Document Control · 2019-06-19 · >1.5 litre intra-operative blood loss following fluid replacement Re-dose cefuroxime, clindamycin, co-amoxiclav, clarithromycin and flucloxacillin

Antibiotic Guidelines for surgical prophylaxis

Microbiology Page 1 of 17

Document Control

Title

Antibiotic Guidelines for Surgical Prophylaxis

Author

Author’s job title Consultant Medical Microbiologist Antibiotic Pharmacist

Directorate Planned Care

Department Microbiology

Version Date

Issued Status Comment / Changes / Approval

0.1 Mar 2013

Draft After consultation with consultant surgeons and Antibiotic Working Group

0.2 Mar 2013

Draft Change to format of poster after d/w consultant anaesthetists

0.3 Mar 13 Draft Addition of PTC and angioplasty guidance after discussion with consultant radiologist Addition of guidance on patients with cardiac disease

1.0 Mar 13 Final Ratified by DTC on 21st March 2013

1.1 Apr 2018

Revision Guideline inserted into new Trust template, references reviewed, redosing information included, distributed to surgeons for approval

2.0 July 2018

Revision Updated with new advice for urology. Added note to introduction mentioning exceptions for ophthalmology and maxillo-facial procedures who do not have NDHT prophylaxis guidelines. Approved at DTC 19th July.

2.1 March 2019

Revision Ophthalmology prophylaxis guidelines added

Main Contact Microbiology Department North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB

Tel: Direct Dial – Tel: Internal – Email:

Lead Director Director of Medicine

Superseded Documents Antibiotic Guidelines for Surgical Prophylaxis v1.2 120718

Issue Date Jun 2018

Review Date July 2021

Review Cycle Three years

Consulted with the following stakeholders:

Trauma and Orthopaedics Directorate

General Surgery Directorate

Pre-operative Assessment clinic

Consultant Anaesthetists

Consultant Urologists

Consultant Gastroenterologists

Consultant Ophthalmologists

Consultant Obstetricians (see separate guideline)

Consultant Gynaecologists

Royal Devon and Exeter Antibiotic Pharmacist



Lead Pharmacist Surgical Directorate NDHT

Approval and Review Process

Antibiotic Working Group Drug & Therapeutics Group

Local Archive Reference G:\ANTIBIOTICSTEWARDSHIP Local Path G:\ANTIBIOTIC STEWARDSHIP\Stewardship\Antibiotic policies\Published policies Filename Antibiotic Guidelines for Surgical Prophylaxis v1.3 010319

Policy categories for Trust’s internal website (Bob) Pharmacy, Microbiology

Tags for Trust’s internal website (Bob) Antibiotic, prophylaxis, pre-op, endocarditis



CONTENTS

Document Control ............................................................................................................... 1

1. Purpose ........................................................................................................................ 4

2. Definitions .................................................................................................................... 4

3. Responsibilities ........................................................................................................... 5

Role of Antibiotic Working Group (AWG) ...................................................................... 5

4. Contacts ....................................................................................................................... 6

5. Management of Surgical Prophylaxis ......................................................................... 6

6. Monitoring Compliance with and the Effectiveness of the Guideline ...................... 6

Suggested audit criteria ................................................................................................. 6

Process for Implementation and Monitoring Compliance and Effectiveness................... 6

7. Equality Impact Assessment ....................................................................................... 6

8. References ................................................................................................................... 7

9. Associated Documentation ....................................................................................... 10

10. Appendix .................................................................................................................... 10



1. Purpose

1.1. This document sets out Northern Devon Healthcare NHS Trust’s best practice guidelines for appropriate microbiological investigation and antimicrobial prophylaxis prescribing in adult patients undergoing trauma and orthopaedic surgery, general surgery, urological surgery, gastroenterological procedures (PEG, ERCP), vascular surgery, ophthalmic surgery, gynaecological surgery and obstetric surgery.

