Plastic surgery in adults - Guideline for Antimicrobial Prophylaxis

Publication: 23/12/2009  --
Last review: 24/11/2016  
Next review: 27/02/2020  
Clinical Guideline
UNDER REVIEW 
ID: 1774 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2016  

 

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

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

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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 electronic Medicines Compendium information on Flucloxacillin 500mg orally one hour pre-op single dose

Doxycycline electronic Medicines Compendium information on Doxycycline 200mg orally one hour pre-op single dose

Ulcerated lesion

Recommended

D

Reduction in wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin400mg IV single dose

Breast surgery
including augmentation

Recommended

A,B

Reduction in wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose

Breast reconstruction with or without implants

Recommended

A,B

Reduction in wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose

Breast expanders

Recommended

C

Reduction in wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose

Hand trauma open
(contaminated +/- >6 hours old prior to surgery)

Recommended

A,B

Reduction in wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV
Start in A&E & continued until wounds closed IV or oral

Teicoplanin electronic Medicines Compendium information on 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 electronic Medicines Compendium information on Flucloxacillin 1g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose

Axillary dissection

Recommended

C

Reduction in wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV single dose

Groin dissection

Recommended

C

Reduction in wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

Teicoplanin electronic Medicines Compendium information on 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 electronic Medicines Compendium information on Flucloxacillin 1g IV, Gentamicin 2mg/kg IBW + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV + Gentamicin IV 2mg/kg IBW + Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV single dose

Skin grafts

Not recommended

A

   

Nil

Nil

Burn excision

Recommended

D

Reduction in wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

Teicoplanin electronic Medicines Compendium information on 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 electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV+ Gentamicin 2 mg/kg IV IBW (if abdominal or perineal site + Metronidazole electronic Medicines Compendium information on 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 electronic Medicines Compendium information on 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 electronic Medicines Compendium information on Clindamycin 600mg IV qds (unless over 65 years old). contact microbiology for advice on patients at high risk for MRSA.

Initial debridement*

Highly recommended.

A2,3 C12

Wound infection

14

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV single dose.

Skeletal stabilisation & definitive wound closure*

Highly recommended

A2,3 C12

Wound infection

14

Teicoplanin electronic Medicines Compendium information on Teicoplanin 400mg IV & Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg IV single dose.

Head and neck - oncology

Recommended

B

Reduction in wound infection

6

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV
Single dose

Teicoplanin electronic Medicines Compendium information on 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 electronic Medicines Compendium information on Flucloxacillin after 3 hours, Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav after 4 hours, Metronidazole electronic Medicines Compendium information on Metronidazole after 8 hours. Do NOT give another dose Teicoplanin electronic Medicines Compendium information on Teicoplanin or Vancomycin electronic Medicines Compendium information on VancomycinGentamicin dose to be repeated if patient undergoes total volume transfusion.

Teicoplanin electronic Medicines Compendium information on Teicoplanin Gentamicin are incompatible, so ALWAYS flush between administrations. Teicoplanin electronic Medicines Compendium information on 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

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 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.

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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

  1. 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
  2. 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.
  3. 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.
  4. 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
  5. 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
  6.  Platt AJ, Page RE. J Hand Surg Br.1995oct;20(5):685-90 Post-operative infection following hand surgery. Guidelines for antibiotic use.
  7.  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.
  8. 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
  9. 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
  10.  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.
  11. 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.
  12. 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

Not supplied

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