GUIDELINE FOR ANTIMICROBIAL PROPHYLAXIS FOR VASCULAR SURGERY

RECOMMENDED ROUTINE PROPHYLAXIS OPTIONS

General comments:

1. Where the recommended antibiotic choice in these guidelines does not seem appropriate for a particular patient, for example due to known infection/ colonisation with drug resistant bacteria, the surgeon is advised to discuss antibiotic prophylaxis choice with the Duty Microbiology team pre-operatively.
2. Patients already on antibiotic TREATMENT
   for infection related to the site of surgery do NOT require additional prophylaxis. If a regular prescribed dose of antibiotic treatment coincides with the timing of the operation ensure that it is administered intra-operatively and not omitted.
3. Antimicrobial dose/route
   Give within 30mins (or up to maximum 1 hour) prior to incision (additional doses may be required1)
4. Further intra-operative doses
   are required of some antibiotics for prolonged procedures or if the patient undergoes total body volume transfusion. For example:
   • Flucloxacillin  after 4 hours of surgery
   • Metronidazole  after 8 hours of surgery.
   • Do NOT give another dose Teicoplanin  or Vancomycin .
   • Gentamicin dose can be repeated after 8 hours if patient undergoes total volume transfusion, ensure total daily dose does not exceed 7mg/kg based on ideal body weight.

FOOTNOTES

1. Gentamicin dosing should be based on ideal body weight (IBW). Use actual body weight if less than ideal body weight.  https://www.mdcalc.com/calc/68/ideal-body-weight-adjusted-body-weight.
2. MRSA Risk factors
   Patients within these categories are considered at increased risk of MRSA infection:
   1. Known previous infection or colonisation with MRSA at any time.
   2. Resident of a long term care facility (nursing home, residential home or any other long term residential facility) without a negative MRSA screening result.
   3. Any history of inpatient hospital stay within the previous 6 months without a negative MRSA screening result
3. Teicoplanin and Gentamicin are incompatible; ALWAYS flush between administrations.
4. Trans-Metatarsal Amputations (TMAs) and more proximal amputations ONLY:
   Post-operative antibiotic prophylaxis may be extended from 24hrs to maximum 5 days post-operatively at the discretion of the responsible vascular consultant.
   
   Regimen: Doxycycline 100mg BD PO + Metronidazole 400mg TDS PO for maximum 4 days.
   
   This is based on a single centre, single blinded randomised trial of 5 days of post-op prophylactic antibiotics for TMA or more proximal amputations demonstrating a significant reduction in surgical site infection and impaired wound healing when compared with 24hrs prophylaxis. There was no impact on length of stay or mortality, and limited data on side effects.