gross contamination of the wound.

Post first debridement:

Continue Cefuroxime IV 1.5g 8 hourly (Add Metronidazole IV 500mg 8 hourly if there is
gross contamination of the wound) until soft tissue closure or for a maximum of 72 hours,
whichever is sooner.

At time of Skeletal Stabilisation and definitive soft tissue closure:

Gentamicin IV 2 mg/kg + Teicoplanin IV 800mg at induction
These should not be continued post-operatively.

5.3 Alternative regimen for patients with severe allergy to penicillins or allergy to
cephalosporins
Start Clindamycin IV 600mg 6 hourly as soon as possible after the injury, and certainly
within three hours, continue until first debridement (excision).

At the time of first debridement give:

Clindamycin IV 600mg + Gentamicin (2mg/kg) at induction

Post first debridement:

Continue Clindamycin IV 600mg 6 hourly until soft tissue closure or for a maximum of 72
hours, whichever is sooner.

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At time of Skeletal Stabilisation and definitive soft tissue closure:
Gentamicin IV 2 mg/kg + Teicoplanin IV 800mg at induction
These should not be continued post-operatively.

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