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Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

In any patient with suspected acute encephalitis with no penicillin allergy give:

Code for IV aciclovir is: 3enc

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• If the patient has any signs of meningism (nuchal rigidity, photophobia and headache) treat as per meningitis. If the diagnosis of meningitis vs encephalitis is unclear, treat for BOTH
• Diagnostic tests for encephalitis should include analysis of cerebrospinal fluid (CSF), serum, respiratory samples and faecal samples, as well as magnetic resonance imaging (MRI) and electroencephalogram (EEG)
• For management of neonates and children with possible L. monocytogenes infection, seek expert advice
• Patients at risk of Listeria infection include: neonates and patients who are older than 50 years, immunocompromised, pregnant or debilitated, or those with a history of hazardous alcohol consumption
• Aciclovir should be started in all patients with suspected acute encephalitis while further investigations are underway, because herpes simplex virus (HSV) is the most common treatable cause
• Use the online calculator in the Therapeutic Guidelines Antibiotic to calculate body surface area in children
• A dose of 500 mg/m² is approximately equal to 20 mg/kg for children younger than 5 years and 15 mg/kg for children 5 years to 12 years
• Herpes simplex encephalitis can usually be excluded and empirical therapy stopped based on negative CSF nucleic acid amplification tests (eg polymerase chain reaction [PCR]) and a normal MRI. However, tests for herpes simplex virus in CSF can be negative in very early disease (before day 3 of illness); consider a repeat lumbar puncture and PCR if clinical suspicion is high

References:

See section on encephalitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

In any patient with suspected acute encephalitis with a penicillin allergy give:

Code for IV aciclovir and IV trimethoprim+sulfamethoxazole is: 3enc

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• If the patient has any signs of meningism (nuchal rigidity, photophobia and headache) treat as per meningitis. If the diagnosis of meningitis vs encephalitis is unclear, treat for BOTH
• Diagnostic tests for encephalitis should include analysis of cerebrospinal fluid (CSF), serum, respiratory samples and faecal samples, as well as magnetic resonance imaging (MRI) and electroencephalogram (EEG)
• For management of neonates and children with possible L. monocytogenes infection, seek expert advice
• Patients at risk of Listeria infection include: neonates and patients who are older than 50 years, immunocompromised, pregnant or debilitated, or those with a history of hazardous alcohol consumption
• Aciclovir should be started in all patients with suspected acute encephalitis while further investigations are underway, because herpes simplex virus (HSV) is the most common treatable cause
• Use the online calculator in the Therapeutic Guidelines Antibiotic to calculate body surface area in children
• A dose of 500 mg/m² is approximately equal to 20 mg/kg for children younger than 5 years and 15 mg/kg for children 5 years to 12 years
• Herpes simplex encephalitis can usually be excluded and empirical therapy stopped based on negative CSF nucleic acid amplification tests (eg polymerase chain reaction [PCR]) and a normal MRI. However, tests for herpes simplex virus in CSF can be negative in very early disease (before day 3 of illness); consider a repeat lumbar puncture and PCR if clinical suspicion is high

References:

See section on encephalitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Please follow the flow chart below:

Image taken from the Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019. Section on Neonatal Herpes Simplex Infection

If patient requires treatment for herpes simplex infection give:

Code for IV aciclovir is: 2neh

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• In neonates, infection with herpes simplex virus (HSV) can present with isolated skin or mucous membrane lesions, encephalitis, pneumonitis or disseminated infection. Management is complex and expert advice is required. Please contact infectious diseases immediately for advice on treatment and management
• The duration of treatment depends on the clinical presentation. Disease affecting the skin, eyes and mouth requires 14 days of intravenous therapy. At least 21 days of intravenous therapy is required for neonates with disseminated disease or encephalitis. Treatment for encephalitis should continue until herpes simplex virus is no longer detected in the cerebrospinal fluid—seek advice from infectious diseases
• The role and duration of therapy in high-risk asymptomatic neonates has not been fully established. The risk to the neonate is related to whether the mother’s herpes simplex virus infection is primary and within 6 to 10 weeks of delivery (higher risk) or recurrent (much lower risk). Examples of higher-risk asymptomatic neonates include:
• neonates with negative herpes simplex virus polymerase chain reaction (PCR) tests, but who are born either via vaginal tract or caesarean section to mothers with primary herpes simplex virus active genital lesions at the time of delivery
• neonates with positive herpes simplex virus PCR swabs (from the conjunctiva, mouth and nasopharynx, or rectum) who are born to mothers with a history of recurrent herpes simplex virus infection
• Some experts recommend 10 days of antiviral therapy (as above) for these infants
• Oral aciclovir should not be used for initial treatment of herpes simplex virus infection in neonates. However, there is evidence for oral suppressive therapy (after completion of the intravenous treatment course) to prevent neurological recurrence following encephalitis in neonates. Suppressive therapy with oral aciclovir can also be considered in preterm neonates (to prevent early reactivation of disease) and in term neonates who have skin, eye or mouth lesions (to prevent cutaneous recurrence). Suppressive therapy is usually continued for at least 6 months. Seek expert advice
• After successful treatment, monitor all infants closely for recurrence of herpes simplex virus infection. If recurrence occurs, seek expert advice
• For more comprehensive information, see the Australasian Society for Infectious Diseases (ASID) guidelines Management of Perinatal Infections

