Antibiotic Prophylaxis in Neurosurgery in Adults (217)

A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Recommendations

Single dose, IV prophylaxis ≤ 60 minutes prior to skin incision / intervention.
Gentamicin*

See appendix 1 for prophylactic dosing
Doses of up to 400mg gentamicin can be given by slow IV injection over 3 – 5 minutes.
If subsequent treatment using gentamicin is required, measure gentamicin concentration 6-14 hours post theatre gentamicin dose, and follow GGC guidance on staffnet for gentamicin dosing. Calculate the gentamicin dose using the online calculator. Discuss with pharmacy if further advice is required (or if out of hours, the on call pharmacist).
Teicoplanin and gentamicin are incompatible when mixed directly and must not be mixed before injection.

If >1.5L blood loss replace fluid and repeat antibiotic dose: cefuroxime, co-amoxiclav, flucloxacillin, metronidazole (all at full prophylactic dose). Give half the original teicoplanin dose if ≥ 1.5L blood loss within the first hour of the operation. Once bleeding is controlled, measure gentamicin concentration. If the gentamicin concentration is < 2.0mg/L re-dose with half the original gentamicin dose.

If surgery >4hrs repeat cefuroxime, co-amoxiclav, flucloxacillin; >8hrs repeat cefuroxime, co-amoxiclav, flucloxacillin, metronidazole. No repeat dosing of teicoplanin if surgery prolonged. If surgery is expected to continue for > 8hours from first gentamicin dose, measure the gentamicin concentration at 6 hours. If the gentamicin concentration is < 2.0 mg/L re-dose with half the original gentamicin dose.

If surgery continues for > 8hours from first antibiotic dose and > 1.5L blood loss

Once bleeding is controlled, measure the gentamicin concentration. If the gentamicin concentration is < 2.0mg/L re-dose with half the original gentamicin dose.

If MRSA: decolonise prior to procedure as per NHS GGC infection control guidelines and discuss with microbiology regarding antibiotic choice.

CPE carriers: If identified as Carbapenemase producing Enterobacteriaceae carriers contact microbiology.

Teicoplanin* if ≤ 40Kg, then teicoplanin 400mg. Give teicoplanin by slow IV injection over 3-5 minutes. Teicoplanin and gentamicin are incompatible when mixed directly, therefore always flush between administrations.

Weight based dosing

Consider increasing the dose of the following antibiotics as below:

	Weight >80 Kg	Weight >160 Kg
Cefuroxime	3g	3g
Metronidazole	1000 mg	1500 mg
	Weight > 100 Kg	Weight > 100 Kg
Co-amoxiclav	Add 1 g IV amoxicillin to 1.2 g Co-amoxiclav	Add 1 g IV amoxicillin to 1.2 g Co-amoxiclav

Table: Procedure > Antibiotic

Procedure	Antibiotic (Single dose IV unless otherwise stated)
Craniotomy	Cefuroxime IV 1.5 g Or If true penicillin/ beta-lactam allergy or MRSA suspected/known Teicoplanin* IV 800mg AND Gentamicin* NB Teicoplanin and gentamicin are incompatible when mixed directly, therefore always flush between administrations.
Clean contaminated (Procedures that breach air sinuses, mastoid air cells or nasal or oral cavity – guidelines as per ENT antibiotic prophylaxis)	Co-amoxiclav IV 1.2 g Or If true penicillin/ beta-lactam allergy or MRSA suspected/known Teicoplanin* IV 800mg AND Metronidazole IV 500 mg
CSF shunt	Flucloxacillin IV 2 g Or If true penicillin/ beta-lactam allergy or MRSA suspected/known Teicoplanin* IV 800mg
Spinal surgery	Flucloxacillin IV 2 g Or Cefuroxime IV 1.5 g Or If true penicillin/ beta-lactam allergy/ MRSA suspected/proven Teicoplanin* IV 800mg
DBS Electrode implantation after first CT brain, prior to Craniotomy	Gentamicin* IV AND Teicoplanin* IV 800mg NB Teicoplanin and gentamicin are incompatible when mixed directly, therefore always flush between administrations.
Change of Implanted Pulse Generator (IPG)/ battery replacement	Gentamicin* IV AND Teicoplanin* IV 800mg NB Teicoplanin and gentamicin are incompatible when mixed directly, therefore always flush between administrations.