Cardiac Surgery in Children - Guideline for antimicrobial prophylaxis

Publication: 27/05/2010  
Last review: 17/11/2016  
Next review: 17/11/2019  
Clinical Guideline
CURRENT 
ID: 2067 
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.

Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required.
Be aware: Chlorhexidine is considered an environmental allergen.
Refer to the asepsis guidance.

Guideline for antimicrobial prophylaxis for Paediatric Cardiac Surgery

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

1. Summary table of routine recommendations

RACHS - (Risk-Adjusted Congenital Heart Surgery)

Procedure

Recommendation

Evidence level

Aim of prophylaxis

Antimicrobial dose/route
Give antimicrobials within 1 hour of skin incision

No MRSA risk
No penicillin allergy
RACHS 1-4 

MRSA risk (previous MRSA infection or known colonisation) or
True penicillin allergy or
RACHS 5-6 

Paediatric Cardiac surgery, sternum closed

Yes

C

To reduce sternal wound infections

Continue antibiotics for 24hours

Continue antibiotics for 24hours

Child 1month to 16 years old

Child 1month to 16 years old

On induction: Flucloxacillin electronic Medicines Compendium information on Teicoplanin  25mg/Kg/dose (max 1g)plus Gentamicin 5mg/Kg (max 160mg) (as slow IV injection over 10mins)

Followed by: Flucloxacillin electronic Medicines Compendium information on Teicoplanin 25mg/Kg (max 1gram) 6hourly for 3 postoperative doses

On induction: Teicoplanin  electronic Medicines Compendium information on Teicoplanin 10mg/Kg (max 400mg ) plus Gentamicin 5mg/Kg (max 160mg) (as slow IV injection over 10mins)

Followed by: Teicoplanin  electronic Medicines Compendium information on Teicoplanin 10mg/Kg (max 400mg) dose to be repeated 12hours after initial dose

Neonate

Neonates

On induction: Flucloxacillin electronic Medicines Compendium information on Teicoplanin  25mg/Kg/dose plus Gentamicin5mg/Kg as slow IV injection over 10mins

Followed by: Flucloxacillin electronic Medicines Compendium information on Teicoplanin  for 24 hours

On induction: Teicoplanin electronic Medicines Compendium information on Teicoplanin 16mg/Kg (as an intravenous infusion over 30 mins) plus Gentamicin 5mg/Kg as slow IV injection over 10mins

Followed by: No further doses of Teicoplanin electronic Medicines Compendium information on Teicoplanin  required in neonates

Procedure

Recommendation

Evidence level

Aim of prophylaxis

Antimicrobial dose/route
Give antimicrobials within 1 hour of skin incision

No MRSA risk
No penicillin allergy
RACHS 1-4 (Appendix 1)

MRSA risk (previous MRSA infection or known colonisation) or
True penicillin allergy or
RACHS 5-6 (Appendix 1)

Paediatric cardiac surgery, sternum open

Yes

C

To reduce sternal wound infections

Continue antibiotics for 48hours in patients with open sternum

Continue Chlorhexidine (over 1 year old) or Octenisan (less than 1 year old) washes until sternum is closed

Continue antibiotics for 48hours in patients with open sternum

Continue Chlorhexidine (over 1 year old) or Octenisan (less than 1 year old) washes until sternum is closed

Child 1month to 16 years old

Child 1month to 16 years old

On induction: Flucloxacillin electronic Medicines Compendium information on Teicoplanin 25mg/Kg/dose (max 1g) plus Gentamicin 5mg/Kg (max 160mg) as (slow IV injection over 10min)

Followed by: Flucloxacillin electronic Medicines Compendium information on Teicoplanin 25mg/Kg (max 1gram) 6hourly for 48 hours and one dose of Gentamicin 5mg/Kg** (max 160mg) 24 hours after the first dose

On induction: Teicoplanin  electronic Medicines Compendium information on Teicoplanin 10mg/Kg (max 400mg ) plus Gentamicin 5mg/Kg (max 160mg) (as slow IV injection over 10mins)

Followed by: Teicoplanin  electronic Medicines Compendium information on Teicoplanin 10mg/Kg (max 400mg) 12 hourly for 2 doses and then 6mg/Kg (max 400mg) once daily and one dose of Gentamicin 5mg/Kg** (max 160mg) 24 hours after the first dose

Neonates

Neonates

On induction: Flucloxacillin  electronic Medicines Compendium information on Teicoplanin25mg/Kg/dose plus Gentamicin5mg/Kg (as slow IV injection over 10mins)

Followed by: Flucloxacillin electronic Medicines Compendium information on Teicoplanin for 48 hours and one dose of Gentamicin * 5mg/Kg (as slow IV injection over 10mins) 24 hours after the first dose

On induction: Teicoplanin  electronic Medicines Compendium information on Teicoplanin 16mg/Kg(as an intravenous infusion over 30 mins) plus Gentamicin5mg/Kg (as slow IV injection over 10mins)