1.2. Guidance on management of open fractures is part of separate guidance.

1.3. This guideline does not include guidance on surgical prophylaxis in maxillofacial procedures.

1.4. This guideline applies to all adults and must be adhered to. Special considerations exist for pregnant and breastfeeding patients; liaise with specialist clinicians as appropriate in these cases. See separate guidance for paediatric patients.

1.5. Non-compliance with this guideline may be for valid clinical reasons only. The reason(s) for non-compliance must be documented clearly in the patient’s notes.

1.6. This guideline is primarily aimed at all prescribing teams but other staff (e.g. nursing staff, pharmacists) may need to familiarise themselves with some aspects of the guideline.

1.7. Implementation of this guideline will ensure that:

Pre-operative antimicrobial prohylaxis is managed according to current evidence and standards of practice in the wider healthcare community.

A standard of care is specified to facilitate a consistent approach between anaesthetics and surgery, microbiology and pharmacy in terms of patient management, specimen processing and drug availability.

2. Definitions

2.1. ACL – anterior cruciate ligament

2.2. I+D – incision and drainage

2.3. IM – intramedullary

2.4. MUA – Manipulation under anaesthetic

2.5. ORIF – Open reduction and internal fixation

2.6. PIP – proximal interphalangeal

2.7. THR – Total hip replacement



2.8. TKR – Total knee replacement

2.9. DHS – Dynamic hip screw

2.10. ERCP – Endoscopic retrograde Cholangiopancreatography

2.11. PEG – Percutaneous endoscopic gastrostomy

2.12. PTC - Percutaneous Transhepatic Cholangiography

2.13. TURP – Trans urethral resection of the prostate

2.14. TURBT – Trans urethral resection of bladder tumour

2.15. YAG PI – YAG laser peripheral iridotomy.

3. Responsibilities

3.1. Responsibility for education and training lies with the Lead Consultant Microbiologist for Antibiotic Stewardship. It will be provided through formal study days and informal training on the ward.

3.2. The author will be responsible for ensuring the guidelines are reviewed and revisions approved by the Drug and Therapeutics Group in accordance with the Document Control Report.

3.3. All versions of these guidelines will be archived in electronic format by the author within the Antibiotic Stewardship policy archive.

3.4. Any revisions to the final document will be recorded on the Document Control Report.

3.5. To obtain a copy of the archived guidelines, contact should be made with the author.

3.6. Monitoring of implementation, effectiveness and compliance with these guidelines will be the responsibility of the Lead Clinician for Antibiotic Stewardship. Where non-compliance is found, the reasons for this must have been documented in the patient’s medical notes.

Role of Antibiotic Working Group (AWG)

3.7. The AWG is responsible for:

Leading antibiotic guideline development and review within Northern Devon Healthcare Trust

Involving all relevant stakeholders in guideline development and review



4. Contacts

4.1. Contact numbers:

Microbiologist Bleep 193. Via switchboard out of hours.

Antibiotic Pharmacist Bleep 029 (Mon-Fri only)

5. Management of Surgical Prophylaxis

5.1. See appendix 1

6. Monitoring Compliance with and the Effectiveness of the Guideline

Suggested audit criteria

6.1. The following could be used:

Percentage of patients undergoing high-risk procedures and urological with a pre-operative MSU within 9 weeks

Percentage of patients with a pre-operative MRSA screen within 9 weeks

Percentage of patients receiving appropriate antimicrobial. Percentage of patients receiving antimicrobial at the appropriate time

pre-operatively. Percentage of isolates from infected prosthetic joints sensitive to

suggested prophylaxis Percentage of patients undergoing urological procedures with post-

procedure infection and sensitivity of isolates

Process for Implementation and Monitoring Compliance and Effectiveness

6.2. Incidents involving pre-operative antibiotic prophylaxis should be reported according to the Trust’s Incident Reporting Policy. Critical incident reports relating to pre-operative antibiotic prophylaxis will be collated by the Antibiotic Pharmacist. Results will be reported on an annual basis to the Drug and Therapeutics Group.

