Vascular Surgery - Guideline for Antimicrobial Prophylaxis

Publication: 14/08/2009  --
Last review: 19/06/2017  
Next review: 19/06/2020  
Clinical Guideline
CURRENT 
ID: 1677 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for Antimicrobial Prophylaxis for Vascular Surgery

  1. Summary table of routine recommendations
  2. Background information
  3. Special antimicrobial prophylaxis recommendations

1. Summary table of routine recommendations

It is the responsibility of the surgical team to prescribe the prophylactic antibiotics, and the anaesthetist to give them within the hour before incision.
Further intraoperative doses are required of some antibiotics for prolonged procedures or if the patient undergoes total body volume transfusion. Give further doses as follows: Flucloxacillin electronic Medicines Compendium information on Flucloxacillin after 3 hours of surgery, Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav after 4 hours of surgery, Metronidazole electronic Medicines Compendium information on Metronidazole after 8 hours of surgery. Do NOT give another dose Teicoplanin electronic Medicines Compendium information on Teicoplanin or  Vancomycin electronic Medicines Compendium information on Vancomycin. Gentamicin dose to be repeated if patient undergoes total volume transfusion.

Procedure

Recommendation for antibiotic prophylaxis

Evidence level

Prophylaxis aims to reduce

NNT

Antimicrobial dose/route ≤ 1 hour before procedure

Routine

MRSA risk factors

Penicillin allergic

Open AAA / aortic reconstruction (elective or ruptured - all approaches)

Recommended

A 3,4

Wound infection

18
4

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav1.2g IV.
Post-op doses at 8 & 16 hours.

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV & Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav1.2g IV.
Post-op: Teicoplanin electronic Medicines Compendium information on Teicoplanin at 12 hrs and Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav at 8 & 16 hours.

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV,
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin400mg IV & Metronidazole electronic Medicines Compendium information on Metronidazole500mg IV.
Post-op: Teicoplanin electronic Medicines Compendium information on Teicoplanin& Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin at 12 hrs and Metronidazole electronic Medicines Compendium information on Metronidazole at 8 & 16 hours. 

Carotid surgery - all

Recommended

C 3,4

Wound infection

 

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin1g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Other arterial surgery (without presence of sepsis)

Recommended

A 3,4

Wound infection

18
4

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin1g IV & Gentamicin 2mg/kg IV IBW single dose.
Post-op: Flucloxacillin electronic Medicines Compendium information on Flucloxacillin at 6, 12 & 18 hours

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV & Gentamicin 2mg/kg IV IBW.
Post-op: Teicoplanin electronic Medicines Compendium information on Teicoplanin at 12 hours.

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV & Gentamicin 2mg/kg IV IBW single dose.
Post-op: Teicoplanin electronic Medicines Compendium information on Teicoplanin at 12 hours

Amputations and arterial reconstruction in patients with pre-existing open wound, ulcer or ischaemic foot and no specific sensitivities available).

Recommended

A3,4

Wound infection

5

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav1.2g IV.
Post-op: repeat at 8 and 16 hours
OR
continuation of current treatment 

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV & Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav1.2g IV.
Post-op: Teicoplanin electronic Medicines Compendium information on Teicoplanin at 12 hours & Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav at 8 and 16 hours
OR
continuation of current treatment 

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV, Gentamicin 2mg/kg IV (IBW) & Metronidazole electronic Medicines Compendium information on Metronidazole500mg IV.
Post-op: Teicoplanin electronic Medicines Compendium information on Teicoplanin at 12 hours & Metronidazole electronic Medicines Compendium information on Metronidazole at 8 & 16 hours
OR
continuation of current treatment 

Varicose vein surgery (no infection or ulceration)

Considered

D

Wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav1.2g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Varicose vein surgery (ulcerated)

Recommended

D

Wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav1.2g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Varicose veins sclerotherapy

Not recommended

D

 

 

 

 

 

Haemodialysis line insertion

Not recommended

A3,4

 

 

 

 

 

A-V fistula formation (Basilic Vein Transposition and Synthetic Grafts only) 

Recommended

D

Wound infection

 

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

A-V fistula formation (Radiocephalic or Brachiocephalic fistulae formation)

Not recommended

D

 

 

 

 

 

Peritoneal dialysis catheter insertion

Recommended

A6

Reduce peritonitis

 

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Angiogram or angioplasty

Not recommended

A 3,4

 

 

 

 

 

IBW = Ideal body weight (kg).  IBW = Height in cm - 100, or see table below.

Teicoplanin electronic Medicines Compendium information on Teicoplanin & Gentamicin are incompatible, so ALWAYS flush between administration. Teicoplanin electronic Medicines Compendium information on Teicoplanin takes 15 minutes to reconstitute so allow time for preparation.

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

Gentamicin dosing in adult male >16years

 

Gentamicin dosing in adult female > 16 years

Use height to select
Gentamicin dose

IBW
from height
(kg)

Use ABW if
less than IBW (kg)

Gentamicin
dose (mg)

 

Use height to select
Gentamicin dose

IBW
from height
(kg)

Use ABW if
less than IBW (kg)

Gentamicin dose (mg)

6’ 3”  (1.9m) +

84.5

78 to 82

 160

6’ 3”  (1.9m) +

79.5

78 to 82

160

6’ 2”  (1.88m)

82.2

6’ 2”  (1.88m)

77.2

72 to 77

 150

6’ 1”  (1.85m)

79.9

6’ 1”  (1.85m)

74.9

6’      (1.82m)

77.6

72 to 77

 150

6’  (1.82m)

72.6

5’ 11” (1.8m)

75.3

5’ 11”  (1.8m)

70.3

66 to 71

140

5’ 10” (1.78m)

