Guideline

Surgical Antibiotic Prophylaxis Guideline

1. Purpose
The purpose of this guideline is to optimise the use of antibiotic prophylaxis for surgical procedures at the
Women’s in Parkville and in Sandringham.
Surgical site infections (SSIs) are a common adverse event in hospitalised patients1; 8-10% of gynaecological
surgery patients undergoing an operative procedure will develop an SSI 2. SSIs have been shown to increase
mortality, readmission rate and length of hospital stay3,4. Appropriate and timely antibiotic prophylaxis has been
shown to be highly effective in reducing the incidence of SSI5. The need for surgical antibiotic prophylaxis
varies according to the type of procedure and its associated risk of SSI.
A number of studies across a range of surgical procedures have shown that there is a narrow window of
opportunity for the administration of effective antimicrobial prophylaxis6. Antibiotics need to be present in the
tissue at the time of incision in order to be effective7.
Ideally prophylactic antibiotics should cover the narrowest spectrum of organisms possible in order to minimise
the development of bacterial resistance8. For this reason it is important to consider the likely source of
pathogens in each type of surgery. For most infections that occur after obstetric or gynaecological surgery, the
source of pathogens is the endogenous flora of the patient’s vagina or skin. The endogenous flora of the
genital tract is polymicrobial, consisting of anaerobes, Gram negative aerobes and Gram positive cocci. In
contrast, laparoscopic procedures that do not breach any mucosal surfaces are more commonly contaminated
with skin organisms only (usually Gram positive organisms such as Staphylococci).

2. Definitions
Surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took
place.
Antibiotic prophylaxis is the use of antibiotics before, during, or after a diagnostic, therapeutic, or surgical
procedure to prevent infectious complications. For surgical prophylaxis, these can generally be given prior to
surgical incision.

3. Responsibilities
Surgeons are responsible for requesting the timely administration of appropriate antibiotic prophylaxis for their
surgical patients.
Anaesthetists are responsible for liaison with surgeons and the provision of appropriate and timely antibiotic
prophylaxis.
Pharmacists are responsible for ensuring prompt availability of required antibiotics. They are also responsible
for provision of information to medical and nursing staff regarding doses of antibiotics and administration.

4. Guideline
Table 1 outlines recommended timing and choice of prophylactic antibiotics for surgical procedures at the
Women’s.
An alternative choice of antibiotic is provided where appropriate (e.g. for a patient with penicillin allergy).
The National Health and Medical Research Council (NHMRC) level of evidence for each recommendation is
included in the Table. For some procedures, such as Caesarean section and hysterectomy, antibiotic
prophylaxis is clearly indicated. For other procedures, such as insertion of an intra-uterine device, medical
termination of pregnancy and diagnostic laparoscopy, antibiotic prophylaxis is usually not required. For other
procedures, the evidence is less clear and recommendations are based upon expert agreement until further
research evidence becomes available.

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Table 1: Antibiotics for surgical prophylaxis

Patients with immediate hypersensitivity reactions (eg. urticaria, angio-oedema, bronchospasm, anaphylaxis) to
penicillins, avoid use of penicillins and cephalosporins.

Patients allergic to penicillins (excluding immediate hypersensitivity reactions eg. urticaria, angio-oedema,
bronchospasm and anaphylaxis), use of cephalosporins can be considered.

Surgery 1st line Level of Alternative Comments

evidence9

Obstetric

Caesarean section10-13 Cefazolin I Clindamycin 600 mg IV over at Antibiotics

(cephazolin) 2 g IV, least 20 minutes, within 60 prior to skin
within 60 minutes minutes (ideally 15-30 incision reduce
(ideally 15-30 minutes) before surgical maternal
minutes) before skin incision infection rate
incision. in emergency
or
caesarean
Vancomycin 25 mg/kg IV section.
(maximum 2g)

Termination of Screen patient for Consensus If STI screening not performed

pregnancy (surgical)13- STIs: C. trachomatis, or results unavailable:
16 N. gonorrhoeae, M.
Azithromycin 1 g oral stat
genitalium and
bacterial vaginosis.
Treat the woman
and her partner(s)
prior to ToP17.