7. Equality Impact Assessment

7.1. The author must include the Equality Impact Assessment Table and identify whether the policy has a positive or negative impact on any of the groups listed. The Author must make comment on how the policy makes this impact.

Table 1: Equality impact Assessment

Group Positive Negative No Impact Comment



Impact Impact

Age X Separate guidance for paediatrics

Disability X

Gender X

Gender Reassignment X

Human Rights (rights to privacy, dignity, liberty and non-degrading treatment)

X

Marriage and civil partnership

X

Pregnancy X Some treatment advice may harm the unborn foetus, discuss on a case-by-case basis with Obstetricians and Pharmacy for advice.

Maternity and Breastfeeding

X Some treatments may be excreted in breast milk. Discuss on a case-by-case basis with Paediatricians and Pharmacy for advice.

Race (ethnic origin) X

Religion (or belief) X

8. References

8.1. SIGN 104. 2008 (updated 2014). Antibiotic Prophylaxis in Surgery. http://www.sign.ac.uk/assets/sign104.pdf

8.2. NICE CG74. 2008 (updated 2017). Surgical Site infections: prevention and treatment. https://www.nice.org.uk/guidance/cg74/chapter/1-Guidance

8.3. NICE CG64. 2008 (updated 2016). Prophylaxis against infective endocarditis : antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. https://www.nice.org.uk/guidance/CG64/chapter/Recommendations#prophylaxis-against-infective-endocarditis

http://www.sign.ac.uk/assets/sign104.pdf

https://www.nice.org.uk/guidance/CG64/chapter/Recommendations#prophylaxis-against-infective-endocarditis

https://www.nice.org.uk/guidance/CG64/chapter/Recommendations#prophylaxis-against-infective-endocarditis



8.4. ERCP Prophylaxis: Allison et al, 2009. Endoscopy Committee of the British Society of Gastroenterologists: Antibiotic prophylaxis in gastrointestinal endoscopy guidelines. Gut 58:869–880. doi:10.1136/gut.2007.136580

8.5. Nelson, Gladman, Barbateskovic. 2014. Cochrane Colorectal Cancer Group: Antimicrobial Prophylaxis for Colorectal Surgery. DOI: 10.1002/14651858.CD001181.pub4

This review has found high quality evidence that antibiotics covering aerobic and anaerobic bacteria delivered orally or intravenously (or both) prior to elective colorectal surgery reduce the risk of surgical wound infection. Our review shows that antibiotics delivered within this framework can reduce the risk of postoperative surgical wound infection by as much as 75%. It is not known whether oral antibiotics would still have these effects when the colon is not empty. This aspect of antibiotic dosing has not been tested. Further research is required to establish the optimal timing and duration of dosing, and the frequency of longer-term adverse effects such as Clostridium difficile pseudomembranous colitis.

8.6. Hall C et al. (1989). A randomized trial to compare amoxycillin/clavulanate with metronidazole plus gentamicin in prophylaxis in elective colorectal surgery. J. Antimicrob. Chemotherapy 24, 195S-202S

8.7. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. DOI: https://doi.org/10.1016/j.jamcollsurg.2016.10.029

Confirm dosing conventions, information on hair removal, double-gloving, uniform changes

8.8. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283.

State for intra-operative redosing after 2 half-lives or excessive blood loss

8.9. NHS Lanarkshire. 2015. Antibiotic Prophylaxis in Orthopaedic Surgery.

5. Frequency of administration

Single dose is indicated for majority of procedures.

Antibiotic administration beyond one dose should comply with the criteria below and the Administration Guidance (appendix 1):

Prolonged procedure

> 4 hours re-dose cefuroxime, clindamycin, co-amoxiclav and flucloxacillin with half pre op dose (use full dose if prophylaxis regime is up to 24 hours (only for orthopaedic primary arthroplasty and at individual surgeons’ discretion))

https://doi.org/10.1016/j.jamcollsurg.2016.10.029



> 8 hours re-dose gentamicin with half pre-op dose if eGFR> 60ml/min/1.73m2 (DO NOT re-dose gentamicin if eGFR< 60ml/min/1.73m2). Re-dose clarithromycin with half pre-op dose. Re-dose metronidazole with full pre-op dose.

