Guidelines for antibiotic

use
By
Doctor Saleem
Holy Family Hospital Rawalpindi

Surgical wound classification

according to contamination
Clean:
Uninfected operative wound in which no
inflammation is encountered and the
respiratory, alimentary, genital, or infected
urinary tract are not entered. Wounds are
primarily closed and, if necessary, drained
with closed drainage.
Infection rate 3.3%

Clean contaminated

Operative wound in which the respiratory,

alimentary, genital or urinary tracts are entered
under controlled conditions and without
unusual contamination
Infection rate 10.8%

Contaminated
Open, fresh, accidental wounds. In addition,
operations with major breaks in sterile
technique or gross spillage from the
gastrointestinal tract, and incisions in which
acute, nonpurulent inflammation is
encountered are included in this category
Infection rate 16.3%

Dirty
Old traumatic wounds with retained devitalized
tissue and those that involve existing clinical
infection or perforated viscera. This definition
suggests that the organisms causing
postoperative infection were present in the
operative field before the operation.
Infection rate 28.6%

Antibiotic Prophylaxis Guidelines

A single preoperative dose of antibiotic is as

effective as full five days course of therapy
assuming uncomplicated procedure.
Prophylactic antibiotics should be
administered within 1 hour prior to incision,
preferably with induction of anesthesia.
Prophylatic antibiotics should target
anticipated organisms.

Contd;

Prophylaxis should not be extended beyond 24 hours

following surgery.
One preoperative and two or three postoperative doses
are sufficient in clean surgery.
Contaminated and dirty procedures should additionally
receive additional postoperative coverage.
During prolonged procedures antibiotic prophylaxis
should be readministered every 3 hours.
Use of antibiotic in procedures classified as
contaminated or infected should be used as therapeutic
and not prophylactic.

Contd;

In traumatically injured patients antibiotics cannot be

given before bacterial contamination occurs.
Cephalosporins especially cephazolin is 1st line
prophylactic agent for most surgical procedures
because of their low toxicity, long serum half life,
broad spectrum of activity, low cost. Third generation
should not be used for routine prophylaxis because
they promote the emergence of resistance.

Available antibiotics

(In Wards)
Inj Augmentin
Inj Ampiclox
Inj Flagyl
Inj Ceftriaxone
Tab novidat
Inj Cephradin

(In Emergency)
Inj ceftriaxone
Inj cefotaxime
Inj Benzyl penicillin
Inj novidat
Inj Flagyl
Inj gentacin
Inj cephradine

Procedure

Likely
Recommen Available
Organisms ded drug

Alternative

CARDIOTHORACI
C

STAPH
AUREUS,
STAPH,EP
STREPT,
GRAM
VE
BACCILI

CEFAZOL CEPHRA
IN,
DINE
CEFAMA
NDOLE,C
EFUROXI
ME

CLINDA
MYCIN,
VANCOM
YCIN

Vascular
Surgery

Staph,
Enterococc
us,gram-ve
baccili

Cefazolin, Cephradine Clindmyci

n
Cefuroxim
e

Head and Organism Clindamy

cin is
Neck
Are
Surgery Anerobes, recomend
ed
Staph
Aureus,
Gram-ve
Urology
surgery
(high risk
Only)
Diabetic,
Catheteriz
ed

Available
Include
metrnidaz
ole +
Cephradi
ne

Altrnate
Cephazoli
n+Metron
idazole

Gram-ve Cefazolin Ciproflox Ciproflox

bacilli
acin
acin,
Enterococ
Gentamyc
us
in

Orthopedi Common 1st line

c surgery Organims

Available 2nd line

1)Closed Staph
aureus,
fracture
Cefazolin Cephradi Clindamy
Staph epi
ne
cin
2) Open
fracture

Staph,
Cefazolin Cephradi Clindamy
+Gentcin n+Gentac cin+
Strept,
in
Gentacin
Gram-ve
Baccili,
Anearobe
s

Amputati Clostridia Metronid

ons
Gram ve azole+
Bacili,
Gentacin
Gram+ve +Flucoxa
cilin
Other
anerobes

Augmenti
n+
Gentacin
+Metroni
dazole

General
Surgery
Gastoduo
denal,Eso
phagial
(High risk
only)

Available
Cephradi
n,
Augmenti
n+Gentac
in

Organism
Enteric
Gram-ve
Bacilli,
Gram +ve
cocci

1st line
Cephazoli
n

2nd line
Clindamy
cin+
Gentacin

Biliary
Tract
Surgery

Enteric
Gram-ve
Bacilli,

Appendic Enteric
ectomy
Gram-ve
bacilli

Cefotaxi Cefotaxi
me single me
dose,
Cefazolin
Cefazolin
+Metroni
dazole
03doses
in non
perforated
,5days in
perforated

Cephradi Cefoxitin
n+Metron
idazole

Colon
Enteric
Surgery Gram-ve
(Elective) Bacilli,
Enterococ
cus,
Anaerobe
s

Oral
Prophyla
xis
Oral
neomycin
+erothroc
in base 1g
Each
at1300,14
00,2100hr
s preop
I/V
Cefazolin
+metroni
dazole

I/v
Cefotaxi
me+
metronida
zole One
dose or
gentacin+
metronida
zole

Oral
neomycin
+metroni
dazole
I/v
Ampicilin
+Gentaci
n+Metron
idazole

Non
elective

Cefoxitin
1g preop+
3 postop
doses 8
hrly

Laprosco
pic
Cholecyst
ectomy

No
antibiotic
prophlaxi
s required

Herial
repair
without
mesh

No
prophylax
is
required

Repair
with
mesh

Cefazolin Cephradi
n
Single
dose

Strangulat Anerobic Cefoxitin Cefotaxi

ed Hernia and
1g 8hrly me+metro
Gram-ve
nidazole
Bacilli

Penetratin
g
abdominal
trauma

Breast
Surgery

Enteric Cefazolin Metronid Metronid

Gram-ve +metroni azole+Cef azole+gen
bacilli
dazole
otaxime tacin
Enteroco
ccus,
Anaerob
es
Augmenti
n

Acute
Cholecyst
itus

Acute
Pancreatit
us(low
risk)
High Risk

Gram ve Ciproflox
Bacilli+A acin
500mg
nerobes
BD+Metr
onidazole
400mg
TDS
Cefuroxi
me

Imipenum

Cefotaxi
me

Antibiotics in pregnancy

Penicillin , Cephalosporin's and Erythromycin

are the drug of choice.
Quinolones, Tetracycline ,Streptomycin are
contraindicated
Amino glycosides , Metronidazole (except 1 st
trimester) , Sulphonamides Can be taken when
indicated.

Thank You