Termination of Not indicated I

pregnancy (medical)13

Manual removal of Cefazolin III-3 Clindamycin 600 mg IV

placenta18-19 (cephazolin) 2 g IV,
+
at the time of
induction Gentamicin 2 mg/kg IV
(maximum 560 mg)
+
Metronidazole 500
mg IV, ending the
infusion at the time
of induction

3rd and 4th degree Cefazolin Consensus Clindamycin 600 mg IV

vaginal tears13,20-24 (cephazolin) 2 g IV
+
within 60 minutes
(ideally 15-30 15-30 Gentamicin 2 mg/kg IV
minutes) before the (maximum 560 mg) within 60
repair minutes (ideally 15-30
minutes) before the repair
+
Followed by
Metronidazole 500
trimethoprim/sulfamethoxazole
mg IV within 60
160/800 orally BD +
minutes (ideally 15-
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30 minutes) before metronidazole 400mg orally

the repair BD for 7 days
Followed by
amoxicillin/clavulanic
acid 875/125 orally
BD for 7 days
Cefalexin
(cephalexin) 500mg
orally QID +
metronidazole
400mg orally BD can
be used as an
alternative regimen)

Gynaecological
Note: Prophylactic antibiotics for vaginal packs can be administered for the duration of vaginal pack use which is
usually 24-48 hours.33
Hysterectomy Cefazolin I Clindamycin 600mg IV + Patients
(cephazolin) 2 g IV, should be
(vaginal)13,25 Gentamicin 2mg/kg IV
within 60 minutes screened and
(maximum 560 mg)
(ideally 15-30 treated for
minutes) before bacterial
surgical incision vaginosis
(repeat dose if before
procedure > 3 hours) hysterectomy27
+
Metronidazole 500
mg IV, within 60
minutes (ideally 15-
30 minutes) before
surgical incision

Hysterectomy Cefazolin I Clindamycin 600mg IV over at

(cephazolin) 2 g IV, least 20 minutes, within 60
(abdominal) 13,26
within 60 minutes minutes (ideally 15-30
(ideally 15-30 minutes) before surgical
minutes) before incision
surgical incision
or
(repeat dose if
procedure > 3 hours) Vancomycin 25 mg/kg IV
(maximum 2g)

Urogynaecological Cefazolin III-3 Clindamycin 600mg IV +

procedures (mid- (cephazolin) 2 g IV,
Consensus Gentamicin 2mg/kg IV
urethral sling/TVT, within 60 minutes
(maximum 560 mg)
colposuspension, (ideally 15-30
vaginal prolapse minutes) before
surgery +/- surgical incision
mesh/SSF)28 (repeat dose if
procedure > 3 hours)

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+
Metronidazole 500
mg IV, within 60
minutes (ideally 15-
30 minutes) before
surgical incision

Hysterosalpingography Azithromycin 1 g oral Consensus

or Hysterosocopy or stat
Chromotubation for
patients with dilated
tubes or a history of PID
or tubal damage28

Hysterosalpingography Not indicated IV

or Hysterosocopy or
Chromotubation with
NO history of PID and
normal tubes on
visualisation29

IUD insertion30 Not indicated I Patients

should be
screened and
treated for
STIs prior to
insertion: C.
trachomatis,
N.
gonorrhoeae,
M. genitalium
and bacterial
vaginosis.

Endometrial biopsy31 Not indicated IV

Laparoscopy32 Not indicated II

(diagnostic or
laparoscopy without
breaching
bowel/uterine/vaginal
cavity)

Laparoscopy Cefazolin Consensus Clindamycin 600 mg IV +

(cephazolin) 2 g IV,
(breach of Gentamicin 2 mg/kg IV
within 60 minutes
bowel/uterine/vaginal (maximum 560mg)
(ideally 15-30
cavity or conversion to
minutes) before
operative laparotomy)
surgical incision
(repeat dose if
procedure > 3 hours)
+
Metronidazole 500
mg IV, within 60
minutes (ideally 15-
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30 minutes) before
surgical incision

NHMRC Levels of Evidence9:

Level I: A systematic review of level II studies
Level II: A randomised controlled trial
Level III-1: A pseudo-randomised controlled trial
Level III-2: A comparative study with concurrent controls
Level III-3: A comparative study without concurrent controls
Level IV: A case series with either post-test outcomes or pre-test/ post-test outcomes

5. Evaluation, monitoring and reporting of compliance to this guideline

Compliance to this guideline or procedure will be monitored, evaluated and reported through:
1. Review of hysterectomy and caesarean surgical site infection rate
2. Spot audits of practice under the Quality Use of Medicines program
3. Laboratory review of infection clusters and antimicrobial resistance

6. References
1. ACOG practice bulletin No. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol
2009;113:1180-9.
2. Kamat AA, Brancazio L, Gibson M. Wound infection in gynecologic surgery. Infect Dis Obstet Gynecol
2000;8:230-4.
3. Australian Council for Safety and Quality in Health Care. Preventing Surgical Site Infection: Toolkit. In;
2011.
4. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the
1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp
Epidemiol 1999;20:725-30.
5. Steinberg JP, Braun BI, Hellinger WC, et al. Timing of antimicrobial prophylaxis and the risk of surgical site
infections: results from the Trial to Reduce Antimicrobial Prophylaxis Errors. Ann Surg 2009;250:10-6.
6. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic
administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281-6.
7. Burke JF. The effective period of preventive antibiotic action in experimental incisions and dermal lesions.
Surgery 1961;50:161-8.
8. Weinstein JW, Roe M, Towns M, et al. Resistant enterococci: a prospective study of prevalence, incidence,
and factors associated with colonization in a university hospital. Infect Control Hosp Epidemiol 1996;17:36-
41.
9. National Health and Medical Research Council. NHMRC levels of evidence and grades for
recommendations for developers of guidelines: National Health and Medical Research Council; 2009.
10. Smaill FM, Gyte GM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean
section. Cochrane Database Syst Rev 2014:CD007482.
11. Costantine MM, Rahman M, Ghulmiyah L, et al. Timing of perioperative antibiotics for cesarean delivery: a

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metaanalysis. Am J Obstet Gynecol 2008;199:301 e1-6.