Followed by: Teicoplanin electronic Medicines Compendium information on Teicoplanin  8mg/Kg once daily(give Teicoplanin electronic Medicines Compendium information on Teicoplanin   as an intravenous infusion over 30 mins) and one dose of Gentamicin * (as slow IV injection over 10mins) 24 hours after the first dose 

*Redose Gentamicin only if no evidence of AKI (Acute Kidney Injury BAPN guideline)

Procedure

Recommendation

Evidence level

Aim of prophylaxis

Antimicrobial dose/route
Give antimicrobials within 1 hour of skin incision

All patients

Sternal Closure,
Re-exploration of open sternum,
Re-sternotomy

Yes

C

To reduce sternal wound infections

Child 1month to 16 years old

Teicoplanin electronic Medicines Compendium information on Teicoplanin  ** 10mg/Kg (max 400mg ) plus Gentamicin # 5mg/Kg (max 160mg) as slow IV injection over 10mins

**Re-dose Teicoplanin electronic Medicines Compendium information on Teicoplanin   if the previous dose of Teicoplanin electronic Medicines Compendium information on Teicoplanin   was more than 12 hours prior to onset of procedure

#Re-dose Gentamicin if the previous dose of Gentamicin was more than 24 hours prior to onset of procedure and no evidence of Acute Kidney Injury (Acute Kidney Injury BAPN guideline)

Neonates

Teicoplanin electronic Medicines Compendium information on Teicoplanin   ** 16mg/Kg (as an intravenous infusion over 30mins) plus Gentamicin## 5mg/Kg as slow IV injection over 10mins

**Re-dose Teicoplanin electronic Medicines Compendium information on Teicoplanin  if the previous dose of Teicoplanin electronic Medicines Compendium information on Teicoplanin  was more than 24 hours prior to onset of procedure

##Re-dose Gentamicin if the previous dose of Gentamicin was more than 24 hours (or 36 hours in neonates less than 7 days age) prior to onset of procedure and no evidence of Acute Kidney Injury (Acute Kidney Injury BAPN guideline)

 

Procedure

Recommendation

Evidence
level

Aim of prophylaxis

Antimicrobial dose/route
Give antimicrobials within 1 hour of starting procedures

All children

Interventional cardiac catheter device placement

Yes

C

To reduce any infections

Child 1month to 16 years old

Teicoplanin electronic Medicines Compendium information on Teicoplanin   10mg/Kg/dose (max 400mg) single dose

Neonates

Teicoplanin electronic Medicines Compendium information on Teicoplanin   16mg/Kg/dose as an intravenous infusion over 30 minutes

 

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2. Background information

Antimicrobial prophylaxis in cardiothoracic surgery has been a standard practice for some years. Post-operative mediastinitis can be a devastating infection with a high mortality leading to prolonged hospitalisation, additional surgery and a significant burden on clinical resources.


Children undergoing cardiac surgery may be at even higher risk of surgical site infections (SSIs) than their adult counterparts because of an immature immune system, longer duration of operation, practice of delayed sternal closure following complex reconstructions and quite often, prolonged central venous access for parenteral nutrition. Currently, there are no randomized trials in children undergoing cardiac surgery. Conclusions, therefore, have been extrapolated from trials conducted in adults.


Antibiotic prophylaxis is only one of the preventative measures to reduce the incidence of SSI, aseptic surgical technique, pre-operative screening and decolonisation, temperature and blood glucose control and post-operative wound management should be vital part of the local care bundles.


A review of antimicrobial prophylaxis in Leeds has been prompted by an increasing number of complex surgeries and growing burden of Methicillin Sensitive Staphylococcus aureus (MSSA) wound infections/bacteraemia and MSSA outbreak in 2012.

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3. Special antimicrobial prophylaxis recommendations

CHOICE AND DURATION OF ANTIBIOTIC THERAPY

The antimicrobial choice needs to be guided by historical and institutional knowledge of common pathogens causing infections following the specific procedure and a recent look back exercise in Leeds suggested Staphylococcus aureus as the most common organism causing cardiac SSIs in children. This has been the basis of changing the antimicrobial prophylaxis to Flucloxacillin electronic Medicines Compendium information on Teicoplanin  and Gentamicin . A single dose of Gentamicin has been chosen to provide synergism for MSSA and additional cover for MRSA as MRSA SSIs have continued to occur in those children who were not identified as at risk of MRSA pre-procedure. Giving a 5mg/kg dose over 10minutes is likely to achieve a transient high peak concentration as with Once daily(OD) Gentamicin and studies using OD Gentamicin have shown no greater incidence of ototoxicity or nephrotoxicity compared with traditional thrice daily dosing (3). A benchmarking exercise in March 2012 reviewing antibiotic prophylaxis at other children cardiac centres in UK supported such prophylactic regime and notably, no concerns regarding renal impairment or Gentamicin toxicity have been reported.