Do not re-dose teicoplanin

>1.5 litre intra-operative blood loss following fluid replacement

Re-dose cefuroxime, clindamycin, co-amoxiclav, clarithromycin and flucloxacillin with half pre-op dose (full dose recommended in certain orthopaedic procedures)

Re-dose gentamicin with half pre-op dose only if a REPEAT eGFR> 60ml/min/1.73m2

Re-dose metronidazole with full pre-op dose

Do not re-dose teicoplanin

8.10. SMC/SAPG. 2016. Recommendations for Redosing Antibiotics for Surgical Prophylaxis. https://www.scottishmedicines.org.uk/files/sapg/SAPG_Recommendations_for_Re-dosing_Antibiotics_for_Surgical_Prophylaxis.pdf

The following antibiotics should be re-dosed 4 hours after administration of initial dose:

ANTIBIOTIC

Amoxicillin

Cefuroxime

Clindamycin

Co-amoxiclav

Flucloxacillin

Half-life 1 hour 1.2 hours 2.4 hours 1 hour 1 hour

Dose* 500mg 750mg 300mg 600mg 500mg

*Use full dose if prophylaxis regime is up to 24 hours (orthopaedics) or up to 48 hours (cardiothoracic)

The following antibiotics have a long half-life and do not require re-dosing except where the surgical procedure lasts 8 hours or more or due to blood loss greater than 1500mls:

Clarithromycin

Co-trimoxazole

Gentamicin (follow local policy regarding re-dosing)

Metronidazole

https://www.scottishmedicines.org.uk/files/sapg/SAPG_Recommendations_for_Re-dosing_Antibiotics_for_Surgical_Prophylaxis.pdf

https://www.scottishmedicines.org.uk/files/sapg/SAPG_Recommendations_for_Re-dosing_Antibiotics_for_Surgical_Prophylaxis.pdf



8.11. Royal Devon and Exeter NHS Foundation Trust. 2017. Adult Obstetric and Gynaecology Antibiotic Prophylaxis Guidelines. https://live-package-files.s3.amazonaws.com/1670/obsgynaeprophylaxisguidelinesweb151117.pdf

8.12. Society of Obstetricians and Gynaecologists of Canada. 2012. Antibiotic Prophylaxis in Gynaecologic Procedures. https://www.jogc.com/article/S1701-2163(16)35222-7/pdf?code=jogc-site

8.13. Denniston and Murray [Eds.]. Oxford Handbook of Ophthalmology 4th Edition 2018 [online] accessed 1st March 2019. http://oxfordmedicine.com/view/10.1093/med/9780198804550.001.0001/med-9780198804550-chapter-10?rskey=JSiFJe&result=1

9. Associated Documentation

Incident reporting policy Antibiotic guidelines for management of severe sepsis and septic shock Antibiotic prescribing policy Penicillin allergy policy

10. Appendix

10.1. Name of guideline on app

Prophylaxis (surgical and other)

10.2. Location on app

Secondary Care Infection Prophylaxis (surgical and other)

10.3. Pre-operative screening for resistant organisms

Pre-operative MRSA screening

See the MRSA policy on BOB for further information on which patients should be screened for MRSA

Pre-operative urine testing for urological procedures

A urine specimen should be submitted before the procedure for all patients

Microbiology will advise if standard prophylaxis covers the isolated organism(s), or alternative agent(s) to use for pre-operative prophylaxis if resistant organisms are isolated.