References:

See section on neonatal herpes simplex infection - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Following penetrating eye injury please start prophylaxis with:

Following surgical repair, consider adding topical therapy

Code for ciprofloxacin or moxifloxacin PO is: 7pen

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Do not use topical antibiotics if an open globe injury is suspected because preservatives are toxic to the intraocular contents
• While there is no definitive evidence on the most effective pre-emptive treatment, intravitreal ceftazidime plus vancomycin may reduce infection rate in high-risk cases if they can be safely administered at the time of surgery
• Moxifloxacin has better intraocular penetration than ciprofloxacin; however, ciprofloxacin can be used if moxifloxacin is not available
• Moxifloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Moxifloxacin can be used in children when it is the drug of choice
• Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Ciprofloxacin can be used in children when it is the drug of choice

References:

See section on penetrating eye injuries - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Scabies Grading Table

For grade 1 scabies:

AND either

AND with either of the above topical agents, on non treatment days, to the crusted areas apply:

Code for ivermectin is: 1sca

This code is valid for ONE day only. Starting from the first day of treatment for this condition. Infectious diseases must be contacted within 24 hours for all crusted scabies patients. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Take skin scrapings around day 5 for grade 1 crusted scabies to ensure treatment is successful
• Ensure topical agents are applied after the patient normally bathes or showers for the day
• For each admission take skin scrapings, FBC, CRP, LFTs, U+E, blood cultures and pregnancy test for females prior to ivermectin
• Ensure ivermectin is taken with a high fat meal to ensure absorption
• It is important to ensure that the dosage of ivermectin is rounded to the nearest 1.5 mg to ensure that half tablets can be given
• Patients with crusted scabies should remain in isolation until approved for clearance by infection control and infectious diseases
• The non-Government organisation ‘One Disease’ is tackling the issue of Crusted Scabies in the Top End. They can assist with education and follow-up of patients and education/treatment of household contacts. They should be notified of all cases of confirmed crusted scabies
• Antibiotics may be required for secondary bacterial sepsis, which may not be clinically evident and may involve multiple organisms, including Gram-negatives in addition to S. aureus and S. pyogenes. Please contact infectious diseases if sepsis or secondary infection is suspected
• Environmental Measures
1. For patient: hospitalisation preferable, with single room isolation and contact precautions whilst caring for patient (long-sleeved gown, gloves, shoes and hair cover). Bin for PPE should be placed inside the room, so PPE can be removed and binned prior to exit
2. The nail beds can serve as a reservoir for mites. Trim nails adequately, and if concerned about concurrent tinea infection of nails, send clippings for fungal microscopy and culture and consider treatment with oral terbinafine
3. Treat all household members with topical therapy (see Scabies guidelines in eTG and CARPA)
4. Wash bed linen and clothes in hot water (50-60°c)
5. Consider insecticide bombing or fumigation (by EHO) of each room of the house
6. Vacuum cleaning can be used to suck up mites
7. Decontaminate items that cannot be washed by removing from any contact for at least 3 days, allowing the scabies mites to die

References:

See section on crusted scabies - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For grade 2 scabies:

AND either

AND with either of the above topical agents, on non treatment days, to the crusted areas apply:

② Calmurid® (urea 10%, lactic acid 5%) second daily until hyperkeratosis has resolved.

