Plastic surgery in adults

Plastic surgery in adults - Guideline for Antimicrobial Prophylaxis

Publication: 23/12/2009

Next review: 27/06/2023

Clinical Guideline

CURRENT

ID: 1774

Approved By: Improving Antimicrobial Prescribing Group

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 during plastic surgery in adults

Summary table of routine recommendations
Background information
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 ensure they have been given within one hour of incision.

Procedure	Recommendation for antimicrobial prophylaxis	Evidence level	Aim of prophylaxis		NNT	Antimicrobial dose/route/timing
						Routine*		MRSA risk* or true penicillin allergy
Ulcerated lesion (minor ops)	Recommended	D	Reduction in wound infection			Flucloxacillin 500mg orally one hour pre-op single dose		Doxycycline 200mg orally one hour pre-op single dose
Ulcerated lesion	Recommended	D	Reduction in wound infection			Co-amoxiclav 1.2g IV single dose		Teicoplanin 400mg IV single dose
Breast surgery including augmentation	Recommended	A,B	Reduction in wound infection			Co-amoxiclav 1.2g IV single dose		Teicoplanin 400mg IV single dose
Breast reconstruction with or without implants	Recommended	A,B	Reduction in wound infection			Co-amoxiclav 1.2g IV single dose		Teicoplanin 400mg IV single dose
Breast expanders	Recommended	C	Reduction in wound infection			Co-amoxiclav 1.2g IV single dose		Teicoplanin 400mg IV single dose
Hand trauma open (contaminated +/- >6 hours old prior to surgery)	Recommended	A,B	Reduction in wound infection			Co-amoxiclav 1.2g IV Start in A&E & continued until wounds closed IV or oral		Teicoplanin 400mg IV + Gentamicin 2mg/kg IBW Start in A&E & continued until wounds closed IV or oral
Upper limb - elective/closed trauma >2 hours operation length +/- implants (metal/ silicone)	Highly recommended	A,B	Reduction in deep wound infection		38	Flucloxacillin 1g IV single dose		Teicoplanin 400mg IV single dose
Axillary dissection	Recommended	C	Reduction in wound infection			Co-amoxiclav 1.2g IV single dose		Teicoplanin 400mg IV single dose
Groin dissection	Recommended	C	Reduction in wound infection			Co-amoxiclav 1.2g IV single dose		Teicoplanin 400mg IV + Gentamicin 2mg/kg IBW single dose
Pressure sores – debridement under anaesthetic	Recommended. If septic, not for prophylaxis but treat infection	D.	Reduction in wound infection			Flucloxacillin 1g IV, Gentamicin 2mg/kg IBW + Metronidazole 500mg IV single dose		Teicoplanin 400mg IV + Gentamicin IV 2mg/kg IBW + Metronidazole 500mg IV single dose
Skin grafts	Not recommended	A				Nil		Nil
Burn excision	Recommended	D	Reduction in wound infection			Co-amoxiclav 1.2g IV single dose		Teicoplanin 400mg IV single dose
Sentinel node biopsy	Not recommended	A,B				Nil		Nil
Soft tissue tumour Excision +\- reconstruction	Recommended	D	Reduction in wound infection			Co-amoxiclav 1.2g IV single dose		Teicoplanin 400mg IV+ Gentamicin 2 mg/kg IV IBW (if abdominal or perineal site + Metronidazole 500mg IV) all single dose
Open / compound fracture (including unsalvageable limb amputation) Antibiotics should start ASAP after injury & ideally within 3 hours with Co-amoxiclav IV 1.2g tds⁹ (or oral where appropriate). Continue for 72 hours after initial debridement or until definitive skin closure. For penicillin allergy, Clindamycin 600mg IV qds (unless over 65 years old). contact microbiology for advice on patients at high risk for MRSA.
Initial debridement*	Highly recommended.	A^2,3 C¹²	Wound infection	14			Teicoplanin 400mg IV & Ciprofloxacin 400mg IV single dose.
Skeletal stabilisation & definitive wound closure*	Highly recommended	A^2,3 C¹²	Wound infection	14			Teicoplanin 400mg IV & Ciprofloxacin 400mg IV single dose.
Head and neck - oncology	Recommended	B	Reduction in wound infection	6			Co-amoxiclav 1.2g IV Single dose		Teicoplanin 400mg IV + Gentamicin IV 2mg/kg IBW single dose
Head and neck- benign	Not recommended	B					Nil		Nil

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

* Give additional peri-operative doses if procedure >4 hours long or if patient undergoes total body volume transfusion: Flucloxacillin after 3 hours, Co-amoxiclav after 4 hours, Metronidazole after 8 hours. Do NOT give another dose Teicoplanin or Vancomycin . Gentamicin dose to be repeated if patient undergoes total volume transfusion.

