Surgical antibiotic prophylaxis

Peri-operative consideratons

Drug administration

  • Preoperative IV antibiotics should be given within 60 minutes (ideally 15 to 30 minutes) before skin incision.
  • Administration after skin incision or > 60 minutes before incision reduces effectiveness
  • One dose is generally sufficient for prophylaxis, when required.
  • A second prophylactic dose should be given intra-operatively if the procedure is longer than two half lives of the agent used:
    • For cephazolin, cefoxitin, benzylpenicillin and piperacillin/tazobactam: give a repeat dose after 4 hours
    • For gentamicin, only a single dose per 24hour period should be given. Seek ID/Pharmacy advice about re-dosing and therapeutic drug monitoring
    • For vancomycin (Loading dose of 25mg/kg or 30mg/kg), give a repeat dose of 15mg/kg (maximum 500mg/dose) after 12 hours and seek ID/pharmacy advice on therapeutic drug monitoring
    • For teicoplanin, only a single dose per 24hour period should be given. Seek ID/Pharmacy advice about re-dosing
    • For lincomycin: give a repeat dose after 8 hours
  • Unless specified below, continued dosing will always require ID discussion and approval.

Pre-existing infections (known or suspected)
If patients are on broad spectrum antibiotics, additional surgical antibiotic prophylaxis may not be necessary. Doses should be scheduled to allow for re-dosing just prior to skin incision.

Multi-drug resistance
Colonisation with known Multi-drug resistant organisms may need to be taken into consideration as an alternative regimen could be required. Seek ID advice.

Neonates
Prophylaxis regimens should be individualised by surgeons in consultation with the ID team. Refer to CHQ Antibiocard or Neofax for neonatal antibiotic dosing advice.

Therapeutic drug monitoring
Seek pharmacist/ID advice on appropriate therapeutic drug monitoring (TDM) and appropriate dosing for patients in renal failure

For more information, refer to CHQ guideline: Paediatric surgical antibiotic prophylaxis

ENT, Head/ Neck/Thoracic, Neurosurgery, Orthopaedic surgery

Cephazolin 30mg/kg (up to 1g max) IV at induction (2g if >80kg).

Note: For Adeno-tonsillectomy and/or grommet insertion – antibiotic prophylaxis not required.

Cochlear implantation:
Cephazolin 30mg/kg (up to 1g max) IV at induction (if >80kg, give 2g). Continue Cephazolin 30mg/kg/dose (max 1g) IV every 8 hours for total of 3 postoperative doses.
Laryngeal reconstruction:
Cephazolin 30mg/kg (up to 1g max) IV at induction (if >80kg, give 2g). Continue Cephazolin 30mg/kg/dose (max 1g) IV every 8 hours for total of 7 days.
For Cranial vault remodelling or Craniosynostosis surgery:
Cephazolin 30mg/kg (up to 1g max) IV at induction (if >80kg, give 2g). Continue Cephazolin 30mg/kg/dose (max 1g) IV every 8 hours for total of 48hours.
ALTERNATIVE (Immediate type or severe penicillin or cephalosporin hypersensitivity):
Substitute cephazolin with Lincomycin 15mg/kg (600mg >12yrs) slow IV. For Cranial vault remodelling or Craniosynostosis surgery, seek ID advice.

Multi resistant organism colonisation:

MRSA: Add Vancomycin 30mg/kg (25mg/kg >12yrs) (up to 1.5 g max) slow IV infusion. For Cranial vault remodelling or Craniosynostosis surgery, seek ID advice.

VRE: Add Teicoplanin 10mg/kg (up to 400mg max) as an IV bolus over 5minutes and contact ID for further advice. For Cranial vault remodelling or Craniosynostosis surgery, seek ID advice.
Note: Vancomycin not required if concurrently MRSA colonised

Pseudomonas aeruginosa: Base antibiotic prophylaxis choice on sensitivities and seek ID advice. For Cranial vault remodelling or Craniosynostosis surgery, seek ID advice.

For more information, refer to CHQ guideline: Paediatric surgical antibiotic prophylaxis.