Code for ivermectin is: 1sca

This code is valid for ONE day only. Starting from the first day of treatment for this condition. Infectious diseases must be contacted within 24 hours for all crusted scabies patients. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Grade 2 scabies usually need to be isolated until at least 7 days of treatment, but a scraping could be sent at day 6 to confirm treatment is successful and skin clear in preparation for de-isolation
• Ensure topical agents are applied after the patient normally bathes or showers for the day
• For each admission take skin scrapings, FBC, CRP, LFTs, U+E, blood cultures and pregnancy test for females prior to ivermectin
• Ensure ivermectin is taken with a high fat meal to ensure absorption
• It is important to ensure that the dosage of ivermectin is rounded to the nearest 1.5 mg to ensure that half tablets can be given
• Patients with crusted scabies should remain in isolation until approved for clearance by infection control and infectious diseases
• The non-Government organisation ‘One Disease’ is tackling the issue of Crusted Scabies in the Top End. They can assist with education and follow-up of patients and education/treatment of household contacts. They should be notified of all cases of confirmed crusted scabies
• Antibiotics may be required for secondary bacterial sepsis, which may not be clinically evident and may involve multiple organisms, including Gram-negatives in addition to S. aureus and S. pyogenes. Please contact infectious diseases if sepsis or secondary infection is suspected
• Environmental Measures
1. For patient: hospitalisation preferable, with single room isolation and contact precautions whilst caring for patient (long-sleeved gown, gloves, shoes and hair cover). Bin for PPE should be placed inside the room, so PPE can be removed and binned prior to exit
2. The nail beds can serve as a reservoir for mites. Trim nails adequately, and if concerned about concurrent tinea infection of nails, send clippings for fungal microscopy and culture and consider treatment with oral terbinafine
3. Treat all household members with topical therapy (see Scabies guidelines in eTG and CARPA)
4. Wash bed linen and clothes in hot water (50-60°c)
5. Consider insecticide bombing or fumigation (by EHO) of each room of the house
6. Vacuum cleaning can be used to suck up mites
7. Decontaminate items that cannot be washed by removing from any contact for at least 3 days, allowing the scabies mites to die

References:

See section on crusted scabies - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For grade 3 scabies:

Ivermectin 200 mcg/kg rounded up to the nearest 1.5 mg orally for seven doses on days 0,1,7,8,14,21 and 28.

AND either

AND with either of the above topical agents, on non treatment days, to the crusted areas apply:

② Calmurid® (urea 10%, lactic acid 5%) second daily until hyperkeratosis has resolved.

Code for ivermectin is: 1sca

This code is valid for ONE day only. Starting from the first day of treatment for this condition. Infectious diseases must be contacted within 24 hours for all crusted scabies patients. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Grade 3 crusted scabies usually require isolation for 10-14 days at least, however a repeat scraping at day 7 is recommended to assess mite load. If this remains positive check topical treatment is being adequately applied and ivermectin dosing is correct
• Ensure topical agents are applied after the patient normally bathes or showers for the day
• For each admission take skin scrapings, FBC, CRP, LFTs, U+E, blood cultures and pregnancy test for females prior to ivermectin
• Ensure ivermectin is taken with a high fat meal to ensure absorption
• It is important to ensure that the dosage of ivermectin is rounded to the nearest 1.5 mg to ensure that half tablets can be given
• Patients with crusted scabies should remain in isolation until approved for clearance by infection control and infectious diseases
• The non-Government organisation ‘One Disease’ is tackling the issue of Crusted Scabies in the Top End. They can assist with education and follow-up of patients and education/treatment of household contacts. They should be notified of all cases of confirmed crusted scabies
• Antibiotics may be required for secondary bacterial sepsis, which may not be clinically evident and may involve multiple organisms, including Gram-negatives in addition to S. aureus and S. pyogenes. Please contact infectious diseases if sepsis or secondary infection is suspected
• Environmental Measures
1. For patient: hospitalisation preferable, with single room isolation and contact precautions whilst caring for patient (long-sleeved gown, gloves, shoes and hair cover). Bin for PPE should be placed inside the room, so PPE can be removed and binned prior to exit
2. The nail beds can serve as a reservoir for mites. Trim nails adequately, and if concerned about concurrent tinea infection of nails, send clippings for fungal microscopy and culture and consider treatment with oral terbinafine
3. Treat all household members with topical therapy (see Scabies guidelines in eTG and CARPA)
4. Wash bed linen and clothes in hot water (50-60°c)
5. Consider insecticide bombing or fumigation (by EHO) of each room of the house
6. Vacuum cleaning can be used to suck up mites
7. Decontaminate items that cannot be washed by removing from any contact for at least 3 days, allowing the scabies mites to die

References:

See section on crusted scabies - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

How long has it been since rash onset?

• Less than 72 hours
• More than 72 hours

Is the patient immunocompromised?

• Yes
• No

Is the patient immunocompromised?

• Yes
• No

Is there widespread/disseminated disease?

