Antibiotics for surgical prophylaxis

Wendy Munckhof, Infectious Diseases Physician and Clinical Microbiologist, Princess

Alexandra Hospital, and Senior Lecturer in Medicine, University of Queensland,
Brisbane
90% of this prophylaxis is inappropriate. Most commonly, the

Summary
Surgical antibiotic prophylaxis is defined as
the use of antibiotics to prevent infections at
the surgical site. Prophylaxis has become the
standard of care for contaminated and cleancontaminated surgery and for surgery involving
insertion of artificial devices. The antibiotic
selected should only cover the likely pathogens.
It should be given at the correct time. For most
parenteral antibiotics this is usually on induction
of anaesthesia. A single dose of antibiotic is
usually sufficient if the duration of surgery is four
hours or less. Inappropriate use of antibiotics for
surgical prophylaxis increases both cost and the
selective pressure favouring the emergence of
resistant bacteria.
Key words: surgery, drug utilisation.

antibiotic is either given at the wrong time or continued for too

long.5 Controversy remains as to duration of prophylaxis and
also as to which specific surgical procedures should receive
prophylaxis.4

Indications for surgical antibiotic prophylaxis

A classification system which ranks procedures according to
their potential risk for infectious complications has greatly
facilitated the study of surgical antibiotic prophylaxis. This
system ranks procedures as:

clean

clean-contaminated

contaminated.

This has become a widely accepted standard (Table 1).6

Widely accepted indications for antibiotic prophylaxis are
contaminated and clean-contaminated surgery and operations
involving the insertion of an artificial device or prosthetic
material. Less well-accepted indications for prophylaxis include

(Aust Prescr 2005;28:3840)

clean operations in patients with impaired host defences

or patients in whom the consequences of infection may be

Introduction
Wound infections are the commonest hospital-acquired
infections in surgical patients.1They result in increased antibiotic
usage, increased costs and prolonged hospitalisation.2
Appropriate antibiotic prophylaxis can reduce the risk of

catastrophic, for example neurosurgery, open heart surgery and

ophthalmic surgery.

Principles of surgical antibiotic prophylaxis

postoperative wound infections, but additional antibiotic use

Decide if prophylaxis is appropriate

also increases the selective pressure favouring the emergence

Determine the bacterial flora most likely to cause

of antimicrobial resistance. Judicious use of antibiotics in the

postoperative infection (not every species needs to be

hospital environment is therefore essential.

covered)

Surgical antibiotic prophylaxis is defined as the use of

antibiotics to prevent infections at the surgical site. It must be

clearly distinguished from pre-emptive use of antibiotics to treat

narrowest antibacterial spectrum required

early infection, for example perforated appendix, even though

toxicity, and ease of administration

The original surgical antibiotic prophylaxis experiments were

performed 40 years ago in pigs. The results concluded that
'the most effective period for prophylaxis begins the moment

Administer dose at the right time

Administer antibiotics for a short period (one dose if

surgery of four hours duration or less)

bacteria gain access to the tissues and is over in three hours'.3

Since then there have been many studies in animal models

principles of antibiotic prophylaxis (see box) becoming an

is now for surgical prophylaxis. However, between 30% and

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Do not use antibiotic prophylaxis to overcome poor

surgical technique

accepted part of surgical practice.4

Approximately 3050% of antibiotic use in hospital practice

Avoid antibiotics likely to be of use in the treatment of

serious sepsis

and in humans undergoing surgery. This has resulted in the

Choose the less expensive drug if two drugs are

otherwise of equal antibacterial spectrum, efficacy,

infection may not be clinically apparent.