If the procedure involves removal or manipulation of stones, then follow instructions as above, but also pre-treat the patient before their procedure for 3 days using the appropriate antibiotic(s) for the organism(s) isolated

https://live-package-files.s3.amazonaws.com/1670/obsgynaeprophylaxisguidelinesweb151117.pdf

https://live-package-files.s3.amazonaws.com/1670/obsgynaeprophylaxisguidelinesweb151117.pdf

https://www.jogc.com/article/S1701-2163(16)35222-7/pdf?code=jogc-site

https://www.jogc.com/article/S1701-2163(16)35222-7/pdf?code=jogc-site

http://oxfordmedicine.com/view/10.1093/med/9780198804550.001.0001/med-9780198804550-chapter-10?rskey=JSiFJe&result=1

http://oxfordmedicine.com/view/10.1093/med/9780198804550.001.0001/med-9780198804550-chapter-10?rskey=JSiFJe&result=1



If the culture is positive AND the patient has clinical signs and symptoms of a UTI (dysuria and/or frequency):

Treat according to the sensitivity pattern of the isolate, following UTI management guidelines as far as possible

Treatment should be for 10 days, if this period includes the procedure then further prophylaxis is not required

If the procedure occurs after this period, then a follow-up MSU should be collected and the patient should proceed as above peri-operatively.

If the culture is negative AND the patient has clinical signs and symptoms of a UTI:

Assess for empirical treatment of a UTI according to Trust guidelines, taking into account previous sensitivities of isolates

If the culture is positive and the patient is asymptomatic:

Isolates should be checked for sensitivity to agents that will be used for prophylaxis

The regimen for prophylaxis should be modified according to the sensitivities, if needed

There is no additional requirement for pre-treatment of the patient before the procedure if they do not have symptoms, unless it involves manipulation of stones (see above)

High risk orthopaedic procedures (Joint replacement involving prosthetic material and hip resurfacing)

All patients undergoing high risk orthopaedic procedures should have a urine specimen sent in the 9 weeks prior to procedure. The reason for sending the specimen, and the nature of the procedure should be clearly marked on the request form

In asymptomatic patients, positive culture results will be used to ensure that standard empirical surgical prophylaxis is appropriate. In cases where there is potential resistance to empirical agents, the Microbiologist will advise on possible alternative peri-operative antibiotic regimes

Patients without urinary symptoms should not receive antibiotics prior to the operation on the basis of culture results

Patients who are symptomatic of a UTI should be treated according to sensitivities on the MSU.

Other procedures

Pre-operative testing of urine in asymptomatic patients is not indicated

Prophylaxis against Endocarditis

Antibiotic prophylaxis against infective endocarditis is not recommended for the following:

Dental procedures Upper and lower GI tract procedures



Genitourinary tract procedures (includes urological, gynaecological and obstetric procedures, and childbirth)

Upper and lower respiratory tract (includes ENT procedures and bronchoscopy)

Chlorhexidine mouthwash should not be offered as prophylaxis against infective endocarditis to people at risk of infective endocarditis undergoing dental procedures

Any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing.

If a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a GI or GU procedures at a site where there is a suspected infection, the person should receive an antibiotic that covers organisms that cause infective endocarditis. Discuss with the Consultant Microbiologist on call (bleep 193, or via switch) in cases of doubt.

10.4. General Information [open/closed]

Comments

All intravenous antibiotics to be administered by the anaesthetist at induction

NB. Prophylaxis may be altered if evidence of resistant flora. It is the responsibility of the operating surgeon to inform the anaesthetist

Discuss with Microbiology (bleep 193) if uncertainty about resistant flora

If antibiotics given already on the ward, they should be re-dosed unless less than 1 hour has elapsed since administration

If choice between flucloxacillin and teicoplanin – give teicoplanin if MRSA positive (or unknown), or allergy to penicillins

During long surgeries, antibiotics with shorter half-lives should be re-dosed to prevent infection

Standard Doses

Unless otherwise shown in guideline:

Teicoplanin IV 400mg if body weight less than 60kg, or 800mg if 60kg or more – does not require redosing peri-operatively under any circumstance.

