Adult Surgical (and Other Interventional) Prophylaxis Guidelines

Antimicrobial prescribing: NHS Borders
NHS Borders

Adult Surgical (and Other Interventional) Prophylaxis Guidelines

The goal of surgical prophylaxis is to reduce the incidence of surgical site infection (SSI), while reducing the risk of adverse effects from the antibiotics used.

All IV doses should be given within 60 minutes prior to skin incision and as close to time of incision as practically possible.

Contaminated or dirty, infected wounds require treatment courses not prophylaxis

Pregnant patients: Gentamicin should be avoided in pregnancy. Cefuroxime is suitable alternative.

Single preoperative doses only to be prescribed unless otherwise stated.

Aim to give indicated prophylaxis before pre-operative urinary catheterisation where this is performed.

Intra-operative re-dosing of surgical prophylaxis

For procedures lasting more than 4 hours, redosing (where indicated) after 4 or 8 hours promotes safe and effective surgical prophylaxis. Decisions around redosing should be made on an individual patient basis taking account of the risks and benefits of repeat dosing. Patients with complex management requirements should be discussed with microbiology colleagues in advance to ensure redosing is safe and appropriate. These recommendations include redosing advice where there is intraoperative blood loss of 1,500 mL or more. It is not recommended to give a repeat dose of antibiotics after every subsequent 1,500 mL blood loss and specialist advice is needed where blood loss exceeds 3,000 mL

Further Intraoperative doses in prolonged procedures of more than 4 hours and/or blood loss >1500ml

 

Antibiotic

Procedure Duration

Blood loss >1500ml

 

Over 4 hours

Over 8 hours

After giving fluid replacement

Amoxicillin IV

Repeat original dose

Repeat original dose (again)

Repeat original dose

Cefuroxime IV

Repeat original dose

Repeat original dose (again)

Repeat original dose

Clindamycin IV

Repeat original dose

Not required

Repeat original dose

Co-amoxiclav IV

Repeat original dose

Repeat original dose (again)

Repeat original dose

Flucloxacillin IV

Repeat original dose

Repeat original dose (again)

Repeat original dose

Gentamicin IV

Not required

Consider

Co-amoxiclav 1.2g IV

Or, in penicillin allergy,

Ciprofloxacin 400mg

Co-amoxiclav 1.2g IV

Or, in penicillin allergy,

Ciprofloxacin 400mg IV

Metronidazole IV

Not required

Repeat original dose

Repeat original dose

Teicoplanin IV

Not required

Not required

Give half original dose if ≥1500ml blood loss within first hour of operation

 

Modifications related to carriage/colonisation with resistant bacteria

MRSA carriage

  • Consider preoperative or perioperative decolonisation
  • If prophylaxis indicated add Teicoplanin IV (400mg or  800mg/600mg for orthopaedic procedures) if not already included in regimen

Gentamicin resistant gram negatives

  • Review microbiology results for available susceptibility information and discuss with microbiologist when feasible
  • When prophylaxis is indicated and susceptibility information is unavailable consider use of meropenem as prophylactic agent.

Modifications related to allergy or other contra-indication to prophylactic antibiotics

Alternatives are generally provided for patients with penicillin allergy. However, as reactions can also occur to these alternatives including teicoplanin, and can be severe, there should be a careful exploration of a patient’s allergy history. Patients should be monitored after administration. For other circumstances when recommended agents cannot be given, please contact microbiology or pharmacy for advice. Omitting agents will affect the cover offered.

Gentamicin dosing

(based on Lothian gentamicin surgical prophylaxis dosing in urology)

Height is used to estimate ideal body weight, dosing equates to approximately 5mg/kg capped at 400mg.

