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Surgical prophylaxis

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💊 Surgical Antibiotic Prophylaxis

Surgical site infection (SSI) risk is reduced most effectively when antibiotics are administered before contamination occurs — typically 30–60 minutes before the first incision. The purpose of prophylaxis is to reduce microbial load at the operative site, not to sterilise it. Prophylaxis should always be procedure-specific and time-limited.

💡 Key Principles:

Give IV antibiotic 30–60 minutes before incision (usually at anaesthetic induction).
Single-dose prophylaxis is sufficient for most operations.
Re-dose if surgery >4 h or blood loss >1.5 L.
Avoid routine postoperative doses to limit antimicrobial resistance.
Adjust for renal function and allergy; involve Microbiology for complex or prolonged cases.

Procedure / Surgical Area	Likely Pathogens	Recommended Prophylaxis	Penicillin Allergy Alternative
Oesophageal / Gastroduodenal	Upper GI flora, Gram-negative enterics	Co-amoxiclav 1.2 g IV single dose at induction	Gentamicin 120 mg IV single dose
Hepatobiliary (incl. open cholecystectomy)	Gram-negative bacilli, Enterococci, Anaerobes	Co-amoxiclav 1.2 g IV at induction	Gentamicin 120 mg IV + Metronidazole 500 mg IV at induction
Colorectal Surgery	Enteric Gram-negative bacilli, Enterococci, Anaerobes	Co-amoxiclav 1.2 g IV at induction (repeat >5 h)	Gentamicin 120 mg IV + Metronidazole 500 mg IV at induction
Genitourinary Procedures – Rigid cystoscopy – TRUS biopsy – TURP	Gram-negative enterics, Enterococci	Rigid cystoscopy → Gentamicin 120 mg IV single dose TRUS biopsy → Ciprofloxacin 1 g PO + Gentamicin 120 mg IV + Metronidazole 1 g PR TURP → Gentamicin 120 mg IV at induction	As above, adjust according to culture results
Obstetric / Gynaecological – Caesarean section – Termination of pregnancy	Enteric Gram-negatives, Enterococci, Anaerobes	Caesarean → Co-amoxiclav 1.2 g IV post-clamping Termination → Metronidazole 1 g PR + Doxycycline 100 mg PO BD × 7 days	Caesarean → Gentamicin 120 mg IV + Metronidazole 500 mg IV Termination → as above
Orthopaedic – Joint replacement / open fracture	S. aureus, S. epidermidis, Clostridium spp.	Joint replacement → Flucloxacillin 1 g IV + Gentamicin 120 mg IV at induction Compound fracture → Co-amoxiclav 1.2 g IV q8h as needed	Teicoplanin 400 mg IV + Gentamicin 120 mg IV (at induction) For compound fracture → Teicoplanin 400 mg IV + Metronidazole 500 mg IV + Gentamicin 120 mg IV
Vascular Surgery	Staphylococci, Streptococci	Co-amoxiclav 1.2 g IV at induction + repeat 8 h later	Teicoplanin 400 mg IV + Gentamicin 120 mg IV (repeat 12 h)
Thoracic Surgery	Staphylococci, Streptococci, Gram-negative enterics	Co-amoxiclav 1.2 g IV at induction	Teicoplanin 400 mg IV + Gentamicin 120 mg IV at induction
Endocarditis Prophylaxis (for high-risk cardiac patients)	Streptococci, Enterococci	Consult Microbiology — tailor to procedure and risk	Consult Microbiology — tailor to procedure and risk
Pacemaker Implantation	Skin flora (Staphylococci)	Co-amoxiclav 1.2 g IV before procedure	Teicoplanin 400 mg IV before procedure (esp. if MRSA risk)
Splenectomy / Hyposplenia	S. pneumoniae, H. influenzae, N. meningitidis	Phenoxymethylpenicillin 500 mg PO BD lifelong + vaccinations (see below)	Erythromycin 500 mg PO OD lifelong + vaccinations

🧠 Educational Notes

MRSA Screening: Screen high-risk patients pre-operatively; add Teicoplanin + Gentamicin if colonised.
Renal Impairment: Seek dosing guidance for Gentamicin, Teicoplanin, or Vancomycin.
Vaccinations after Splenectomy: Pneumococcal, Meningococcal, and H. influenzae b vaccines ≥2 weeks pre-surgery if possible; annual influenza vaccine advised.
Stewardship: Never extend prophylaxis into the postoperative period unless there is established infection.

In summary, surgical prophylaxis aims to prevent contamination rather than treat infection. A single, correctly timed dose at induction offers the best protection with minimal resistance risk. Always verify dosing against BNF and NICE local policy.

📚 References

NICE NG125: Surgical site infections: prevention and treatment
British National Formulary (BNF)
Public Health England (PHE) / UKHSA: Antimicrobial Prescribing Guidance (2024)

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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