Flucloxacillin IV 1g if body weight less than 60kg, or 2g if 60kg or more – redosing is required after 4 hours or blood loss >1500mL, following fluid replacement

Gentamicin IV 160mg – redosing with 80mg is required after 8 hours or blood loss >1500mL, following fluid replacement, in normal renal function ONLY (GFR 60mL/min or more). Dose may need adjusting to take into account pre-existing therapy for total daily dose, which should not exceed 5mg/kg ideal body weight.

Metronidazole IV 500mg – redosing is required after 8 hours, or blood loss >1500mL, following fluid replacement



Co-amoxiclav IV 1.2g – redosing is required after 4 hours in normal renal function (care not to exceed total of 4 doses in 24 hours, including regular therapy). Severe renal impairment [<30mL/min], redosing only required after 8 hours (and maximum 2 doses in 24 hours, including regular therapy). Redosing required if blood loss >1500mL, following fluid replacement.

Ciprofloxacin IV 400mg – redosing is required after 8 hours, no redosing required in case of intra-operative blood loss

Clindamycin 600mg IV – redosing is required after 4 hours or blood loss >1500mL, following fluid replacement

Cefuroxime 1.5g IV – redosing is required after 4 hours for patients with GFR above 20mL/min (severe renal impairment redosing only required after 8 hours), or blood loss >1500mL, following fluid replacement

10.5. Non-Surgical Procedures [open/closed]

Angioplasty

Antibiotics not required

PEG Insertion

1st Line

Co-amoxiclav

Penicillin allergy or MRSA positive

Teicoplanin

PTC/ERCP

High risk if biliary stasis, pancreatic pseudocyst, previous cholangitis, insertion of biliary stent

PTC or High Risk ERCP Ciprofloxacin 750mg PO 90 minutes before procedure Or Gentamicin at induction

Low risk Antibiotics not required In patients with biliary obstruction caused by a stone, it is reasonable to withhold prophylaxis if it is expected that the obstruction will be relieved. Antibiotics can be given post-procedure if the obstruction persists

10.6. General Surgery

Appendicectomy

Gentamicin plus Metronidazole

Breast Cancer

Flucloxacillin or Teicoplanin (depending on allergy status and MRSA status)



Cholecystectomy (laparoscopic)

No antibiotics

Cholecystectomy (open)


Colorectal


Exploratory Laparotomy

No antibiotics (Give treatment dose antibiotics during surgery if infection diagnosed)

Hernia Repair (ASA status 2 or less)

No antibiotics

Hernia Repair (ASA status 3 or more)


10.7. Obstetrics

Caesarean section

See separate guideline for management of Caesarean section and antibiotic prophylaxis

10.8. Trauma and Orthopaedics

NB. in revision surgery with suspected infection antibiotics should not be given at induction, but withheld until immediately after intra-operative sampling.

High risk: Any joint replacement involving prosthetic material; Hip resurfacing

Teicoplanin plus Gentamicin

Moderate risk: ACL reconstruction (if using interference screw); Excision arthroplasty; External fixation; Intra-medullary nailing; K wires; Laminectomy; Open reduction with internal fixation; Osteotomy


Low risk: All other procedures including: Arthroscopy; Carpal Tunnel; Cheilectomy; Decompression; Discography; Excision of cystic lesions etc.; Fasciotomy; Incision and drainage; Manipulation under anaesthesia; Open rotator cuff repair; Removal of foreign body or metalwork; Steroid injection; Tendon release; Wedge resection / Zadeks; Wound closure; Wound exploration / washout

No antibiotics



10.9. Urology

Screen all patients’ urine before a procedure. Always check pre-operative urine results for evidence of resistant organisms For non-stone procedures, microbiology advice will be tailored to ensure that isolated organisms are covered with alternative antibiotics if standard prophylaxis will not suffice. For stone procedures, microbiology advice as for non-stone procedures but patients should also be pre-treated for 3 days before the procedure with an antibiotic that covers the isolated organisms.