*When height <5 foot use actual body weight to calculate gentamicin dose to maximum of 240 mg (females) or 280mg (males)

Administered as IV bolus over 3 – 5 minutes

Avoid gentamicin if eGFR <20mls/min, seek advice on an alternative from microbiology

Female

Height (feet/inches)

Height (cm)

Gentamicin dose

< 5’

<152

5mg/kg* (max 240mg)

5’ – 5’1”

152 – 155

240mg

>5’1” – 5’6”

>155 – 168

280mg

>5’6” – 5’10”

>168 – 178

320mg

>5’10” – 6’2”

>178 – 188

360mg

> 6’2”

>188 cm

400mg

 

 

 

Male

Height (feet/inches)

Height (cm)

Gentamicin dose

<5’

<152

5mg/kg* (max 280mg)

5’ – 5’4”

152 – 163

280mg

>5’4” – 5’8”

>163 – 173

320mg

>5’8” – 6’1”

>173 – 185

360mg

>6’1”

>185

400mg

 

General Surgery

 

General Surgery

Appendectomy

 

Amoxicillin 1g IV  (or teicoplanin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV(see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

Colorectal surgery

Amoxicillin 1g IV  (or teicoplanin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

Upper GI Surgery

Amoxicillin 1g IV  (or teicoplanin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

Open cholecystectomy

Amoxicillin 1g IV  (or teicoplanin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

Laparoscopic cholecystectomy

Prophylaxis not recommended unless high risk

intraoperative cholangiogram, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, immunosuppression, insertion of prosthetic devices, pregnancy (if pregnant use cefuroxime prophylaxis)

 Amoxicillin 1g IV  (or teicoplanin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

ERCP

 

Ongoing cholangitis – continue established therapy otherwise ciprofloxacin single dose 750mg orally 60-90mins pre procedure

Biliary obstruction / CBD stones / stent change where biliary decompression is not achieved – commence and complete course of treatment with procedure

Where complete biliary drainage unlikely to be achieved e.g. PSC, hilar cholangiocarcinoma. Communicating pancreatic cyst or pseudocyst – ciprofloxacin single dose 750mg orally 60-90mins pre procedure

Biliary complications following liver transplant ciprofloxacin single dose 750 mg orally 60-90mins pre procedure plus vancomycin dosed by guideline

Breast surgery

Prophylaxis should be considered for procedures for breast cancer especially if extending towards the axilla.

Prophylaxis should be considered for breast re-shaping procedures.

Prophylaxis is advised for breast surgery involving the insertion of implants.

 

Flucloxacillin 1g IV

or, if penicillin allergy,

Teicoplanin  400 mg IV

 

Hernia repair with or without mesh

Prophylaxis not routinely recommended

Consider in patients with mesh insertion if: obesity, diabetes, or other risk factors for SSI)

Teicoplanin 400 mg IV

plus

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

Haemorrhoidectomy, including stapled haemorrhoidopexy

Amoxicillin 1g IV  (or teicoplainin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

 

Urology

 

Urology

Transrectal prostate biopsy

Ciprofloxacin 500mg oral 60 minutes before procedure and at 12 hours post procedure

Transurethral resection of prostate

Gentamicin 

Dose as per table above

If long term catheter in place preoperatively add:

Amoxicillin 1g IV  (or teicoplainin 400mg IV if beta-lactam allergy)

TURBT (Local practice)

Gentamicin  Dose as per table above

If long term catheter in place preoperatively add

Amoxicillin 1g IV  (or teicoplainin 400mg IV if beta-lactam allergy)

 

Obstetrics and Gynaecology

 

Obstetrics and Gynaecology

Caesarean Section

Cefuroxime 1.5g IV as a single agent

Or, in immediate (type 1) beta-lactam sensitivity

Clindamycin 900mg IV as a single agent

Gynaecology majors, including PFRs

Amoxicillin 1g IV  (or teicoplainin 400mg IV if beta-lactam allergy)

plus 

Gentamicin IV (see gentamicin surgical prophylaxis dosing table above)  

plus  

Metronidazole 500mg IV

Termination of pregnancy

Doxycycline 100 mg bd orally for 7 days

Applicable groups:

    • Anyone under 20 years old
    • Those undergoing a surgical procedure
    • Previous Chlamydial infection
    • Two or more partners in last year (unless negative NAATS since last partner)

 

Orthopaedic Surgery

 

 Orthopaedic Surgery

Total Joint Arthroplasty (antibiotic loaded cement is also recommended in addition to IV antibiotics)

