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Antibiotic Surgical Prophylaxis (ASP) Decision Flow From antimicrobial prescription Diagram form: documentation for ordering Type of surgical procedure alternative ASP from Pharmacy or Pharmacy Emergency Cupboard Choice of Agent Duration of ASP

Recommended options All surgery: only 1 YES NO intra-operatively (<24 hrs) * Primary/ Reason Secondary Option *Cardiothoracic surgery: up to 48 hours 2 Documented colonization or infection with 3rd Option known pathogen that won’t be covered by WDGMC ASP guideline

1) Indicate indication of Please document reason on Rx: Prophylaxis antimicrobial prescription 2) Prescribed as per protocol: form for ordering No, indicate reason alternative antibiotic WDGMC: Effective date: 07-09-2016 (Version 2) Antibiotic Surgical Prophylaxis (ASP) Decision Flow Diagram Appropriate dosage, route and timing of administration ASP should be administered ≤ 60 minutes before skin incision (optimal 30 minutes) Administration after skin incision or > 60 minutes before incision reduces effectiveness; 120 minutes for or fluoroquinolones

Recommended Dosage, Route and Duration of administration Redosing interval in hours (from initiation of Preoperative dose) Antimicrobial * Redose in event of massive blood Adult Pediatric loss * 15-20 mg/kg single dose, IV 10-15 mg/kg single dose IV bolus NA bolus (over 2-3 min) (over 2-3 min) / 2.4 g ≥ 70 kg IVI (over 30 min) ≥ 3 mo: 25mg/5mg/kg 4 < 3 mo or < 4kg: 25mg/5 mg/kg IVI (over 30 min) 12 2 g IVI (over 30 min) 40 mg/kg IVI (over 30 min) 2 2 g ≥ 70 kg, 3 gram ≥ 120kg IVI 30 mg/kg IVI (over 30 min) 4 (over 30 min) 1.5 g IVI (over 30 min) 50 mg/kg IVI (over 30min) 2 Ciprofloxacin 400 mg IVI (over 60 min) 10mg/kg IVI (over 30 min) NA Clindamycin 900 mg ≥ 70 kg;600 mg < 70 kg 10 mg/kg IVI (over 30 min) 4 IVI (over 30 min) Fluconazole 400 mg IVI (over 30 min) 6 mg/kg IVI (over 30 min) NA Gentamicin 5-7 mg/kg/dose Single dose,IVI 2.5 mg/kg/dose IVI (over 60 min) NA infusion (over 60 min)

Levofloxacin 500 mg IVI (over 60 min) 10 mg/kg IVI (≤ 250 mg: over 30 min) NA Metronidazole 500 mg – 1 g IVI (over 30 min) 15 mg/kg IVI (30 min) NA - 4.5 g IVI (over 30 min) (over 30 min) *Infants 2-9 mo: 80 2 mg/kg of the piperacillin component IVI *Children > 9 mo and ≤ 40kg: 100 mg/kg of the piperacillin component Vancomycin 15 mg/kg single dose IVI (over 15 mg/kg IVI (over 30 min/ 500 mg) NA 30 min/ 500 mg) WDGMC: Effective date: 07-09-2016 (Version 2) WDGMC Antibiotic Surgical Prophylaxis (ASP) Guideline

Type of Procedure Primary Option Secondary Option Beta-lactam allergy

Colo-rectal Cefoxitin Amoxicillin/clavulanic acid Clindamycin + Gentamicin

Gastro-duodenal Cefazolin Amoxicillin/clavulanic acid Clindamicin Biliary Tract 1;2;5;6 Pipperacilin/Tazobactam Amoxicillin/clavulanic acid Clindamycin + Gentamicin

Amoxicillin/clavulanic acid Cefazolin Clindamycin + Gentamicin Kidney Transplant Indication for Fluconazole addition (ASHP Guidelines): high risk for : antifungal prophylaxis adjusted for renal function. If pancreas transplant as well: include antifungal prophylaxis Piperacillin -tazobactam Amoxicillin/clavulanic acid Clindamycin + Gentamicin/ Amikacin

Liver Transplant 1;3;4 Indication for Fluconazole addition (ASHP Guidelines): includes one or more of the following: known colonization with candida; renal failure; choledochojejunostomy; retransplantation or reoperation Pancreas 1;7 Piperacillin/tazobactam Amoxicillin/clavulanic acid Clindamycin + Gentamicin Head & Neck Amoxicillin/clavulanic acid Cefazolin Clindamycin Vascular & Thoracic Amoxicillin/clavulanic acid Cefazolin Clindamycin

