The use of antibiotics to prevent surgical site infection (SSI) is one of the keys to optimize postoperative recovery. Harms associated with antibiotic use (E.g.: allergic/adverse drug reactions) must be taken into consideration when prescribing antibiotic for surgical prophylaxis.

Healthcare providers should comply with the recommendations stipulated in Policy of Surgical Antibiotic Prophylaxis of Ministry of Health, Malaysia.

The principle of antibiotic prophylaxis is to prevent SSI by reducing the burden of microorganisms at the surgical site during the operative procedure. Single-dose prophylaxis is usually sufficient. If antibiotic prophylaxis is continued postoperatively, duration should be less than 24 hours (up to 48 hours for cardiac surgery), regardless of the presence of intravascular catheters or indwelling drains.

In a situation where the patient has pre-existing infections (known or suspected) and will go for a procedure, appropriate treatment regimen is required instead of prophylactic regimen. The optimal time for administration of pre-operative antibiotics is 60 minutes prior to surgical incision. Some antibiotics such as fluoroquinolones and vancomycin require administration over one to two hours; therefore, the administration of these antibiotics should begin within 120 minutes before surgical incision.

An additional dose (re-dosing) of prophylactic antibiotic during operation is indicated if:

• Excessive blood loss (> 1500 ml)

• Procedures exceed two half-lives of the drug

• There are other factors that may shorten the half-life of the prophylactic agent (e.g., extensive burns)

Below is the recommended redosing for common antimicrobial use for surgical antibiotic prophylaxis: 

Individual risk factors for every patient must be considered prior to prescribing SAP. Antibiotic choice/dose may need to be modified according to patient factors such as allergies, renal function and obesity.  For patients with penicillin allergy, vancomycin or clindamycin is recommended unless stated otherwise.  For obese patients, the dose that need adjustment is vancomycin (1.5g if more than 75kg) and cefazolin (2g if less than 120kg and 3g if more than 120kg).

The optimal time for administration of most pre-operative doses is 60 minutes before surgical incision. The antibiotic should be infused completely prior to the incision. 

The need for and choice of SAP depends on the surgical wound classification (clean, clean-contaminated, contaminated, dirty-infected). Choose the appropriate SAP according to local or national guideline. 

In cases of known or suspected pre-existing infections, the appropriate antibiotic treatment regimen is required instead of prophylactic regimen, while ensuring the antibiotic choice has activity against the organism(s) that is most likely to cause post-operative infection. The administration of the treatment dose must be adjusted to ensure adequate plasma and tissue concentrations are achieved at the time of surgical incision and throughout the duration of the surgical procedure. Advice from Infectious Disease physicians is recommended. Patients who are colonized with Methicillin Resistant Staphylococcus aureus (MRSA) should be decolonized before surgery (refer to Policies and Procedures on Infection Prevention and Control, Ministry of Health). 

Post-operative antibiotics are indicated only if infection is suspected or confirmed. For suspected infections, antibiotic regimen may need to be modified according to clinical judgement and microbiological results.

• Ensure antibiotics are ordered so that they are given at the appropriate time based on current guidelines.

• Prescribe the appropriate surgical antibiotic prophylaxis according to local or national guidelines.

• In cases when the prescriptions do not adhere to guidelines, the reason for non-adherence needs to be documented on the medication chart or case notes.

• Prescriber to inform patients and their caregivers about their antimicrobial therapy before surgery.

• Ensure timely supply of antibiotics for surgical prophylaxis, which also includes mechanisms to control access to restricted antimicrobials according to local policy.

• Advice prescribers and nurses with regards to the choice, dose, route, duration and monitoring of antibiotic used in surgical prophylaxis.

• Monitor antibiotic use related to surgical prophylaxis.

• Understand and aware of the existence of policy and guideline of surgical antibiotic prophylaxis for various surgical specialties.

• Ensure administration of prescribed antibiotic for surgical prophylaxis is safe and timely.

• Monitor antibiotic use related to surgical prophylaxis.

• Assist patients and caregivers to gain information and understand about their antimicrobial therapy prior to surgical procedure.