 

Cefuroxime 1.5g IV at induction as a single agent, followed by 2 doses of 750mg IV at 8 hourly intervals

Or, in immediate (type 1) beta-lactam sensitivity

Teicoplanin  IV 800mg (600mg if weight ≤ 60kg) single dose

plus

Gentamicin IV according to gentamicin surgical prophylaxis table above, single dose

Other arthroplasty procedures

All intramedullary nails

Other internal fixations

Cefuroxime 1.5g IV as a single agent

Or, in immediate (type 1) beta-lactam sensitivity

Teicoplanin  IV 800mg (600mg if weight ≤ 60kg) single dose

plus

Gentamicin IV according to gentamicin surgical prophylaxis table above, single dose

 

Gastrointestinal Endoscopy

 

Gastrointestinal Endoscopy

PEG insertion

Co-amoxiclav 1.2g IV

Or, in penicillin allergy, teicoplanin 400mg IV

Variceal banding in presence of ascites

Co-amoxiclav 1.2g IV

or in immediate (type 1 ) beta-lactam sensitivity

Teicoplainin 6mg/kg

plus

gentamicin  IV (see gentamicin surgical prophylaxis dosing table above)

Variceal bleeding

doses assume normal renal function

Co-amoxiclav 1.2g IV 8 hourly for 5 days

or in immediate (type 1) beta-lactam sensitivity

Co-trimoxazole 960mg IV 12 hourly

(PO when route available)

 

Editorial Information

Last reviewed: 30/04/2026

Next review date: 30/04/2029

Author(s): Duguid, A.

Version: 3.0

Reviewer name(s): Duguid, A.

References

SAPG Good practice recommendations for redosing antibiotics for surgical prophylaxis in adults.https://www.sapg.scot/media/7247/20221121-gprs-for-redosing-antibiotics-for-surgical-prophylaxis.pdf

SAPG Guidance

https://www.sapg.scot/guidance-qi-tools/good-practice-recommendations/surgical-antibiotic-prophylaxis-in-adults-and-children-in-nhs-scotland/ 

https://www.sapg.scot/guidance-qi-tools/good-practice-recommendations/surgical-prophylaxis/good-practice-recommendations-for-re-dosing-antibiotics-for-surgical-prophylaxis-in-adults/

British Society of Gastroenterology.Antibiotic prophylaxis in gastrointestinal endoscopy. Gut 2009; 58: 869-880.

https://gut.bmj.com/content/58/6/869

Antibiotic prophylaxis in surgery, general principles NHS GGC

https://www.rightdecisions.scot.nhs.uk/media/cf3cw4u1/1039-principles-of-surgical-prophylaxis-v8.pdf

Bratzler DW,Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013;70:195–283.

NHS Lothian surgical prophylaxis in urological surgery 

https://www.rightdecisions.scot.nhs.uk/antimicrobial-prescribing-nhs-lothian/antimicrobial-prophylaxis/adult-surgical-prophylaxis/urological-surgery/

https://www.sapg.scot/guidance-qi-tools/good-practice-recommendations/surgical-antibiotic-prophylaxis-in-adults-and-children-in-nhs-scotland/ 

https://www.sapg.scot/guidance-qi-tools/good-practice-recommendations/surgical-prophylaxis/good-practice-recommendations-for-re-dosing-antibiotics-for-surgical-prophylaxis-in-adults/

British Society of Gastroenterology.Antibiotic prophylaxis in gastrointestinal endoscopy. Gut 2009; 58: 869-880.

https://gut.bmj.com/content/58/6/869

Antibiotic prophylaxis in surgery, general principles NHS GGC

https://www.rightdecisions.scot.nhs.uk/media/cf3cw4u1/1039-principles-of-surgical-prophylaxis-v8.pdf

Bratzler DW,Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013;70:195–283.

NHS Lothian surgical prophylaxis in urological surgery 

https://www.rightdecisions.scot.nhs.uk/antimicrobial-prescribing-nhs-lothian/antimicrobial-prophylaxis/adult-surgical-prophylaxis/urological-surgery/