Adult ENT Antibiotic Surgical Prophylaxis Guidelines

Full Title of Guideline: Surgical Antibiotic Prophylaxis Guidelines for

Adult Patients within ENT
Author (include email and role): Tim Hills (Lead Pharmacist Antimicrobials and
Infection Control)
Mr Mat Daniel (ENT Consultant)
Dr Vivienne Weston (Consultant Microbiologist).
Division & Speciality: Diagnostics and Clinical Support, Microbiology
Scope (Target audience, state if Trust Prescribers, trained nurses and pharmacists working
wide): within adult ENT
Review date (when this version goes out 28th February 2022
of date):
Explicit definition of patient group Applies to: Adult patients undergoing ENT
to which it applies (e.g. inclusion and procedures
exclusion criteria, diagnosis):
Excludes: Paediatrics.

Changes from previous version (not Addition of advice regarding the use of antibiotic
applicable if this is a new guideline, enter prophylaxis for patients with epistaxis treated with nasal
below if extensive): packing.
Summary of evidence base this Evidence base 1a and 4+5
guideline has been created from:
SIGN 104: Antibiotic prophylaxis in surgery. July
2008, updated April 2014. Available online:
http://www.sign.ac.uk/ (accessed 24/4/2018)

Recommended best practice based on clinical

experience of guideline developers

This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert.
Caution is advised when using guidelines after the review date or outside of the Trust.

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Surgical Antibiotic Prophylaxis Guidelines for Adult Patients within
ENT
Contents Page
1. Introduction 3
2. Risk of infection 3
3. Antibiotic Prophylaxis – Principles 4
3.1 Timing for Administration 4

3.2 Additional Intra-operative doses 4

3.3 Post-operative antibiotic prophylaxis 4

4. Summary Table for ENT Prophylaxis Regimens in adult patients. 5

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 1. Introduction:

• Surgical site infection (SSI) is one of the most common healthcare associated
infections resulting in an average additional hospital stay of 6.5 days per case.
• In operations with a higher risk of infection (e.g. clean-contaminated surgery), peri-
operative antibiotic prophylaxis has been shown to lower the incidence of infection.
• High antibiotic levels at the site of incision for the duration of the operation are
essential for effective prophylaxis.
• Studies have shown that the administration of prophylactic antibiotics after wound
closure do not reduce infection rates further and can result in harm (see below).
• Administration of antibiotics also increases the prevalence of antibiotic-resistant
bacteria and predisposes the patient to infection with organisms such as Clostridium
difficile, a cause of antibiotic-associated colitis. This risk increases with the duration
that antibiotics are given for and is higher in the elderly, immunosuppressed, patients
who have a prolonged hospital stay or who have received gastro-intestinal surgery.

2. Risk of infection:

The risk of SSI depends on a number of factors; these can be related to the patient or
the operation and some of them are modifiable (see table 1):

Table 1: Risk factors that increase the rate of SSI

Patient Operation

• Age • Duration of surgical scrub / Skin

• Nutritional status antisepsis
• Diabetes • Preoperative shaving/ preoperative
• Smoking skin prep.
• Obesity • Length of operation
• Coexistent infections at a remote body site • Appropriate antimicrobial prophylaxis
• Colonization with microorganisms • Operating room ventilation
(e.g. Staph. aureus) • Inadequate sterilization of instruments
• Immunosuppression (inc. taking • Foreign material in the surgical site
glucocorticoid steroids or • Surgical drains
immunosuppressant drugs) • Surgical technique inc. haemostasis,
• Length of preoperative stay poor closure, tissue trauma
• Coexistent severe disease that either limits • Post-operative hypothermia
activity or is incapacitating.
• Malignancy

The risk is also related to the amount of contamination with microorganisms the so-
called “class” of the operation (see table 2):

Table 2: Definitions of operation class.