73

5’ 10”  (1.78m)

68

5’ 9”  (1.75m)

70.7

66 to 71

 140

5’ 9”  (1.75m)

65.7

60 to 65

 130

5’ 8”  (1.72m)

68.4

5’ 8”  (1.72m)

63.4

5’ 7”  (1.7m)

66.1

5’ 7”  (1.7m)

61.1

5’ 6”  (1.67m)

63.8

60 to 65

130

5’ 6”  (1.67m)

58.8

55 to 59

 120

5’ 5”  (1.65m)

61.5

5’ 5”  (1.65m)

56.5

5’ 4”  (1.62m)

59.2

55 to 59

 120

5’ 4”  (1.62m)

54.2

5’ 3”  (1.6m)

56.9

5’ 3”  (1.6m)

51.9

49 to 54

100

5’ 2”  (1.57m)

54.6

5’ 2”  (1.57m)

49.6

5’ 1”  (1.55m)

52.3

49 to 54

100

5’ 1”  (1.55m)

47.3

43 to 48

90

5’  (1.52m) or under

50

5’  (1.52m) or under

45

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2. Background information

The aim of antimicrobial prophylaxis in vascular surgery is a reduction in surgical site infection. Current practise has been reviewed in light of publication of new guidance from the
National Institute for Health and Clinical Excellence (NICE)4 and the Scottish Intercollegiate Guideline Network 3 and in the current era of increasing Clostridium difficile infection, meticillin-resistant Staphylococcus aureus (MRSA) infection and increasing concerns about community-acquired MRSA. Reducing the risk of acquisition of these pathogens by avoiding unnecessary antimicrobial exposure is a pressing concern.

For many vascular procedures there is no evidence that antimicrobial prophylaxis is of benefit to patients and its use is therefore not recommended. These guidelines should be applicable to the majority of patients but where the recommendations in these guidelines do not seem appropriate for a particular patient, the surgeon is advised to discuss the case with a microbiologist.

There is increasing evidence linking the use of cefalosporins even as a 24 hour prophylaxis to increased C.difficile infection5

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3. Special antimicrobial prophylaxis recommendations

Vascular surgery4
One systematic review was identified.
One Cochrane systematic review (35 RCTs) was identified that sought to determine the effectiveness of perioperative strategies to prevent infection in patients undergoing peripheral arterial reconstruction. [Evidence level (EL) = A] Ten studies compared antibiotic prophylaxis with placebo. A meta-analysis of these ten studies demonstrated that prophylactic systemic antibiotics reduced the risk of wound infection (RR 0.25, 95% CI 0.17 to 0.38) compared with placebo or no prophylaxis.

There is evidence from one trial that the use of antibiotics results in fewer wound infections than placebo in patients undergoing leg amputation for arteriosclerosis. [EL = A] There is evidence that the use of systemic antibiotics results in fewer wound infections in patients undergoing peripheral arterial reconstruction. [EL = A3

Historically, the most common pathogen found in early onset infections were coagulase-positive staphylococci, such as S. aureus, and in late-onset infections coagulase negative staphylococci such as S. epidermidis were most common1. More recently, mixed pathogens have predominated as causative organisms in these infections. S. aureus and S. epidermidis, together with E coli, currently make up 75% of early and late graft infections. Proteus spp. and P. aeruginosa have also been found. MRSA was reported to be the most common organism isolated in vascular graft infections; MRSA graft infections is associated with a significant increase in the risk of  amputation and prolonged duration of hospitalisation1.

For the insertion peritoneal dialysis line, there is evidence to show that a single dose of  Vancomycin electronic Medicines Compendium information on Vancomycin  is superior than a single dose of cefazolin to prevent early peritonitis.6 The ISPD Guidelines of 2005 recommend Vancomycin electronic Medicines Compendium information on Vancomycin as prophylaxis. For the UK population, all patients are screened for MRSA, and the rate is less than 10% in the LTH renal unit. Where patients have MRSA risk factors, they would receive Teicoplanin electronic Medicines Compendium information on Teicoplanin instead of Vancomycin electronic Medicines Compendium information on Vancomycin to decrease the time required.7

Table 5
Infect Control Hosp Epidemiol 2008; 29:996-1011 Antimicrobial-Resistant Pathogens Associated With Healthcare-Associated Infections: Annual Summary of Data Reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007

Evidence level (A,B,C, D)
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus (no national guidelines exist, guidelines from different learned bodies   contradict each other, or no evidence exists)

Provenance

Record: 1677
Objective:
Clinical condition:

Peripheral arterial disease

Target patient group: Vascular
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Evidence base

  1. International Journal of Infectious Diseases 2007 11(S1) S17–S22  Surgical site and vascular infections: treatment and prophylaxis Shervanthi Homer-Vanniasinkam
  2. Gemmell CG, Edwards DI, Fraise AP, Gould FK, Ridgway GL, Warren RE, et al. Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the UK. 2006. p. 589-608
  3. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Ed Leaper D, Collier M, Evans D, Farrington M, Gibbs E, Gould K, et al. 2008
  4. Surgical Site Infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor: Royal College of Obstetrics and Gynaecology, Press; 2008. (NICE)
  5. Fenton P et al. Journal Hospital Infection Volume 68, Issue 4, April 2008, Pages 376-37 Clostridium infection following hip surgery.
  6. Gadallah MF et al. Am J Kidney Dis 2000; 36(5):1014-19  Preoperative antibiotic prophylaxis in preventing postoperative peritonitis in newly placed peritoneal dialysis catheter.
  7. Piraino B et al Peritoneal Dialysis International 2005 25; 107-31ISPD Guidelines / Recommendations

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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