Vancomycin electronic Medicines Compendium information on Teicoplanin  and Teicoplanin electronic Medicines Compendium information on Teicoplanin  are no more effective than beta-lactam agents like Flucloxacillin electronic Medicines Compendium information on Teicoplanin  for the prevention of surgical site infections after cardiac surgery as shown by a recent meta-analysis. In sub analyses, beta-lactams were superior to glycopeptides for prevention of chest SSIs (RR, 1.47; 95% CI, 1.11–1.95) and approached superiority for prevention of deep-chest SSIs (RR, 1.33; 95% CI, 0.91–1.94) and SSIs caused by gram-positive bacteria (RR, 1.36; 95% CI, 0.98–1.91). However, glycopeptides were found to be to be superior to beta lactam agents for preventing SSIs caused by MRSA (4) supporting an alternative regime for patients at high risk of MRSA infection (2). A glycopeptide may also be used effectively in the setting of allergy to Penicillin or Cephalosporin.

MRSA carriage has been identified as a high risk factor for SSIs in patients undergoing cardiac surgery and such patients should have decolonisation therapy with intranasal Mupirocin prior to surgery (1). Naspetin may be used as an alternative to Mupirocin if MRSA strain found to be Mupirocin resistant. If MRSA screening results are not available at the time of surgery, these patients should have decolonisation therapy, as per Leeds Teaching Hospitals Trust guidelines.

 

There is a considerable body of evidence supporting the need for the timely administration of preoperative antibiotics, which means administration within 1 hour of the skin incision (Evidence level A). A single dose of antibiotic with long half life is adequate to achieve activity throughout the procedure; however, an additional intra-operative dose of Flucloxacillin electronic Medicines Compendium information on Flucloxacillin is required for cardiac surgery lasting more than 4 hours (1).

Sternal Closure
Open chest management and delayed sternal closure after cardiac surgery is a therapeutic option in the treatment of the severely impaired heart in paediatric cardiac surgery, however, delayed sternal closure is associated with increased rate of postoperative infection rate and therefore an attempt should be made to close the skin in those haemodynamically unstable patients where cardiac compression by sternal closure is not tolerated. These children should be continued on antiseptic skin washes till the sternum can be closed (Octenisan or Chlorhexidine washes as guided by the age of the child). The duration of antibiotic prophylaxis should not exceed 48hours and should not be dependent on indwelling catheters or drains of any type as it does not offer any additional protection against infectious complications.

ECMO
Patients on extracorporeal life support should receive the same antibiotic prophylaxis; however, there should be a low threshold for broadening coverage as and when required.

Summary & Conclusions

  1. Prophylactic antibiotics should be routinely administered to paediatric patients undergoing cardiac surgery and interventional cardiac catheter placements. The recommended regimen for cardiac surgery is Flucloxacillin electronic Medicines Compendium information on Flucloxacillin  25mg/kg/dose with Gentamicin 5mg/kg/dose intravenously at induction of anaesthesia and 6 hourly Flucloxacillin electronic Medicines Compendium information on Flucloxacillin  25mg/kg/dose for 3 subsequent doses (prophylaxis should not exceed 24hours). Whilst the recommended regimen for interventional cardiac catheter placements is Teicoplanin  electronic Medicines Compendium information on Flucloxacillin 10mg/kg/dose at induction of anaesthesia (as these patients are not currently routinely screened for MRSA, so their status is unknown). Please refer to table 1 for prophylaxis details.
  2. Teicoplanin electronic Medicines Compendium information on Flucloxacillin   10mg/kg/dose should replace the Flucloxacillin electronic Medicines Compendium information on Flucloxacillin  as antimicrobial prophylaxis for patients who have been screened as MRSA positive or identified as high risk for MRSA (if screening results not available) or have a true penicillin allergy or fall into RACHS 5-6 category. Please refer to table 1 for prophylaxis details and dosing regime.
  3. The duration of antibiotic prophylaxis should not be dependent on catheters, lines, nor drains of any type.
  4. Microbiology opinion should be sought for individual patients with complex microbiological problems, patients in renal failure or those who are already receiving antimicrobials for chest infections, necrotising enterocolitis, endocarditis etc

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Provenance

Record: 2067
Objective:
Clinical condition:

Paediatric cardiac surgery procedures

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

Evidence base

Evidence Levels

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)

References

  1. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; 2008.
  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. Elhanan, K et al. Gentamicin Once Daily versus Thrice Daily in Children. Journal of Antimicrobial Chemotherapy. 1995; 35:327-332
  4. Bolon MK, Morlote M, Weber SG, Koplan B, Carmeli Y, Wright SB. Glycopeptides are no more effective than beta-lactam agents for prevention of surgical site infection after cardiac surgery: a meta-analysis. Clinical Infectious Diseases. 2004 May 15; 38(10):1357-63.
  5. Bass, KD et al. Pharmacokinetics of Once Daily Gentamicin Dosing in Pediatric Patients. J Pediatr Surg. 1998; 33:1104-1107
  6. RACHS-1 for ANZPIC Registry: Information booklet Jan 2012 RACHS Information Booklet.pdf

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.1

Related information

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