• Yes
• No

• Widespread disease is characterised by rash in > 1 dermatome often accompanied by systemic symptoms

If patient is immunocompromised and has disseminated shingles:

Code for aciclovir iv is: 3shi

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Treatment should continue for 10-14 days (IV + PO)
• If ocular involvement is present or suspected please contact ophthalmology promptly for review. This includes involvement of the first division of the trigeminal nerve, particularly if there are lesions on the nose as they signify involvement of the nasociliary branch which also innervates the globe
• Treat acute neuropathic pain associated with shingles as per recommendations in the Therapeutic Guidelines section on neuropathic pain
• For patients over 60 years of age a vaccine is available and may be indicated despite previous herpes zoster infection. See the Australian Immunisation Handbook on the library database for details
• In herpes zoster, transmission occurs with both contact and aerosolisation of the vesicle fluid. Airborne Transmission Based precautions must be used when caring for the patient
• After significant clinical improvement switch to oral antiviral therapy (see regimen for uncomplicated shingles) to complete 7 days total (IV + oral)
• To calculate body surface area in paediatrics use:
  √ (Height (cm) x Weight (kg)) ÷ 3600  

References:

See section on herpes zoster therapy - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Uncomplicated shingles treatment:

Code for PO aciclovir or PO valaciclovir is: 7shi

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• If ocular involvement is present or suspected please contact ophthalmology promptly for review. This includes involvement of the first division of the trigeminal nerve, particularly if there are lesions on the nose as they signify involvement of the nasociliary branch which also innervates the globe
• There is evidence that oral valaciclovir is more effective than oral aciclovir in reducing pain in patients with shingles
• Treat acute neuropathic pain associated with shingles as per recommendations in the Therapeutic Guidelines section on neuropathic pain
• There is more safety data to support the use of aciclovir in pregnancy, however there is also some evidence that valaciclovir is safe in pregnancy
• For patients over 60 years of age a vaccine is available and may be indicated despite previous herpes zoster infection. See the Australian Immunisation Handbook on the library database for details
• In herpes zoster, transmission occurs with both contact and aerosolisation of the vesicle fluid. Airborne Transmission Based precautions must be used when caring for the patient

References:

See section on herpes zoster therapy - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Uncomplicated shingles treatment:

In a non-immunocompromised patient there is little benefit from antiviral therapy if the onset of the rash was more than 72 hours prior to presentation.

• There may be some circumstances where treatment may be indicated please contact the infectious diseases team to discuss particular concerns
• If ocular involvement is present or suspected please contact ophthalmology promptly for review. This includes involvement of the first division of the trigeminal nerve, particularly if there are lesions on the nose as they signify involvement of the nasociliary branch which also innervates the globe
• Treat acute neuropathic pain associated with shingles as per recommendations in the Therapeutic Guidelines section on neuropathic pain
• In herpes zoster, transmission occurs with both contact and aerosolisation of the vesicle fluid. Airborne Transmission Based precautions must be used when caring for the patient
• For patients over 60 years of age a vaccine is available and may be indicated despite previous herpes zoster infection. See the Australian Immunisation Handbook on the library database for details

References:

See section on herpes zoster therapy - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is surgical prophylaxis required?

1. Common procedures which do not routinely require surgical prophylaxis are:
• Clean breast surgery without implantation or removal of malignancy
• Lymph node biopsy
• Hernia repair without insertion of prosthetic material (in patient with BMI < 30)
• Surgery on varicose veins without the insertion of prosthetic material
• Superficial surgery through clean skin (clean plastic surgery)
• Routine upper or lower gastroinstestinal endoscopy
• Myringoplasty or tympanoplasty
• Routine arthroscopy
2. If the patient is already on antibiotics, surgical prophylaxis is not required if:
1. The antimicrobial matches the surgical prophylaxis regimen
2. Less than two half lives passed since the antibiotic was last administered (see antibiotic half lives table)
3. And surgery is expected to finish within 2 half lives of the antibiotic (see antibiotic half lives table)

What type of surgery is being performed?

• Assisted vaginal delivery
• Abdominal surgery
• Amputation of a lower limb
• Appendicectomy
• Biliary surgery
• Blepharoplasty
• Breast surgery
• Caesarean section
• Colorectal surgery
• Ear, nose and throat surgery
• Endoscopic ultrasound (diagnostic)
• Endoscopic gastroduodenal procedure (without aspiration)
• Endoscopic oesophageal procedure (without aspiration)
• Endoscopic ultrasound with fine needle aspiration of cystic lesion
• Endoscopic ultrasound of with fine needle aspiration of solid lesions
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Gastroduodenal surgery
• Gastrostomy or jejunostomy tube insertion
• Gynaecological surgery
• Head and neck surgery
• Hernia repair
• Hysterectomy
• Implantable cardiac device insertion
• Neurosurgery procedures
• Maxillofacial procedures
• Oesophageal surgery
• Opthalmic surgery
• Oral maxillofacial procedures
• Orthopaedic surgery
• Parotidectomy
• Rhytidectomy
• Simple head and neck lymph node excision
• Small intestinal surgery
• Spinal surgery
• Submandibular lymph node excision
• Surgical termination of pregnancy
• Thoracic surgery
• Thyroidectomy
• Urological surgery
• Vascular surgery

• The critical period for successful prophylaxis is 4 hours following implantation of organisms into a wound
• In general, a single preoperative dose of a parenteral drug is sufficient and should be given within 30 min preceding the first skin incision
• If the operation is delayed, if there is significant blood loss during surgery, or if surgery is prolonged then a second dose may be required. See the table below for details

Is the patient known to be, or at risk of colonisation with MRSA? (See below)

• MRSA colonised or at risk
• No MRSA colonisation or risk

Risk factors for MRSA colonisation are:

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation which has not been cleared, hospital stay for > 5 days immediately prior to surgery

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is gentamicin contraindicated in this patient? (See below)

• Gentamicin contraindicated
• No gentamicin contraindications

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

Is the limb ischemic?

