Makindo Medical Notes

**Key Considerations**: Optimal prophylaxis is typically achieved with a single, preoperative, intravenous antibiotic dose. It’s crucial to administer the antibiotic approximately 30-60 minutes before the first incision (often at induction of anesthesia). Prophylaxis should be tailored based on the expected organisms and patient-specific factors, including allergy and renal function. Re-dosing may be necessary in prolonged surgeries or in cases of significant blood loss.

General Considerations

• Timing: Antibiotic should be administered 30-60 minutes before the first incision.
• Duration: Postoperative antibiotics are generally discouraged due to minimal added benefit and increased resistance risk. However, intraoperative re-dosing may be required if surgery exceeds 4 hours, if there is substantial blood loss (>1.5L), or for extensive fluid replacement.
• Renal Adjustment: Modify doses as needed for patients with renal impairment; consult a microbiologist if unsure.
• Exclusions: For "clean" surgeries, routine prophylaxis is not usually recommended. Prophylaxis should be considered only if there are specific risk factors, such as immunosuppression, diabetes, or insertion of foreign material.

Oesophageal/Gastroduodenal Surgery

• Likely Pathogens: Gram-positive upper respiratory flora, Gram-negative enteric organisms.
• Prophylaxis: Antibiotics generally not indicated unless risk factors present (e.g., obesity, oesophageal obstruction, decreased gastric acidity).
  • Standard: Co-Amoxiclav 1.2g IV, single dose at induction.
  • Penicillin Allergy: Gentamicin 120mg IV, single dose.

Hepatobiliary Surgery (Including Open Cholecystectomy)

• Likely Pathogens: Gram-negative bacilli (enterics), enterococci, anaerobes.
• Prophylaxis: Generally not indicated for elective clean cases; indicated if bile spillage, recent jaundice, or acute inflammation.
  • Standard: Co-Amoxiclav 1.2g IV at induction.
  • Penicillin Allergy: Gentamicin 120mg IV + Metronidazole 500mg IV at induction.

Colorectal Surgery

• Likely Pathogens: Gram-negative bacilli (enterics), enterococci, anaerobes.
• Prophylaxis:
  • Standard: Co-Amoxiclav 1.2g IV at induction, repeat if surgery >5 hours.
  • Penicillin Allergy: Gentamicin 120mg IV + Metronidazole 500mg IV at induction.

Genitourinary Surgery

• Pathogens: Gram-negative enterics, enterococci.
• Procedure-Specific Recommendations:
  • Cystoscopy (rigid): Gentamicin 120mg IV single dose.
  • Transrectal Ultrasound and Biopsy: Ciprofloxacin 1g PO + Gentamicin 120mg IV + Metronidazole 1g PR.
  • Transurethral Resection of Prostate (TURP): Gentamicin 120mg IV at induction; if positive culture, adjust based on sensitivity.

Obstetric and Gynecological Surgery

• Likely Pathogens: Gram-negative bacilli (enterics), enterococci, anaerobes.
• Procedure-Specific Recommendations:
  • Caesarean Section: Co-Amoxiclav 1.2g IV post-umbilical clamping. For penicillin allergy: Gentamicin 120mg IV + Metronidazole 500mg IV.
  • Termination of Pregnancy: Metronidazole 1g PR at induction + Doxycycline 100mg bd PO for 7 days.

Orthopedic Surgery

• Likely Pathogens: Staphylococcus aureus, S. epidermidis, Clostridium spp.
• Procedure-Specific Recommendations:
  • Joint Replacement/Open Fracture Repair: Flucloxacillin 1g IV + Gentamicin 120mg IV at induction. Penicillin allergy: Teicoplanin 400mg IV + Gentamicin 120mg IV.
  • Compound Fracture Repair: Co-Amoxiclav 1.2g IV at induction, repeated every 8 hours as needed. For penicillin allergy: Teicoplanin 400mg IV + Metronidazole 500mg IV + Gentamicin 120mg IV.

Vascular Surgery

• Likely Pathogens: Staphylococci, Streptococci.
• Prophylaxis: Co-Amoxiclav 1.2g IV at induction, repeat dose 8 hours later. For penicillin allergy: Teicoplanin 400mg IV + Gentamicin 120mg IV, repeat every 12 hours.

Thoracic Surgery

• Likely Pathogens: Staphylococci, Streptococci, Gram-negative enterics.
• Prophylaxis: Co-Amoxiclav 1.2g IV at induction. For penicillin allergy: Teicoplanin 400mg IV + Gentamicin 120mg IV at induction.

Endocarditis Prophylaxis

• Indications: High-risk cardiac patients (e.g., valvular disease, previous endocarditis) undergoing gastrointestinal/genitourinary procedures.
• Prophylaxis: Administer antibiotics based on suspected pathogens; consult microbiology for tailored therapy.

Pacemaker Implantation

• Prophylaxis: Co-Amoxiclav 1.2g IV single dose before the procedure. For penicillin allergy or MRSA carriers: Teicoplanin 400mg IV single dose before the procedure.

Splenectomy or Dysfunctional Spleen

• Prophylaxis: Phenoxymethylpenicillin (Penicillin V) 500mg PO bd lifelong. Penicillin allergy: Erythromycin 500mg PO od.
• Vaccinations: Ensure vaccinations against S. pneumoniae, H. influenzae, and N. meningitidis are administered at least 2 weeks pre-surgery if possible. Annual influenza vaccination is also recommended.

Additional Notes

• High-Risk Scenarios: If patients are known MRSA carriers, adjust prophylaxis accordingly. For example, use Teicoplanin and Gentamicin as primary agents.
• Renal Adjustments: Consult with microbiology for dosing adjustments in patients with renal impairment, particularly for Gentamicin, Teicoplanin, and Vancomycin.
• MRSA Screening: Screen patients in advance if they fall into high-risk categories or have previously tested positive for MRSA.