Teicoplanin & Gentamicin are incompatible, so ALWAYS flush between administrations. Teicoplanin takes up to 15 minutes to reconstitute so allow time for preparation.

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	66 to 71	140
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	60 to 65	130	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	49 to 54	100
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	49 to 54	100	5’ (1.52m) or under	45	43 to 48	90

2. Background information

The aim of antimicrobial prophylaxis when used in plastic surgery is a reduction in surgical site infection (SSI) - a potentially debilitating and occasionally life-threatening complication.

The continued presence of meticillin-resistant Staphylococcus aureus (MRSA) in the Trust and the ongoing problem of Clostridium difficile infection have prompted a review of surgical prophylaxis. It is appropriate to use a single pre-operative dose of prophylaxis in most situations to reduce the risks related to antimicrobial use while gaining maximum benefit from prophylaxis (NICE, SIGN).

These guidelines should be applicable to the majority of patients. 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.

3. Special antimicrobial prophylaxis recommendations

Infection at the site of surgery can cause significant morbidity in reconstructive surgery patients.
Most commonly a SSI will cause a wound discharge with delayed wound healing and poor scarring. This is itself can have a detrimental effect on the psychological and physical outcome for a patient having reconstructive surgery to improve form and /or function.

However, with more severe wound infections patients have lengthier hospitals stays and may require further surgery to deal with the infection and it consequences on their wound and general well being.

The organism responsible for SSI are generally endogenous to the patient (i.e on their, skin, intestines, nasal) sometimes however there are exogenous (from surrounding people / objects).

The most common organism responsible for SSI in reconstructive surgery is Staphylococcus aureus. The number of micro organisms needed to cause an SSI is fewer in the presence of an implant (metal/ silicone) which are often used in reconstructive and hand surgery.

The patient population in plastic and reconstructive surgery is often elderly which immediately places them at higher risk of SSI. Associated with this they often have co morbidities such as diabetes mellitus, obesity, immunosuppression, malnutrition and peripheral vascular disease.

The aim of prophylactic antibiotics is to reduce the number of microorganisms which can contaminate the surgical wound at the time of surgery,. This along with careful tissue handling will decrease the risk of post operative infection.

In reconstructive surgery the site of surgery is often variable and in free tissue transfer there may be two or more distant surgical sites thus the antibiotics chosen for prophylaxis must be considered carefully.

For open fractures, the guidance from the British orthopaedic Association and British Association of Plastic Reconstructive and Aesthetic Surgeons Standard for Trauma (2009)¹² will be followed but peri-operative gentamicin will be replaced by ciprofloxacin due to the high incidence of post-operative renal impairment in severe trauma patients.

These guidelines are to act as a reference for the more frequent procedures that are undertaken in our speciality. If there are patients who do not “fit any of the boxes” then more specific advice can be obtained from a consultant microbiologist.

Provenance

Record:	1774
Objective:
Clinical condition:	Plastic surgery in adults
Target patient group:	All adults
Target professional group(s):	Pharmacists Secondary Care Doctors
Adapted from:

Evidence base

References

Gemmell CG 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
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.
NICE Clinical Guideline 74: Surgical site infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor.: Royal College of Obstetrics and Gynaecology, Press; 2008.
Simo R, French G. Current opin Otolaryngol Head Neck Surg 2006 April;14(2):55-61 The use of prophylactic antibiotics in Head and Neck oncology surgery
Hoffman RD, Adams BD. Hand Clin 1998 Nov;14(4):657-66. The role of antibiotics in the management of elective and post traumatic hand surgery
Platt AJ, Page RE. J Hand Surg Br.1995oct;20(5):685-90 Post-operative infection following hand surgery. Guidelines for antibiotic use.
Landes G, Harris PGet al. J Plast Reconstr Aesthet Surg2008 Nov;61(11):1347-56. Prevention of surgical site infection and appropriateness of antibiotic prescribing habits in plastic surgery.
Throckmorton AD, Boughey JC et al. Ann Surg oncology.2009 Sept;16(9):2464-9. Postoperative prophylactic antibiotics and surgical site infection rates in breast surgery patients
Ahmadi AH, Cohen BE, Shayani P. Plast Reconstr Surg. 2005 Jul;116(1):126-31. A prospective study of antibiotic efficacy in preventing infection in reduction mammaplasty
Whittaker JP, Nancarrow JD, Sterne GD J Hand Surg.BR 2005 May:30(2):162-7 The role of antibiotic prophylaxis in clean incised hand injuries : a prospective randomized placebo controlled double blind trial.
Ichikawa S, Ishihara M, Okazaki T et al. J Pediatr Surg. 2007 Jun; 42(6):1002-7; Prospective study of antibiotic protocols for managing surgical site infections in children.
British orthopaedic Association and British Association of Plastic Reconstructive and Aesthetic Surgeons Standard for Trauma (2009)

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)

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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