• Yes
• No

Is the limb ischemic?

• Yes
• No

Is the limb ischemic?

• Yes
• No

Is the limb ischemic?

• Yes
• No

For surgical prophylaxis in a patient with life-threatening penicillin reaction/anaphylaxis use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis in a patient with life-threatening penicillin reaction/anaphylaxis use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis prior to amputation of an ischaemic lower limb in a patient with life-threatening penicillin reaction/anaphylaxis use:

• If actual body weight is more than 20% over the ideal body weight, use ideal body weight to calculate the dose. For morbidly obese patients, seek expert advice

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis prior to amputation of a non-ischaemic lower limb in a patient with life-threatening penicillin reaction/anaphylaxis or cephalosporin allergy:

• If actual body weight is more than 20% over the ideal body weight, use ideal body weight to calculate the gentamicin dose. For morbidly obese patients, seek expert advice
• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis prior to amputation of a lower limb in a patient without life-threatening penicillin reaction/anaphylaxis or cephalosporin allergy, at risk of MRSA use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis in a patient without life-threatening penicillin reaction/anaphylaxis use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis prior to amputation of a lower limb in a patient without a life threatening reaction/anaphylaxis to penicillin at low risk of MRSA use:

For surgical prophylaxis prior to amputation of a lower limb in a patient without a life threatening reaction/anaphylaxis to penicillin at low risk of MRSA:

Surgical prophylaxis is not normally recommended for this procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is the patient known to be, or at risk of colonisation with MRSA? (See below)

• MRSA colonised or at risk
• No MRSA colonisation or risk

Risk factors for MRSA colonisation are:

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation which has not been cleared, hospital stay for > 5 days immediately prior to surgery

Is the patient known to be, or at risk of colonisation with MRSA? (See below)

• MRSA colonised or at risk
• No MRSA colonisation or risk

Risk factors for MRSA colonisation are:

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation which has not been cleared, hospital stay for > 5 days immediately prior to surgery

Is gentamicin contraindicated in this patient? (See below for contraindications)

• Gentamicin contraindicated
• No gentamicin contraindications

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

Is gentamicin contraindicated in this patient? (See below for contraindications)

• No gentamicin contraindications
• Gentamicin contraindicated

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

For surgery in a patient with a life threatening reaction/anaphylaxis to penicillin without MRSA risk factors use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgery in a patient with a life threatening reaction/anaphylaxis to penicillin without MRSA risk factors use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgery in a patient with a life threatening reaction/anaphylaxis to penicillin, intolerant of gentamicin use:

• Please check the patients previous microbiology. If past MRSA is sensitive to trimethoprim+sulfamethoxazole then this will be sufficient for prophylaxis, if it was resistant then please add teicoplanin as per treatment for an MRSA colonised patient without gentamicin contraindications
• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgery in a patient with a life threatening reaction/anaphylaxis to penicillin, intolerant of gentamicin use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis in a patient in a patient without life-threatening penicillin reaction/anaphylaxis use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis in a patient in a patient without life-threatening penicillin reaction/anaphylaxis use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is antibiotic prophylaxis confirmed as necessary?

• Yes
• No

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is antibiotic prophylaxis confirmed as necessary?

• Yes
• No

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is antibiotic prophylaxis confirmed as necessary?

• Yes
• No

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is antibiotic prophylaxis confirmed as necessary?

• Yes
• No

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is antibiotic prophylaxis confirmed as necessary?

• Yes
• No

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is prophylaxis for amputation of a limb?

• Yes
• No

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is antibiotic prophylaxis confirmed as necessary?

• Yes
• No

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is antibiotic prophylaxis confirmed as necessary?

