ENT Surgery in Children

ENT Surgery in Children - Guideline for Antimicrobial Prophylaxis during

Publication: 28/02/2011

Next review: 02/10/2023

Clinical Guideline

CURRENT

ID: 2075

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 ENT Surgery in Children

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 before incision.

Procedure	Prophylaxis recommended?	Evidence level	Prophylaxis intended to reduce	NNT	Antimicrobial dose/route Administered within 1 hours of incision/procedure
Procedure	Prophylaxis recommended?	Evidence level	Prophylaxis intended to reduce	NNT	Routine	MRSA risk^# or penicillin allergic
General ear surgery	NO	A ⁽¹⁾
Mastoid using cartilage graft	Yes	D	Surgical site infection	-	Flucloxacillin 50mg/kg iv single dose	Teicoplanin 10mg/kg (max 400mg ) iv single dose
Routine nose, sinus and endoscopic sinus surgery or nasendoscopy	NO	C ⁽²⁾		-
Complex septorhinoplasty	YES if graft used, discuss on case-by-case basis	A ⁽³⁾	Surgical site infection	-	Co-amoxiclav 30mg/kg iv single dose (if required). Discuss on case-by-case basis	Teicoplanin 10mg/kg (max 400mg ) iv single dose (if required). Discuss on case-by-case basis
Tonsillectomy	NO			-
Adenoidectomy	NO	A ⁽⁴⁾		-
Grommet insertion	YES when bleeding or purulence	B ^(5-7)	Reduction of otorrhoea	13	Topical Cilodex single dose	Topical Cilodex single dose
Head and Neck surgery (clean, benign lesion)	NO	D		-
Head and neck surgery (malignant lesions, neck dissection, contaminated)	YES	A ^(8-13)	Reduction in wound infection	6	Co-amoxiclav 30mg/kg iv single dose	Teicoplanin 10mg/kg (max 400mg ) iv single dose
Endocarditis risk	NO unless active infection at site of operation			-	Discuss with microbiology

#see Guidance on MRSA risk and prophylaxis

2. Background information

The aim of antimicrobial prophylaxis in ENT 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)(14) and the Scottish Intercollegiate Guideline Network (15) 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 ENT 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.

3. Special antimicrobial prophylaxis recommendations

Complex ear surgery
A Cochrane review suggested that antibiotic prophylaxis is not required for any ear surgery (1). However the review could not tease out simple ear operations from complex operation from contaminated operations and suggested a further randomised trial on this question. In view of high local infection rates in this setting we have opted to give prophylaxis for complex ear surgery involving cartilaginous grafts. Colonisation with Pseudomonas can occur in patients with chronic ear pathology but this is unlikely to cause post-auricular wound infections and is not considered to require routine systemic prophylaxis. The most likely cause of surgical site infection in these patients remains staphylococci and streptococci hence the choice of Flucloxacillin or Teicoplanin for prophylaxis.
[Evidence level D]

Endocarditis prophylaxis
Specific prophylaxis for patients at increased risk of developing endocarditis is no longer recommended (16). However, localised infections in patients at increased risk of endocarditis should be investigated (with microbiological sampling as appropriate) and treated promptly. If a patient at increased risk of endocarditis has active infection they should ideally be commenced on appropriate antimicrobial therapy prior to an ENT procedure at the site of infection.
[Evidence level C]

Provenance

Record:	2075
Objective:
Clinical condition:	ENT surgery
Target patient group:	Children
Target professional group(s):	Pharmacists Secondary Care Doctors
Adapted from:

Evidence base

References

Verschuur HP, de Wever WW, van Benthem PP. Antibiotic prophylaxis in clean and clean-contaminated ear surgery. Cochrane database of systematic reviews (Online). 2004(3):CD003996.
Annys E, Jorissen M. Short term effects of antibiotics (Zinnat) after endoscopic sinus surgery. Acta Otorhinolaryngol Belg. 2000;54(1):23-8.
Andrews PJ, East CA, Jayaraj SM, Badia L, Panagamuwa C, Harding L. Prophylactic vs postoperative antibiotic use in complex septorhinoplasty surgery: a prospective, randomized, single-blind trial comparing efficacy. Arch Facial Plast Surg. 2006 Mar-Apr;8(2):84-7.
Sanchez-Carrion S, Prim MP, De Diego JI, Sastre N, Pena-Garcia P. Utility of prophylactic antibiotics in pediatric adenoidectomy. International journal of pediatric otorhinolaryngology. 2006 Jul;70(7):1275-81.
Kocaturk S, Yardimci S, Yildirim A, Incesulu A. Preventive therapy for postoperative purulent otorrhea after ventilation tube insertion. Am J Otolaryngol. 2005 Mar-Apr;26(2):123-7.
Nawasreh O, Al-Wedyan IA. Prophylactic ciprofloxacin drops after tympanostomy tube insertion. Saudi Med J. 2004 Jan;25(1):38-40.
Zipfel TE, Wood WE, Street DF, Wulffman J, Tipirneni A, Frey C, et al. The effect of topical ciprofloxacin on postoperative otorrhea after tympanostomy tube insertion. Am J Otol. 1999 Jul;20(4):416-20.
Becker GD, Parell GJ. Cefazolin prophylaxis in head and neck cancer surgery. The Annals of otology, rhinology, and laryngology. 1979 Mar-Apr;88(2 Pt 1):183-6.
Dor P, Klastersky J. Prophylactic antibiotics in oral, pharyngeal and laryngeal surgery for cancer: (a double-blind study). The Laryngoscope. 1973 Dec;83(12):1992-8.
Johnson JT, Myers EN, Thearle PB, Sigler BA, Schramm VL, Jr. Antimicrobial prophylaxis for contaminated head and neck surgery. The Laryngoscope. 1984 Jan;94(1):46-51.
Johnson JT, Yu VL, Myers EN, Muder RR, Thearle PB, Diven WF. Efficacy of two third-generation cephalosporins in prophylaxis for head and neck surgery. Arch Otolaryngol. 1984 Apr;110(4):224-7.
Velanovich V. A meta-analysis of prophylactic antibiotics in head and neck surgery. Plast Reconstr Surg. 1991 Mar;87(3):429-34; discussion 35.
Coskun H, Erisen L, Basut O. Factors affecting wound infection rates in head and neck surgery. Otolaryngol Head Neck Surg. 2000 Sep;123(3):328-33.
Leaper D, Collier M, Evans D, Farrington M, Gibbs E, Gould K, et al. Surgical site infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor.: Royal College of Obstetrics and Gynaecology, Press; 2008.
SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; 2008.
NICE. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. NICE clinical guideline 64. National Institue for Health and Clinical Excellence; 2008.

Evidence level.
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, or 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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