Indication for addition of glycopeptide: documented MRSA colonisation/ infection (add single dose of Vancomycin) Gynaecology, Hysterectomy Procedures Cefazolin or Amoxicillin/clavulanic acid Cefoxitin Clindamycin + Gentamicin

Orthopaedics Cefazolin Glycopeptide Clindamycin

Indication for a glycopeptide: documented MRSA colonization or infection (add single dose of Vancomycin) Amoxicillin/clavulanic acid or Urology Cefuroxime Fluoroquinolone Co-trimoxazole WDGMC: Effective date: 07-09-2016 (Version 2) Reference List Specific references: 1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. 2013. Clinical practice guidelines for antimicrobial prophylaxis in surgery. American Journal of Health-System Pharmacy , 70:195-283

2. Cortes A, Sauvanet A, Bert F, Janny S, Sockeel P, Kianmanesh R, Ponsot P, Ruszniewski P, Belghiti J. 2005. Effect of bilecontamination on immediate outcomes after pancreoticoduodenectomy for tumor.Journal of American College of Surgeons , 202:1 (as referenced by Lermite et al, 2006).

3. Fagiuoli S, Colli A, Bruno R, Craxi A, Gaeta GB, Grossi P, Mondelli MU, Puoti M, Sagnelli E, Stefani S, Toniutto P, Burra P. 2014. Management of infections pre-and post liver transplantation: Report on an AISF consensus conference. Journal of Hepatology , 60: 1075- 1089.

4. Kawecki D, Chmura A, Pacholczyk M, Lagiewska B, Adadynski L, Wasiak D, Malkowski P, Sawicka-Grzelak A, Rokosz A, Szymanowska A, Swoboda-Kopec E, Wroblewska M, Rowinski W, Durlik M, Luczak, M. 2007. Surgical Site Infections in Liver Recipients in the Early Posttransplantation Period: Etiological Agents and Susceptibility Profiles. Transplantation Proceedings , 39:2800-2806.

5. Krajden SK, Yaman M, Fuksa M, Langer JC, Rowan J, Burul CJ, Wooster DL, Deitel M, Borowy ZJ, Smith LC,Baida M, Chong J. 1993. Piperacillin versus Cefazolin given perioperatively to high –risk patients who undergo open Cholecystectomy: a double-blind, randomized trial. Canadian Journal of Statistics , 36: 245-250. Available from: https://www.researchgate.net/publication/14873971_Piperacillin_versus_cefazonlin_given_perioperatively_to_high risk_patients_who_undergo_open_cholecystectomy_A_double-blind_randomized_trial . Date of access: 07-09-2016.

6. Lermite E, Pessaux P, Teyssedou C, Etienne A, Brehant O, Arnaud JP. 2006. Effect of preoperative endoscopic biliary drainage on infections morbidity after pancreatoduodenectomy: a case-control study. The American Journal of Surgery , 195:442-446.

7. Michalak G, Kwiatkowski A, Bieniasz M, Meszaros J, Czerwinski J, Wszola M, Nosek R, Ostrowski K, Chmura A, Danielewicz R, Lisik W, Adadynski L, Fesolowicz S, Dobrowolska A, Durlik M and Rowinski W. 2005. Infectious complications after simultaneous pancreas-kidney transplantation. Transplantation Proceedings , 37:3560-3563. General references: • South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR). 2013. Policy clinical guideline surgical antibiotic prophylaxis guideline. Available from: www.sahealth.sa.gov.au • CHOC Children's antibiotic for surgical prophylaxis guideline. 2010. Available from: http://www.choc.org • SIGN: Scottish Intercollegiate Guidelines Network, NHS, Healthcare Improvement Scotland. 2008. Antibiotic prophylaxis in surgery, a national clinical guide. Available from: http://www.sign.ac.uk/guidelines/fulltext/104/ • NHS foundation trust, Royal Devon and Exeter. 2011. Adult surgical antibiotic prophylaxis guidelines. Available from: http://www.rdehospital.nhs.uk/docs/prof/antimicrobial/Surgical_prophylaxis_guidelines.pdf • Mediclinic. 2013. Corporate policy surgical antimicrobial prophylaxis WDGMC: Effective date: 07-09-2016 (Version 2)