Cystoscopy or stent insertion (only if recurrent UTI or asymptomatic bacteriuria)

Gentamicin (NB. See also general advice above)

Endoscopic stone fragmentation


Percutaneous nephrostomy or nephrolithotomy


Trans-rectal biopsy

Ciprofloxacin 750mg PO (120 minutes pre-procedure) or Ciprofloxacin 400mg IV (at induction)

TURBT or TURP

Gentamicin

10.10. Vascular Surgery

With graft material

Teicoplanin plus Gentamicin

Without graft material

No antibiotics

10.11. Ophthalmology

Header

Treat any eye infections before surgery as per guidelines.

No adjustment is made for MRSA status.

The risk of anaphylaxis in patients with penicillin allergy is very small. As the antibiotics are administered in a controlled environment with an anaesthetist present, the benefit generally outweighs any small risk.

Cefuroxime should not be given to patients with documented anaphylaxis to cephalosporins.



In high risk patients (Immunosuppressed, Blepharitis, previous Scleritis, Atopia, Rosacea) then Chloramphenicol drops should be pre-operatively, usually on the morning of surgery.

Cataract – Eyedrops may be with or without preservative, depending on

patient tolerance.

Immediately post-operatively, administered by surgeon: single dose intra-cameral cefuroxime

First line: Chloramphenicol 0.5% eyedrops PLUS Dexamethasone 0.1% or Prednisolone 1% eyedrops – BOTH 1 drop QDS to affected eye(s) for 28 days.

Second line: Ofloxacin 0.3% / Levofloxacin 0.5% P/F eyedrops PLUS Dexamethasone 0.1% or Prednisolone 1% eyedrops – BOTH 1 drop QDS to affected eye(s) for 28 days.

High risk procedure: add anti-inflammatory NSAID such as bromfenac (yellox) [contains preservative], flurbiprofen [preservative-free], ketorolac [contains preservative], nepafenac [contains preservative], diclofenac (not usually held as stock, order in advance of procedure if needed) [preservative-free]

Trabeculectomy – Eyedrops should be preservative-free

Immediately post-operatively, administered by surgeon: single dose sub-conjunctival betamethasone/dexamethasone and cefuroxime injection

Dexamethasone 0.1% P/F eyedrop – 1 drop to affected eye(s) every 2 hours for 2 months, PLUS

Chloramphenicol 0.5% P/F eyedrop – 1 drop to affected eye(s) QDS for 4 weeks, PLUS

Atropine 1% P/F eyedrops – 1 drop to affected eye(s) BD for 3 weeks

Uveitis: as per high risk cataract Intra-vitreal injection: no prophylaxis usually advised Lid procedures

Reconstruction: Chloramphenicol 1% eye ointment apply to affected eyelid(s) BD/TDS for 2-3 weeks PLUS Flucloxacillin 500mg QDS PO for 7 days

Oculoplastic / punctoplasty: as per reconstruction PLUS Maxitrol® drops – 1 drop to affected eye(s) QDS for 2-3 weeks

Bleb needling plus 5-FU injection: As per trabeculectomy, except for


Autologous blood injection into bleb: Eyedrops should be preservative-free




Chloramphenicol 0.5% P/F eyedrop – 1 drop to affected eye(s) QDS for 4 weeks, PLUS

Atropine 1% P/F eyedrops – 1 drop to affected eye(s) BD for 3 weeks

YAG PI

Maxitrol® drops – 1 drop to affected eye(s) QDS for 1-2 weeks, PLUS

Glaucoma drops to reduce intra-ocular pressure, as indicated

10.12. Other Relevant Guidelines [closed]

Medicines Policy

Infection Prevention and Control MRSA Policy

Antimicrobial Prescribing Policy NDDH

Severe Sepsis and Septic Shock Guidelines

10.13. Organisms and Sensitivities [closed]

10.14. Version Control [closed]

Antibiotic Guidelines for Surgical Prophylaxis v1.2 11072018