10.7 Surgical Prophylaxis

Additional Information

• Surgical infection can be prevented by pre-operative chlorhexidine gluconate (2%-4%) bath/body wipes preferably one day prior to, and on the day of surgery. Adopting hair clipping instead of shaving in surgical site preparation can help in reducing surgical site infections.
• Classification of operative wounds and risk of infection is tabulated below:

  Classification	Criteria	Risk(%)
  Clean	Elective, not emergency, non-traumatic, primarily closed; no acute inflammation; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered	< 2
  Clean- contaminated	Urgent or emergency case that is otherwise clean; elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g., appendectomy) not encountering infected urine or bile; minor technique break	<10
  Contaminated	Non-purulent inflammation; gross spillage from gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique; penetrating trauma < 4 hours old; chronic open wounds to be grafted or covered	Approx. 20
  Dirty	Purulent inflammation (e.g., abscess); preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract; penetrating trauma > 4 hours old	Approx. 40

• Antibiotic prophylaxis in specific procedures is tabulated below:

  Specific Operations	Expected organism	Antibiotic of choice	Dosage in adults
  Esophagus	S. aureus, Streptococci	Cefazolin	1-2 g IV
  Thoracic	S.aureus,S. epidermidis	Cefazolin	1-2 g IV
  Gastroduodenal	Gram-positive cocci, enteric gram-negative bacilli	Cefazolin	1-2 g IV
  Colorectal	Enteric gram- negative bacilli, anaerobes	Cefazolin + Metronidazole	1-2g IV+500 mg
  Appendectomyfor uncomplicated appendicitis	Enteric gram- negative bacilli, anaerobes	Cefuroxime	1-2 g IV
  Biliary	Enteric gram- negative bacilli	Cefazolin	1-2 g IV
  Vascular	S. aureus, S. epidermidis, enteric gram- negative bacilli	Cefazolin	1-2 g IV
  Breastandhernia	S.aureus,S. epidermidis	Cefazolin	1-2 g IV
  Urology-Clean with entry into urinary tract		Cefazolin (the addition of a single dose of an aminoglycoside may be recommended for placement of prosthetic material e.g., penile prosthesis)
  Urology-Clean withoutentryinto urinary tract		Cefazolin (the addition of a single dose of an aminoglycoside may be recommended for placement of prosthetic material e.g., penile prosthesis)
  Genitourinary Lower tract instrumentation withriskfactors for infection (includes transrectal prostatebiopsy)		Fluoroquinolones, Cefazolin
  Liver transplantation		Piperacillin -tazobactam	4.5 g
  Heart/Lung transplantation		Cefazolin	1-2 g IV
  Hysterectomy		Cefazolin	1-2 g IV
  Caesarean section		Cefazolin	1-2 g IV
  Neurosurgery		Cefazolin	1-2 g IV
  Small Intestine		Cefazolin	1-2 g IV+500 mg

  Administration of prophylactic antimicrobials should be performed only when indicated. It should be administered within 1 hour before incision for all antimicrobials except Vancomycin and Fluoroquinolones, for which it should be administered within 2 hours before incision.

  Redosing should be considered to maintain adequate tissue levels on the basis of on agent half- life. A single dose of a prophylactic antimicrobial is adequate for most surgical procedures. If Cefazolin is not available, use Inj Cefuroxime 1.5 g IV instead.

• Doses of drugs used in Musculoskeletal infections is tabulated below:

  Drug	Adult dose	Pediatricdose
  Ceftriaxone	2g 12 OD	50 mg/kg 12 hrly
  Ceftazidime	2g q 6-8 hrly	50 mg/kg 8 hrly
  Cefepime	2g 8-12 hrly	50 mg/ kg 12 hrly
  Cefotaxime	2g 6 hrly	50 mg/kg 6 hrly
  Meropenem	2g 8 hrly	40 mg/kg 8 hrly
  Colistin	9 million unit loading and then 3 million 8 hrly	150,000 units/ kg loading and then 50,000 units/ kg 8 hrly
  Polymyxin B	7,50,000 q12h	15-25,000 units/ kg loading and then 5000-7500 units/kg 8 hrly
  Fosfomycin	4g 6 hrly	75-100 mg/kg/dose 6 hrly
  Cotrimoxazole	3-6 mg/kg of TMP TDS
  Vancomycin	15 mg/kg (max 2 g) 8 hrly	15 mg/kg 6 hrly
  Cloxacillin	2 g 4 hrly	50 mg/kg 6 hrly
  Doxycycline	100 mg 12 hrly	1.5-2 mg/kg 12 hrly
  Chloramphenicol	1-2 g 6 hrly	25 mg/kg 6 hrly
  Metronidazole	400 mg 8 hrly	10 mg/kg 8 hrly
  Amphotericin B	1 mg/kg/day
  Liposomal amphotericin B	3-5 mg/kg/day
  Fluconazole	800 mg loading and then 400 mg OD	12 mg/kg loading and then 6 mg/ kg daily g/kg loading in neonates and then 12mg/kg daily