Cardiac surgery

Cephazolin 50mg/kg (up to 2g max) IV at induction as loading dose, then 30mg/kg/dose (up to 1g) every 8 hours for further 3 doses

Eradication of Staph Aureus nasal colonisation in cardiac surgery patients:
Apply Mupirocin 2% (Bactroban ®) intranasally twice daily. Ideally start 2 days prior to surgery. Continue for a total of 5 days.
ALTERNATIVE (Immediate type or severe penicillin or cephalosporin hypersensitivity):
Substitute Cephazolin IV with:
Lincomycin IV 15mg/kg (600mg >12yrs) as slow infusion
PLUS Gentamicin IV 5mg/kg as a single dose (infuse over 30minutes)
If 1month to 10years old: 5mg/kg (Maximum dose 320mg as a single dose)
If more than 10years old: 5mg/kg (Maximum dose 560mg as a single dose)

Multi resistant organism colonisation:

MRSA: Add Vancomycin 30mg/kg (25mg/kg >12yrs) (up to 1.5 g max) slow IV infusion

VRE: Add Teicoplanin 10mg/kg (up to 400mg max) as an IV bolus over 5minutes and contact ID for further advice
Note: Vancomycin not required if concurrently MRSA colonised

Pseudomonas aeruginosa: Base antibiotic prophylaxis choice on sensitivities and seek ID advice.

For more information, refer to CHQ guideline: Paediatric surgical antibiotic prophylaxis.

Abdominal surgery

For abdominal surgery including appendicectomy, colorectal, upper GIT or biliary surgery (including laparoscopic surgery):
Cefoxitin 40mg/kg (up to 2g max) IV at induction.

Note:
For Endoscopic or colonoscopic procedures: antibiotic prophylaxis not indicated.
For appendicitis, if antibiotics to continue for treatment, see CHQ Paediatric Antibiocard: Empirical Antibiotic Guidelines for recommendations.

Kasai procedure and similar biliary reconstructive surgery:
Continue Cefoxitin 40mg/kg/dose (max 2g) IV every 8 hours until biliary drain is removed.
Gastro-intestinal anastomosis performed, without bowel prep: Continue Cefoxitin 40mg/kg/dose (max 2g) IV every 8 hours for total 3 postoperative doses.
ALTERNATIVE (Immediate type or severe penicillin or cephalosporin hypersensitivity):
Substitute Cefoxitin IV with:]
Metronidazole IV 7.5mg/kg (Max 500mg) as a single dose (infuse over 20 minutes)
PLUS Gentamicin IV 5mg/kg as a single dose (infuse over 30minutes)
If 1month to 10years old: 5mg/kg (Maximum dose 320mg as a single dose)
If more than 10years old: 5mg/kg (Maximum dose 560mg as a single dose)

Multi resistant organism colonisation:

MRSA: Add Vancomycin 30mg/kg (25mg/kg >12yrs) (up to 1.5 g max) slow IV infusion

VRE: Add Teicoplanin 10mg/kg (up to 400mg max) as an IV bolus over 5 minutes and contact ID for further advice.
Note: Vancomycin not required if concurrently MRSA colonised.

Pseudomonas aeruginosa: Base antibiotic prophylaxis choice on sensitivities and seek ID advice.

For more information, refer to CHQ guideline: Paediatric surgical antibiotic prophylaxis.

Liver transplantation

For further information, see LCCH Paediatric Post-Liver Transplant Medication Management Guideline.

Piperacillin / Tazobactam IV 100mg/kg/dose (Max 4gram Piperacillin component) as a single dose, (infused over 30 minutes before procedure).
A second dose to be given after 4 hours intra-operatively if surgery prolonged.
Prophylaxis should be no greater than 24 hours, with a single dose sufficing in most cases.

If abdomen left unsutured or chronic cholangitis present, continue Piperacillin/Tazobactam IV 100mg/kg (Max 4gram Piperacillin component) every 6 hourly for 72hours

For use in high risk patients per transplant surgeon (e.g. PELD score >22, cholestasis, second transplant, previous Kasai surgery)
Liposomal Amphotericin IV 1mg/kg (max 50mg/dose) once DAILY and CONTINUE FOR 5 DAYS.