• Yes
• No

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no penicillin allergy
• immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Will the procedure involve incision through the oral mucosa only? (e.g. cleft lip or palate repair)

• yes
• no (skin and oral mucosa incisions anticipated)

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is the patient known to be, or at risk of colonisation with MRSA? (See below)

• MRSA colonised or at risk
• No MRSA colonisation or risk

Risk factors for MRSA colonisation are:

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation which has not been cleared, hospital stay for > 5 days immediately prior to surgery

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is the patient known to be, or at risk of colonisation with MRSA? (See below)

• MRSA colonised or at risk
• No MRSA colonisation or risk

Risk factors for MRSA colonisation are:

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation which has not been cleared, hospital stay for > 5 days immediately prior to surgery

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

For surgical prophylaxis in a patient at risk of MRSA, without life-threatening penicillin reaction/anaphylaxis use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is gentamicin contraindicated in this patient? (See below)

• Gentamicin contraindicated
• No gentamicin contraindications

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

For surgical prophylaxis in a patient with life-threatening penicillin reaction/anaphylaxis use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis in a patient with life-threatening penicillin reaction/anaphylaxis use:

• If actual body weight is 20% or more above ideal body weight dose gentamicin based on ideal body weight

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis in a patient without life-threatening penicillin reaction/anaphylaxis or cephalosporin allergy:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is surgical prophylaxis required?

1. Common head and neck procedures which do not routinely require surgical prophylaxis are:
• Thyroidectomy
• simple lymph node excision (including submandibular lymph node excision)
• parotidectomy
• clean procedures (not listed above)
2. If the patient is already on antibiotics, surgical prophylaxis is not required if:
1. The antimicrobial matches the surgical prophylaxis regimen
2. Less than two half lives passed since the antibiotic was last administered (see antibiotic half lives table)
3. And surgery is expected to finish within 2 half lives of the antibiotic (see antibiotic half lives table)

Will the incision be through mucosal surfaces?

• Yes
• No

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

For a patient with life-threatening penicillin reaction/anaphylaxis use:

• When gentamicin is indicated, if there is at least a moderate likelihood that the procedure will continue longer than 6 hours then consider using a 5mg/kg dose
• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For a patient with life-threatening penicillin reaction/anaphylaxis use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is surgery predicted to be complicated? (i.e. Is entry into the bowel lumen anticipated?)

• Yes
• No

Is the hysterectomy abdominal or vaginal?

• abdominal
• vaginal

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

Diagnostic Criteria for Penicillin Allergy:

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is the procedure a re-operation of a joint arthroplasty?

• yes
• no

Is the procedure a re-operation of a joint arthroplasty?

• yes
• no

Is the patient known to be, or at risk of colonisation with MRSA? (See below)

• MRSA colonised or at risk
• No MRSA colonisation or risk

Risk factors for MRSA colonisation are:

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation which has not been cleared, hospital stay for > 5 days immediately prior to surgery

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For major orthopaedic surgery in a patient with a life threatening reaction/anaphylaxis to penicillin use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For orthopaedic surgery in a patient with a life threatening reaction/anaphylaxis to penicillin use as a single dose:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis for termination of pregnancy give:

• The Therapeutic Guidelines recommend doxycycline 4g po prior to termination of pregnancy however due to poor tolerability a single dose of azithromycin and PR metronidazole is the preferred regimen for TEHS patients (as per the RCOG guidelines)
• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is there any obstruction present?

• Yes
• No

• Obstruction could be due to postoperative adhesions, malignancy, Crohn disease or hernia

Is antibiotic prophylaxis confirmed as necessary?

• Yes
• No

• Antibiotic prophylaxis is not recommended for non-invasive urological surgery in a patient with sterile urine
• For:
  1. Endoscopic urological procedures:
     • Propylaxis is not required for non–invasive urological surgery (eg diagnostic cystoscopy) in a patient with sterile urine. Antibiotic prophylaxis is indicated if there are specific risk factors for infection (renal and ureteric stone procedures, tumor resection, ureteric obstruction)
  2. Open or laparoscopic urological procedures:
     • Prophylaxis is not required for open or laparoscopic urological procedures where the urinary tract is not entered (eg vasectomy, scrotal surgery, varicocele ligation) in a patient with sterile urine, unless there are specific risk factors for infection (eg urinary tract obstriction), or the procedure involves prosthetic material
  3. TURP and Transrectal prostatic biopsy:
     • Prophylaxis is always required
• Preoperative treatment of bacteriuria does not negate the need for surgical antibiotic prophylaxis. An exception is when gentamicin is given preoperatively to treat bacteriuria and is also indicated as prophylaxis

What type of procedure is being performed?