38

Choose an antibiotic, based on the steps above, with the

Review antibiotic prophylaxis protocols regularly as both

cost and hospital antibiotic resistance patterns may change

Table 1
Classification of surgical procedures according to infection risk 6
Type of surgery

Definition

Examples

Indication for surgical

antibiotic prophylaxis

Clean surgery

Healthy skin incised

Herniorrhaphy, mastectomy,
Mucosa of respiratory, alimentary, cosmetic surgery
genitourinary tract and
oropharyngeal cavity not traversed

Not recommended

Insertion of prosthesis or artificial

device

Hip replacement, heart valve

Recommended

Clean-contaminated

Respiratory, alimentary or
genitourinary tract is penetrated
under controlled conditions
without unusual contamination

Laryngectomy, uncomplicated
appendicectomy, cholecystectomy,
transurethral resection of prostate
gland

Recommended

Contaminated

Macroscopic soiling of operative

field

Large bowel resection, biliary or

genitourinary tract surgery with
infected bile or urine

Strongly recommended

Table 2
Commonest postoperative infective pathogen by type of surgery
Type of surgery

Commonest postoperative pathogens

Suitable antibiotic choice

Insertion of prosthetic heart valves

Staphylococci

Intravenous cephalothin or
intravenous cephazolin

Instrumentation of the lower

urinary tract

Enteric Gram-negative bacteria,

enterococci

Intravenous gentamicin

Colorectal surgery

Enteric Gram-negative bacteria,

enterococci anaerobes

Intravenous metronidazole plus

either intravenous cephalothin or
intravenous cephazolin or
intravenous gentamicin

Upper respiratory tract surgery

Aerobic and microaerophilic

streptococci, anaerobes

Intravenous cephalothin or
intravenous cephazolin

Insertion of prosthetic joints

Choice of antibiotic

multi-resistant pathogens and also because broad spectrum

The choice of the antibiotic for prophylaxis is based on several

antibiotics may be required later if the patient develops serious

factors. Always ask the patient about a prior history of antibiotic

sepsis. The use of 'third generation' cephalosporins such as

allergy, as beta-lactams are the commonest type of antibiotics

ceftriaxone and cefotaxime should therefore be avoided in

used in prophylaxis. A history of severe penicillin allergy

surgical prophylaxis. Often several antibiotics are equal in

(anaphylaxis, angioedema) means that cephalosporins are

also contraindicated, as there is a small but significant risk of
cross-reaction.
Most importantly, the antibiotic should be active against
the bacteria most likely to cause an infection (Table 2). Most
postoperative infections are due to the patient's own bacterial
flora. Prophylaxis does not need to cover all bacterial species

terms of antibacterial spectrum, efficacy, toxicity, and ease of

administration. If so, the least expensive drug should be chosen,
as antibiotics for surgical prophylaxis comprise a large portion
of hospital pharmacy budgets.
Commonly used surgical prophylactic antibiotics include:

intravenous 'first generation' cephalosporins cephazolin or

cephalothin

found in the patient's flora, as some species are either not

particularly pathogenic or are low in numbers or both.

intravenous gentamicin

It is important to select an antibiotic with the narrowest

intravenous or rectal metronidazole (if anaerobic infection is

antibacterial spectrum required, to reduce the emergence of

likely)

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39

oral tinidazole (if anaerobic infection is likely)

concentration, particularly if the antibiotic has a short half-life.

intravenous flucloxacillin (if methicillin-susceptible

Continuing antibiotic prophylaxis until surgical drains have been

staphylococcal infection is likely)

removed is illogical and also of unproven benefit.

intravenous vancomycin (if methicillin-resistant

Conclusion

staphylococcal infection is likely).7

Parenteral 'second generation' cephalosporins such as
cefotetan have improved anaerobic and aerobic Gram-negative
cover compared to first generation cephalosporins. They are
sometimes used as a more convenient, but more expensive,
alternative to the combination of metronidazole plus either first
generation cephalosporin or gentamicin for abdominal surgical
prophylaxis.

Surgical antibiotic prophylaxis is an effective management

strategy for reducing postoperative infections, provided
that appropriate antibiotics are given at the correct time for
appropriate durations and for appropriate surgical procedures.
In most cases, surgical antibiotic prophylaxis is given as a
single intravenous dose as soon as the patient is stabilised
under anaesthetic, prior to skin incision. It is important to use
a narrow spectrum antibiotic appropriate to the site of surgery.