ALTERNATIVE (Immediate type or severe penicillin or cephalosporin hypersensitivity)
Delayed hypersensitivity (e.g. Rash) use:
Meropenem IV 20mg/kg/dose (Max 1 gram) every 8 hourly intraoperatively

Immediate hypersensitivity (e.g. anaphylaxis) use:
Aztreonam IV 30mg/kg/dose (Max 2 grams) every 6 hourly intraoperatively
PLUS VANCOMYCIN 15mg/kg/dose (Max 500mg) every 6 hourly intraoperatively

Prophylaxis should be no greater than 24 hours, with a single dose sufficing in most cases.

Multi resistant organism colonisation:
MRSA: Add Vancomycin 30mg/kg (25mg/kg >12yrs) (up to 1.5 g max) slow IV infusion

VRE: Add Teicoplanin 10mg/kg (up to 400mg max) as an IV bolus over 5 minutes and contact ID for further advice.
Note: Vancomycin not required if concurrently MRSA colonised.

For more information, refer to CHQ guideline: Paediatric surgical antibiotic prophylaxis.

Renal transplantation

Piperacillin / Tazobactam IV 100mg/kg/dose (Max 4gram Piperacillin component) as a single dose, (infused over 30 minutes before procedure).
A second dose to be given after 6 hours intra-operatively if surgery prolonged.
Prophylaxis should be no greater than 24 hours, with a single dose sufficing in most cases.

ALTERNATIVE (Immediate type or severe penicillin or cephalosporin hypersensitivity)
Delayed hypersensitivity (e.g. Rash) use:

Meropenem IV 20mg/kg/dose (Max 1 gram) every 8 hourly intraoperatively

Immediate hypersensitivity (e.g. anaphylaxis) use:
Aztreonam IV 30mg/kg/dose (Max 2 grams) every 6 hourly intraoperatively
PLUS Vancomycin 30mg/kg (25mg/kg >12yrs) (up to 1.5 g max) slow IV infusion

Prophylaxis should be no greater than 24 hours, with a single dose sufficing in most cases.

Multi resistant organism colonisation:
MRSA:
Add Vancomycin 30mg/kg (25mg/kg >12yrs) (up to 1.5 g max) slow IV infusion

VRE: Add Teicoplanin 10mg/kg (up to 400mg max) as an IV bolus over 5 minutes and contact ID for further advice.
Note: Vancomycin not required if concurrently MRSA colonised.

For more information, refer to LCCH Paediatric Renal transplant procedure (QH staff only).

Percutaneous transhepatic cholangiogram

(with or without stent placement) with expected incomplete drainage (e.g. Primary sclerosing cholangitis, hilar strictures) or recent ERCP (within 1 week)

Piperacillin / Tazobactam IV 100mg/kg/dose (Max 4g Piperacillin component) as a single dose, infused over 30 minutes before procedure.

ALTERNATIVE (Immediate type or severe penicillin or cephalosporin hypersensitivity)
Substitute Piperacillin/Tazobactam IV with:
Gentamicin IV 5mg/kg as a single dose (infuse over 30minutes)
If 1month to 10years old: 5mg/kg (Maximum dose 320mg as a single dose)
If more than 10years old: 5mg/kg (Maximum dose 560mg as a single dose)

MRSA, VRE or Pseudomonas aeruginosa colonisation, seek ID advice.
For more information, refer to CHQ guideline: Paediatric surgical antibiotic prophylaxis.

Interventional radiology

(including Percutaneous endoscopic gastrostomy (PEG) or jejunostomy (PEJ) or nephrostomy tube placement)

Cephazolin IV 30mg/kg (up to 1gram max) at induction (2gram if >80kg)

ALTERNATIVE (Immediate type or severe penicillin or cephalosporin hypersensitivity)

Substitute Cephazolin IV with:

Gentamicin IV 5mg/kg as a single dose (infuse over 30minutes)

If 1month to 10years old: 5mg/kg (Maximum dose 320mg as a single dose)

If more than 10years old: 5mg/kg (Maximum dose 560mg as a single dose)

MRSA, VRE or Pseudomonas aeruginosa colonisation, seek ID advice.
For more information, refer to CHQ guideline: Paediatric surgical antibiotic prophylaxis.