• Endoscopic procedure
• TURP (transurethral resection of prostate)
• Transrectal prostate biopsy
• Transperineal prostate biopsy
• Open or laparoscopic procedure

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• Gentamicin contraindicated

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• Gentamicin contraindicated

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

For surgical prophylaxis use:

• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure
• If there is untreated bacteruria the gentamicin dose should be increased to 3mg/kg

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Surgical prophylaxis is not normally recommended

• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis use:

• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure
• If there is untreated bacteruria the gentamicin dose should be increased to 3mg/kg

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is gentamicin contraindicated in this patient? (See below)

• Gentamicin contraindicated
• No gentamicin contraindications

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• Gentamicin contraindicated

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

Has the patient had a life-threatening reaction or anaphylaxis to penicillin? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

For surgical prophylaxis in a patient with a life threatening reaction/anaphylaxis to penicillin intolerant of gentamicin use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis in a patient with life-threatening penicillin reaction/anaphylaxis use:

• If actual body weight is 20% or more above ideal body weight dose gentamicin based on ideal body weight

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure
• If patient has untreated bacteruria increase the gentamicin dose to 3mg/kg

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis for transrectal prostatic biopsy in a patient with no recent travel to SE Asia use:

• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

Code for ciprofloxacin is: 1uro

This code is valid for A SINGLE DOSE only. IFD must be contacted if any further doses are to be given

If the procedure is delayed beyond 6 hours the 500 mg dose should be repeated prior to surgery

If the patient has had recent travel to South East Asia contact infectious diseases as they may be colonised with an ESBL producing organism

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is entry into the bowel lumen anticipated?

• Yes
• No

Is gentamicin contraindicated in this patient? (See below)

• Gentamicin contraindicated
• No gentamicin contraindications

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

Diagnostic Criteria for Penicillin Allergy:

• Non-life threatening reactions such as minor rash, skin irritation, nausea, diarrhoea or vomiting should not usually be considered life threatening and may not be an allergic reaction at all
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin
• Life-threatening reactions include SJS, DRESS, TENS or any reaction that led to respiratory compromise

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

Diagnostic Criteria for Penicillin Allergy:

• Non-life threatening reactions such as minor rash, skin irritation, nausea, diarrhoea or vomiting should not usually be considered life threatening and may not be an allergic reaction at all
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin
• Life-threatening reactions include SJS, DRESS, TENS or any reaction that led to respiratory compromise

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is gentamicin contraindicated in this patient? (See below)

• Gentamicin contraindicated
• No gentamicin contraindications

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

For open or laparoscopic urological procedures:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure
• If there is untreated bacteruria the gentamicin dose should be increased to 3mg/kg

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is the patient known to be, or at risk of colonisation with MRSA?

• MRSA colonised or infected
• No MRSA colonisation or infection

For open or laparoscopic urological procedures:

• If there is a risk of entry into the bowel lumen (eg ileal conduit, rectoceale repair) then add metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV, within 30 minutes of surgical incision
• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For open or laparoscopic urological procedures where gentamicin is contraindicated and patient has MRSA infection:

• If there is a risk of entry into the bowel lumen (eg ileal conduit, rectoceale repair) then add metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV, within 30 minutes of surgical incision
• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For open or laparoscopic urological procedures where gentamicin is contraindicated:

• If there is a risk of entry into the bowel lumen (eg ileal conduit, rectoceale repair) then add metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV, within 30 minutes of surgical incision
• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

Diagnostic Criteria for Penicillin Allergy:

• Non-life threatening reactions such as minor rash, skin irritation, nausea, diarrhoea or vomiting should not usually be considered life threatening and may not be an allergic reaction at all
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin
• Life-threatening reactions include SJS, DRESS, TENS or any reaction that led to respiratory compromise

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

For open or laparoscopic urological procedures:

• If there is a risk of entry into the bowel lumen (eg ileal conduit, rectoceale repair) then add metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV, within 30 minutes of surgical incision
• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure
• If there is untreated bacteruria the gentamicin dose should be increased to 3mg/kg

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For open or laparoscopic urological procedures:

• If there is a risk of entry into the bowel lumen (eg ileal conduit, rectoceale repair) then add metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV, within 30 minutes of surgical incision
• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure
• If there is untreated bacteruria the gentamicin dose should be increased to 3mg/kg

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is surgical prophylaxis required?

• For ERCP surgical prophylaxis is not required for:
• ERCP with evidence of biliary tract obstruction if complete biliary drainage is likely to be achieved
• Other ERCP procedures if the patient does not have communicating pancreatic cysts or pseudocysts
• For ERCP surgical prophylaxis is required for:
• ERCP involving transpapillary or transmural drainage of pseudocyst
• ERCP with evidence of biliary tract obstruction ONLY IF complete biliary drainage may not be achieved
• other ERCP procedures ONLY if the patient has communicating pancreatic cysts or pseudocysts
• If the patient is already on antibiotics, surgical prophylaxis is not required if:
1. The antimicrobial matches the surgical prophylaxis regimen
2. Less than two half lives passed since the antibiotic was last administered (see antibiotic half lives table)
3. And surgery is expected to finish within 2 half lives of the antibiotic (see antibiotic half lives table)

(If prophylyaxis is needed) Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• Gentamicin contraindicated