The bacterial flora in some hospitalised patients may

Hospital surgical antibiotic prophylaxis protocols should be

include multi-resistant bacteria such as methicillin-resistant

regularly reviewed, as both the cost of individual antibiotics

staphylococci. An assessment then needs to be made for

and the endemicity of multi-resistant bacteria in certain units or

each surgical procedure about whether or not prophylaxis

hospitals are subject to frequent change.

with parenteral vancomycin is indicated. Unnecessary use of

vancomycin selects for vancomycin-resistant enterococci (VRE),

References

vancomycin-intermediate Staphylococcus aureus (VISA), and

1.

vancomycin-resistant Staphylococcus aureus (VRSA), the first

two of which already occur in Australian hospitals.

Route and timing of antibiotic administration

It is critical to ask the patient about beta-lactam allergy prior
to anaesthesia to minimise the risk of anaphylaxis under
anaesthesia. A test dose of antibiotic is not necessary before
surgery if the patient denies antibiotic allergy.
Prophylactic antibiotics are usually given intravenously as a
bolus on induction of anaesthesia to ensure adequate tissue
concentrations at the time of surgical incision. This timing of
dosing is particularly important for most beta-lactams which
have relatively short half-lives. Vancomycin has to be infused
over one hour so it must be started earlier so the infusion

Horan TC, Culver DH, Gaynes RP, Jarvis WR, Edwards JR,
Reid CR. Nosocomial infections in surgical patients in the
United States, January 1986 June 1992. Infect Control
Hosp Epidemiol 1993;14:73-80.

2. McGowan JE Jr. Cost and benefit of perioperative

antimicrobial prophylaxis: methods for economic analysis.
Rev Infect Dis 1991;13(Suppl 10):S879-89.
3. Burke JF. The effective period of preventative antibiotic
action in experimental incisions and dermal lesions. Surgery
1961;50:161-8.
4. Patchen Dellinger E, Gross PA, Barrett TL, Krause PJ,
Martone WJ, McGowan JE Jr, et al. Quality standard for
antimicrobial prophylaxis in surgical procedures. Clin Infect
Dis 1994;18:422-7.
5. Dettenkofer M, Forster DH, Ebner W, Gastmeier P, Ruden H,
Daschner FD. The practice of perioperative antibiotic
prophylaxis in eight German hospitals. Infection 2002;30:164-7.

pre-medication so that peak tissue levels are attained at the

6. Howard JM, Barker WF, Culbertson WR, Grotzinger PJ,

Iovine VM, Keehn RJ, et al. Postoperative wound infections:
the influence of ultraviolet irradiation of the operative room
and of various other factors. Ann Surg 1964;160(Suppl 2):
1-196.

most critical time, the time of surgical incision.

7.

finishes just before induction.

Intramuscular antibiotics are less commonly used than
intravenous antibiotics. They are typically given at the time of

Oral or rectal antibiotics need to be given earlier to ensure

adequate tissue concentrations during surgery. Metronidazole
suppositories are commonly used in bowel surgery and must
be given 24 hours before it begins. Topical antibiotics are not
recommended, with the exceptions of ophthalmic or burns

Therapeutic Guidelines: Antibiotic. Version 12. Melbourne:

Therapeutic Guidelines Limited; 2003.

8. McDonald M, Grabsch E, Marshall C, Forbes A. Single- versus

multiple-dose antimicrobial prophylaxis for major surgery: a
systematic review. Aust N Z J Surg 1998;68:388-96.
Conflict of interest: none declared

surgery.

Duration of antibiotic administration

Persistence of tissue concentrations past the period of surgery
and recovery of normal physiology following anaesthesia
does not improve efficacy and increases toxicity and cost. If
the operation lasts four hours or less, one antibiotic dose is
usually sufficient.8 In prolonged surgery of greater than four
hours, further antibiotic doses may be required to maintain the

40

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Self-test questions
The following statements are either true or false
(answers on page 51)
5. Narrow spectrum antibiotics are not appropriate for use in
surgical prophylaxis.
6. Surgical antibiotic prophylaxis should continue until any
surgical drains are removed.