Class Definition
Clean Operations in which no inflammation is encountered and the respiratory, alimentary or
genitourinary tracts are not entered. There is no break in aseptic operating theatre
technique.
Clean-contaminated Operations in which the respiratory, alimentary or genitourinary tracts are entered but
without significant spillage.
Contaminated Operations where acute inflammation (without pus) is encountered, or where there is
visible contamination of the wound. Examples include gross spillage from a hollow viscus
during the operation or compound/open injuries operated on within four hours
Dirty Operations in the presence of pus, where there is a previously perforated hollow viscus,
or compound/open injuries more than four hours old.

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Peri-operative antibiotics are generally recommended for clean-contaminated or
contaminated operations. “Dirty” operations (e.g. perforated appendectomy) generally
require treatment with antibiotics.

3. Antibiotic Prophylaxis

3.1 Timing for Administration

• Antibiotic prophylaxis administered too early or too late increases the risk of SSI.
Studies suggest that antibiotics are most effective when given ≤60 minutes
before skin is incised.
• The pragmatic approach is to administer prophylaxis towards the end of
induction and ensure that surgery starts within 60 minutes of this time
wherever possible.

3.2 Additional Intra-operative doses

Antibiotic Recommended re-dosing
• High antibiotic levels, at the site of incision, interval/dose to give
for the duration of the operation, are Cefuroxime 4 hours, give 1.5g IV
essential for effective prophylaxis. Clindamycin 4 hours give 600mg IV
• Patients who experience major blood loss Co-amoxiclav 4 hours, give 1.2g IV
(greater than 1500ml) should have fluid Metronidazole 8 hours, give 500mg IV
resuscitation, followed by re-dosing with the
Teicoplanin re-dosing not recommended
recommended prophylaxis regimen for that Table 3: Recommend re-dosing interval
operation (see section 4).
• For operations lasting more than 4 hours re-dosing may be necessary (see table
3)

3.3 Post-operative antibiotic prophylaxis

Studies have shown that giving additional antibiotic prophylaxis after wound
closure does not reduce infection rates further. Post-operative antibiotics should
only be given to treat active/on-going infection unless specifically recommended
for the surgical procedure (see section 4).

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 4. Summary Table for ENT Antibiotic Prophylaxis Regimens in Adult Patients

Procedure Standard Mild Penicillin Severe Penicillin / Previous / Comments /

Antibiotic Dose / Allergy Cephalosporin current MRSA Further
Route (Not to be used in serious Allergy colonisation Information
penicillin allergy, e.g. urticarial
rash within the first 72 hours,
anaphylaxis or angioedema)
HEAD AND NECK SURGERY - THROAT

Tonsillectomy No antibiotic No antibiotic prophylaxis No antibiotic prophylaxis No antibiotic

prophylaxis required required required prophylaxis required
Adenoidectomy (by curettage or No antibiotic No antibiotic prophylaxis No antibiotic prophylaxis No antibiotic
suction monopolist) prophylaxis required required required prophylaxis required
Clean head and neck surgery (no No antibiotic No antibiotic prophylaxis No antibiotic prophylaxis No antibiotic
mucosal breach) including : prophylaxis required required required prophylaxis required
Parotidectomy, Thyroidectomy, Bilateral
neck dissection
Major head and neck surgery (with Cefuroxime 1500mg IV and Clindamycin 600mg IV at Teicoplanin 800mg If procedure is
Co-amoxiclav 1.2g IV
mucosal breach) Metronidazole 500mg IV at induction IV and prolonged (>4 hours)
at induction
induction Metronidazole IV – re-dosing of
500mg at induction antibiotics maybe
appropriate (see
table 3, page 4).
Salivary gland Contamination No antibiotic No antibiotic prophylaxis No antibiotic prophylaxis No antibiotic
surgery unlikely prophylaxis required required required prophylaxis required
Possible Co-amoxiclav 1.2g IV Cefuroxime 1500mg IV and Clindamycin 600mg IV at Teicoplanin 800mg
contamination (e.g. at induction Metronidazole 500mg IV at induction IV and
mucosal breach) induction Metronidazole IV
500mg at induction

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 Procedure Standard Mild Penicillin Severe Penicillin / Previous / Comments /
Antibiotic Dose / Allergy Cephalosporin current MRSA Further
Route (Not to be used in serious Allergy colonisation Information
penicillin allergy, e.g. urticarial
rash within the first 72 hours,
anaphylaxis or angioedema)
NASAL SURGERY
Routine nose, sinus and endoscopic No antibiotic No antibiotic prophylaxis No antibiotic prophylaxis No antibiotic If active infection,
nasal surgery prophylaxis required required required prophylaxis required treat with appropriate
antibiotics. Review
choice with
microbiology results.
Nasal Packing General Patients No antibiotic No antibiotic prophylaxis No antibiotic prophylaxis No antibiotic
for Epistaxis packed for <48 hours prophylaxis required required required prophylaxis required

Immunocompromised Oral Flucloxacillin Oral Doxycycline 200mg Oral Doxycycline 200mg Oral Doxycycline
(e.g. poorly 500mg QDS until day one then 100mg OD day one then 100mg OD 200mg day one then
controlled diabetes, packs removed until packs removed until packs removed 100mg OD until
on high dose packs removed
immunosuppression,
neutropenic)
General Patients Oral Flucloxacillin Oral Doxycycline 200mg Oral Doxycycline 200mg Oral Doxycycline Patient will probably
packed for >48 hours 500mg QDS until day one then 100mg OD day one then 100mg OD 200mg day one then need definitive
on a case by case packs removed until packs removed until packs removed 100mg OD until management e.g.
basis following senior packs removed theatre, embolisation,
decision due to dissolvable nasal
equivocal evidence. packs
Septorhino- Routine procedures No antibiotic No antibiotic prophylaxis No antibiotic prophylaxis No antibiotic
plasty prophylaxis required required required prophylaxis required

Complex procedures Co-amoxiclav 1.2g IV Cefuroxime 1500mg IV and Clindamycin 600mg IV at Teicoplanin 800mg
e.g. ‘free’ cartilage at induction Metronidazole 500mg IV at induction IV and
replacement or Graft induction Metronidazole IV
500mg at induction

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 Procedure Standard Mild Penicillin Severe Penicillin / Previous / Comments /
Antibiotic Dose / Allergy Cephalosporin current MRSA Further
Route (Not to be used in serious Allergy colonisation Information
penicillin allergy, e.g. urticarial
rash within the first 72 hours,
anaphylaxis or angioedema)
Closure of CSF leak with intranasal Cefuroxime 1.5mg IV and Clindamycin 600mg IV at Teicoplanin 800mg
Co-amoxiclav 1.2g IV
pathology / pack in position Metronidazole 500mg IV at induction IV and
at induction
induction Metronidazole IV
500mg at induction

EAR SURGERY

Cochlear Implants Cefuroxime 1.5g IV Cefuroxime 1.5g IV Clindamycin 600mg IV at Teicoplanin 800mg
induction IV at induction

Bone anchored hearing aids attract Cefuroxime 1.5g IV Cefuroxime 1.5g IV Clindamycin 600mg IV at Teicoplanin 800mg
surgery induction IV at induction
Bone anchored hearing aids connect No antibiotic No antibiotic prophylaxis No antibiotic prophylaxis No antibiotic
prophylaxis required required required prophylaxis required
Ossiculoplasty or stapedectomy No antibiotic No antibiotic prophylaxis No antibiotic prophylaxis No antibiotic
prophylaxis required required required prophylaxis required
Mastoidectomy or tympanomastoid No antibiotic No antibiotic prophylaxis No antibiotic prophylaxis No antibiotic
surgery prophylaxis required required required prophylaxis required
Grommet Insertion Single dose of Single dose of Single dose of Ciprofloxacin
Ciprofloxacin eye Ciprofloxacin eye drops eye drops (unlicensed) in
drops (unlicensed) in (unlicensed) in ear during ear during procedure.
ear during procedure.
procedure.

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