Tenckhoff peritoneal dialysis catheter insertion

Cephazolin 30mg/kg (up to 1g max) IV at induction (2g if >80kg)
ALTERNATIVE (Immediate type or severe penicillin or cephalosporin hypersensitivity)-seek ID advice
For MRSA, VRE or Pseudomonas aeruginosa colonisation, seek ID advice.

Urinary tract surgery

Prophylaxis indicated only if suspected or confirmed abnormal urinary tract.

None required if patient is already receiving ongoing oral antibiotic prophylaxis.

Alternatively, Gentamicin IV 5mg/kg as a single dose (infuse over 30minutes)

If 1month to 10years old: 5mg/kg (Maximum dose 320mg as a single dose)

If more than 10years old: 5mg/kg (Maximum dose 560mg as a single dose)

MRSA, VRE or Pseudomonas aeruginosa colonisation, seek ID advice.
For more information, refer to CHQ guideline: Paediatric surgical antibiotic prophylaxis.

Micturating cystourethrogram (MCUG)

Trimethoprim/Sulfamethoxazole 4mg/kg (Trimethoprim component) orally as a single dose prior to procedure/imaging.

If patient is on existing antibiotic UTI prophylaxis, increase antibiotic to a therapeutic dose for a single dose prior to procedure/imaging

For more information, refer to CHQ guideline: Paediatric surgical antibiotic prophylaxis

Hypospadias

Cephazolin IV 30mg/kg (up to 1g max) at induction (2g if >80kg)

Then

Oral Trimethoprim/sulfamethoxazole 2mg/kg once daily (Trimethoprim component) until IDC removed.

ALTERNATIVE (Immediate type or severe penicillin or cephalosporin hypersensitivity):
Substitute Cephazolin IV with:

Gentamicin IV 5mg/kg as a single dose (infuse over 30minutes)

If 1month to 10years old: 5mg/kg (Maximum dose 320mg as a single dose)

If more than 10years old: 5mg/kg (Maximum dose 560mg as a single dose)

MRSA, VRE or Pseudomonas aeruginosa colonisation, seek ID advice.

Dental

Prophylaxis only indicated for surgical removal of a bone-impacted tooth or periapical surgery in a patient with a history of recurrent dental infections OR immunocompromised patients.
Oral phenoxymethylpenicillin 40mg/kg (up to 2gram max) (2gram for >12yrs) 1 hour before the procedure
OR
Oral amoxycillin 50mg/kg (up to 2gram max) (2gram > 12yrs) 1 hour before the procedure
OR
IV Benzylpenicillin 30mg/kg (up to 1.2gram max) (1.2gram >12yrs) within 30minutes before procedure
ALTERNATIVE (Immediate type or severe penicillin or cephalosporin hypersensitivity)
Substitute penicillin with oral clindamycin 10mg/kg/dose (up to 450mg) 1 hour before the procedure
OR
substitute penicillin with Lincomycin 15mg/kg/dose (600mg >12yrs) as a slow IV infusion

MRSA, VRE or Pseudomonas aeruginosa colonisation, seek ID advice.
For more information, refer to CHQ guideline: Paediatric surgical antibiotic prophylaxis.

Amputations (ischaemic limbs and lower limbs)

Benzylpenicillin 30mg/kg (up to 1.2g max) IV at induction, then every six hours for 3 further doses.
ALTERNATIVE (Immediate type or severe penicillin or cephalosporin hypersensitivity)
Substitute benzylpenicillin with Lincomycin 15mg/kg (600mg >12yrs) slow IV.
MRSA, VRE or Pseudomonas aeruginosa colonisation, seek ID advice.
For more information, refer to CHQ guideline: Paediatric surgical antibiotic prophylaxis.

Burns

Antibiotics based on microbiological results where possible.

If no microbiology: Flucloxacillin IV 50mg/kg/dose (Max 2g),

OR

If dirt contaminated wound: Piperacillin/Tazobactam IV 100mg/kg/dose (Max 4g Piperacillin component)

Antibiotics should not be continued post procedure in absence of documented infection.

For more information, refer to CHQ guideline: Paediatric surgical antibiotic prophylaxis