12. Gyte GM, Dou L, Vazquez JC. Different classes of antibiotics given to women routinely for preventing
infection at caesarean section. Cochrane Database Syst Rev 2014:CD008726.
13. eTG July 2016 edition: Antibiotics. Accessed via
https://tgldcdp.tg.org.au.acs.hcn.com.au/topicTeaser?guidelinePage=Antibiotic&etgAccess=true on 6 Jan
2019
14. Low N, Mueller M, Van Vliet HAAM, Kapp N. Perioperative antibiotics to prevent infection after first-
trimester abortion. Cochrane Database Syst Rev 2012:CD005217.
15. The care of women requesting induced abortion. RCOG Evidence-based Clinical Guideline, Number 7.
November 2011. (Accessed at https://www.rcog.org.uk/globalassets/documents/guidelines/abortion-
guideline_web_1.pdf - Copy and Paste into browser to view)
16. Sawaya GF, Grady D, Kerlikowske K, Grimes DA. Antibiotics at the time of induced abortion: the case for
universal prophylaxis based on a meta-analysis. Obstet Gynecol 1996;87:884-90.
17. Cameron ST, Sutherland S. Universal prophylaxis compared with screen-and-treat for Chlamydia
trachomatis prior to termination of pregnancy. BJOG 2002;109:606-9.
18. Ely JW, Rijhsinghani A, Bowdler NC, Dawson JD. The association between manual removal of the
placenta and postpartum endometritis following vaginal delivery. Obstet Gynecol 1995;86:1002-6.
19. WHO guidelines for the management of postpartum haemorrhage and retained placenta 2009.
20. Duggal N, Mercado C, Daniels K, Bujor A, Caughey AB, El-Sayed YY. Antibiotic prophylaxis for prevention
of postpartum perineal wound complications: a randomized controlled trial. Obstet Gynecol 2008;111:1268-
73.
21. Robson S, Higgs P. Third- and fourth-degree injuries. RANZCOG O&G Magazine 2011; 13(2): 20-22.
22. The management of third- and fourth-degree perineal tears. RCOG Green-top Guideline No.29. June 2015.
23. Monash Health Clinical Guideline: Perineal trauma management. 2015.
24. Buppasiri P, Lumbiaganon P, Thinkhamrop J, Thinkhamrop B. Antibiotic prophylaxis for third- and fourth-
degree perineal tear during vaginal birth. Cochrane Database Systematic Reviews. 2014.
25. Duff P, Park RC. Antibiotic prophylaxis in vaginal hysterectomy: a review. Obstet Gynecol 1980;55:193S-
202S.
26. Tanos V, Rojansky N. Prophylactic antibiotics in abdominal hysterectomy. J Am Coll Surg 1994;179:593-
600.
27. Larsson PG, Carlsson B. Does pre- and postoperative metronidazole treatment lower vaginal cuff infection
rate after abdominal hysterectomy among women with bacterial vaginosis? Infect Dis Obstet Gynecol
2002;10:133-40.
28. Antibiotic prophylaxis in gynaecologic procedures. SOGC Clinical Practice Guideline No.275. April 2012
29. Kasius JC, Broekmans FJ, Fauser BC, Devroey P, Fatemi HM. Antibiotic prophylaxis for hysteroscopy
evaluation of the uterine cavity. Fertil Steril 2011;95:792-4.
30. Grimes DA, Schulz KF. Prophylactic antibiotics for intrauterine device insertion: a metaanalysis of the
randomized controlled trials. Contraception 1999;60:57-63.
31. Foden-Shroff J, Redman CW, Tucker H, et al. Do routine antibiotics after loop diathermy excision reduce
morbidity? Br J Obstet Gynaecol 1998;105:1022-5.
32. Kocak I, Ustun C, Emre B, Uzel A. Antibiotics prophylaxis in laparoscopy. Ceska Gynekol 2005;70:269-72.
33. Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG
2009;116:748-757.

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7. Legislation/Regulations related to this guideline

C. trachomatis and N. gonorrhoeae infection are Department of Health notifiable conditions. Forms for
notification can be found at http://ideas.health.vic.gov.au/notifying/what-to-notify.asp.

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