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

For surgical prophylaxis in a patient with contraindications to gentamicin use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis in a patient with no gentamicin contraindications use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure
• If there is untreated bacteruria the gentamicin dose should be increased to 3mg/kg

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is the patient known to be, or at risk of colonisation with MRSA? (See below)

• MRSA colonised or at risk
• No MRSA colonisation or risk

Risk factors for MRSA colonisation are:

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation which has not been cleared, hospital stay for > 5 days immediately prior to surgery

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Does the patient have a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

For surgical prophylaxis in a patient with life-threatening penicillin reaction/anaphylaxis use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis in a patient with life-threatening penicillin reaction/anaphylaxis use as a single agent:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis in a patient without life-threatening penicillin reaction/anaphylaxis or cephalosporin allergy:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is the patient known to be, or at risk of colonisation with MRSA? (See below)

• MRSA colonised or at risk
• No MRSA colonisation or risk

Risk factors for MRSA colonisation are:

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation which has not been cleared, hospital stay for > 5 days immediately prior to surgery

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Does the patient have a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is gentamicin contraindicated in this patient? (See below for contraindications)

• Gentamicin not contraindicated
• Gentamicin contraindicated

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

For surgical prophylaxis in a patient with life-threatening penicillin reaction/anaphylaxis use as a single agent:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis in a patient without life-threatening penicillin reaction/anaphylaxis or cephalosporin allergy:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgical prophylaxis in a patient without life-threatening penicillin reaction/anaphylaxis use:

• Tobramycin eye drops should only be considered for patients hypersensitive to chloramphenicol but this does not have activity against Gram-positive organisms
• Active conjunctivitis, dacryocystitis or blepharitis must be treated and resolved before surgery.
• Prevention of endophthalmitis involves a combination of preoperative screening, antisepsis, intraoperative techniques, and postoperative patient care.
• Antibiotics (particularly vancomycin) in irrigation solutions should not be used
• There is a lack of evidence to support use of topical quinolones, seek expert advice if topical quinolones are deemed necessary

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has the patient had a life-threatening reaction or anaphylaxis to penicillin or a cephalosporin allergy? (See below for details on penicillin allergy severity)

• no allergy, or immediate non-severe or delayed non-severe penicillin hypersensitivity
• immediate severe or delayed severe penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Anaphylaxis/life-threatening reaction

• This includes anaphylaxis (see below) and other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is the patient known to be, or at risk of colonisation with MRSA? (See below)

• MRSA colonised or at risk
• No MRSA colonisation or risk

Risk factors for MRSA colonisation are:

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation which has not been cleared, hospital stay for > 5 days immediately prior to surgery

Is gentamicin contraindicated in this patient? (See below for contraindications)

• No gentamicin contraindications
• Gentamicin contraindicated

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

For surgery in a patient with a life threatening reaction/anaphylaxis to penicillin without MRSA risk factors use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure
• Postoperative antibiotic doses can be considered for up to a maximum of 24 hours for patients undergoing laryngectomy

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For surgery in a patient with a life threatening reaction/anaphylaxis to penicillin without MRSA risk factors use:

• If surgery is prolonged for more than 3 hours see the surgical prophylaxis antibiotic half life nomogram for details on when to redose antibiotics
• A repeat intra-operative dose may also be required if there is excessive blood loss during the procedure
• Postoperative doses of antibiotics are only required in defined circumstances (eg some cardiac and vascular surgeries, laryngectomy, total knee arthroplasty and lower limb amputation). Prophylaxis should not continue beyond 24 hours regardless of the surgical procedure
• Postoperative antibiotic doses can be considered for up to a maximum of 24 hours for maxillofacial surgery

References:

See section on surgical prophylaxis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have an active infection or a wound at high risk of infection? See below for details

• Yes
• No

• Wounds with delayed presentation for washout (8 hours or more)
• Puncture wounds which can not be debrided adequately
• Wounds on the hands feet or face
• Wounds involving deeper tissues (eg. bones, joints, tendons)
• Wounds in immunocompromised patients
• Wounds which also involve an open fracture (see open fracture section)
• Risk factors for severe disease such as; liver disease, iron overload, immune compromise due to immunosuppressive medications, diabetes or malignancy

Was the wound exposed to fresh or salt water? See below for details

• Yes
• No

• Wounds with delayed presentation for washout (8 hours or more)
• Puncture wounds which can not be debrided adequately
• Wounds on the hands feet or face
• Wounds involving deeper tissues (eg. bones, joints, tendons)
• Wounds in immunocompromised patients
• Wounds which also involve an open fracture (see open fracture section)
• Risk factors for severe disease such as; liver disease, iron overload, immune compromise due to immunosuppressive medications, diabetes or malignancy

Does the patient have a penicillin allergy? See below for details on penicillin allergy severity

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR