Neurosurgery Antibiotic Prophylaxis Guideline
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Nottingham Antibiotic Guidelines Committee
June 2017 Review June 2020
Neurosurgery Antibiotic Prophylaxis Guideline for Adult and
Paediatric Patients
Mr Tim Hills (Lead Pharmacist Antimicrobials and Infection
Control)
Dr Shanika Crusz (Consultant Microbiologist)
Mr Graham Dow (Consultant Neurosurgeon)
Mr Luke Dowdeswell (Senior Clinical Pharmacist)
Neurosurgery - MSKN
Trust Wide
June 2020
Adult and paediatric patients undergoing Neurosurgical
procedures outlined within the guideline
1. Adult dose Teicoplanin increased to 800mg
2. Paediatric dose teicoplanin increased to max 800mg
3. Gliadel moved to special implants section
4. Extended 24h prophylaxis for special implants
5. MSSA/MRSA decolonisation prior to special implant
surgery
6. Addition of single dose of gentamicin to the teicoplanin
for severe penicillin/cephalosporin allergic patients
undergoing clean/contaminated surgery
7. Addition of cefuroxime to the teicoplanin and
metronidazole for the MRSA positive open injury
trauma patient
8. Addition of gentamicin to the teicoplanin and
metronidazole for the severe penicillin/cephalosporin
allergic open injury trauma patient
National SIGN guidelines on Surgical Antibiotic
Prophylaxis Guideline 104 available from www.sign.ac.uk
S. aureus screening and decolonisation reduces the risk of
surgical site infections in patients undergoing deep brain
stimulation surgery. Lefebvre et al Journal of Hospital Infection
95 (2017) 144-7
Recommended best practice based on clinical experience of
guideline developers.
Page 1 of 6
Contents Page
1. Introduction 3
2. Risk of infection 3
3. Antibiotic Prophylaxis – Principles 4
3.1 Timing for Administration 4
4
3.2 Additional Intra-operative doses
3.3 Post-operative antibiotic prophylaxis 4
4. MRSA decolonisation 4
5. Summary Table for Neurosurgery Antibiotic Prophylaxis Regimens 5
5.1 Adults 5
5.2 Paediatrics 6

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1.Introduction:

 Surgical site infection (SSI) is one of the most common healthcare associated
infections resulting in an average additional hospital stay of 6.5 days per case.
 In operations with a higher risk of infection (e.g. clean-contaminated surgery), peri-
operative antibiotic prophylaxis has been shown to lower the incidence of infection.
 High antibiotic levels at the site of incision for the duration of the operation are
essential for effective prophylaxis.
 Studies have shown that the administration of prophylactic antibiotics after wound
closure does not reduce infection rates further and can result in harm (see below).
 Administration of antibiotics also increases the prevalence of antibiotic-resistant
bacteria and predisposes the patient to infection with organisms such as
Clostridium difficile, a cause of antibiotic-associated colitis. This risk increases with
the duration that antibiotics are given for and is higher in the elderly,
immunosuppressed, patients who have a prolonged hospital stay or who have
received gastro-intestinal surgery.

2. Risk of infection:
The risk of SSI depends on a number of factors; these can be related to the patient or
the operation and some of them are modifiable (see Table 1):

Patient Operation
 Age  Duration of surgical scrub / Skin
 Nutritional status antisepsis
 Diabetes  Preoperative shaving/ preoperative skin
 Smoking prep.
 Obesity  Length of operation
 Coexistent infections at a remote body site  Appropriate antimicrobial prophylaxis
 Colonization with microorganisms  Operating room ventilation
(e.g. Staph. aureus)  Inadequate sterilization of instruments
 Immunosuppression (inc. taking  Foreign material in the surgical site
glucocorticoid steroids or  Surgical drains
immunosuppressant drugs)  Surgical technique inc. haemostasis,
 Length of preoperative stay poor closure, tissue trauma
 Coexistent severe disease that either limits  Post-operative hypothermia
activity or is incapacitating.
 Malignancy

Table 1 Risk factors that increase the rate of SSI

The risk is also related to the amount of contamination with microorganisms the so-
called “class” of the operation (see Table 2):

Class Definition
Clean Operations in which no inflammation is encountered and the respiratory, alimentary or
genitourinary tracts are not entered. There is no break in aseptic operating theatre
technique.
Clean-contaminated Operations in which the respiratory, alimentary or genitourinary tracts are entered but
without significant spillage.
Contaminated Operations where acute inflammation (without pus) is encountered, or where there is
visible contamination of the wound. Examples include gross spillage from a hollow viscus
during the operation or compound/open injuries operated on within four hours
Dirty Operations in the presence of pus, where there is a previously perforated hollow viscus, or
compound/open injuries more than four hours old.
Table 2 Definitions of operation class.

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Peri-operative antibiotics are generally recommended for clean-contaminated or
contaminated operations. “Dirty” operations (e.g. perforated appendectomy) generally
require treatment with antibiotics.

3 Antibiotic Prophylaxis

3.1 Timing for Administration

 Antibiotic prophylaxis administered too early or too late increases the risk of
SSI. Studies suggest that antibiotics are most effective when given ≤30 minutes
before skin is incised.
 The pragmatic approach is to administer prophylaxis towards the end of
induction and ensure that surgery starts within 30 minutes of this time
wherever possible.

3.2 Additional Intra-operative doses

Antibiotic Recommended re-dosing
 High antibiotic levels, at the site of interval/Adult dose to give
incision, for the duration of the operation, Cefuroxime 4 hours, give 1.5g IV
are essential for effective prophylaxis. Flucloxacillin 3 hours, give 1g IV
 Patients who experience major blood loss Gentamicin re-dosing not recommended
(greater than 1500ml) should have fluid Metronidazole 8 hours, give 500mg IV
resuscitation, followed by re-dosing with
Teicoplanin re-dosing not recommended
the recommended prophylaxis regimen Table 3: Recommend re-dosing interval
for that operation (see section 5).
 For operations lasting more than 4 hours re-dosing may be necessary (see
table 3)

3.3 Post-operative antibiotic prophylaxis

 Studies have shown that giving additional antibiotic prophylaxis after wound
closure does not reduce infection rates further. Post-operative antibiotics
should only be given to treat active/on-going infection unless specifically
recommended against the surgical procedure (see section 5 special implants).

4. MRSA / MSSA decolonisation prior to:

Special implants If pre-op screen positive:
Elective surgery Mupirocin 2% (Bactroban) nasal
ointment (topically to each nostril) TDS
for 5 days prior to surgery PLUS
Octenisan washes OD for 5 days and
wash hair twice in the five days starting
prior to surgery.

Emergency surgery Send screen and start Mupirocin 2%

(Bactroban) nasal ointment (topically to
each nostril) TDS, stop if screen
negative continue if positive for 5 days at
the point of admission PLUS Octenisan
washes OD for 5 days and wash hair
twice in the five days at the point of
admission.

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 Section 5.0: Summary Table for Neurosurgical Antibiotic Prophylaxis Regimens in Adult Patients

Procedure Standard Antibiotic Dose / If MRSA positive Severe Penicillin /

Route (if necessary) Cephalosporin Allergy
(NB will cover for MRSA)
Clean Neurosurgery (incl IV Cefuroxime single dose 1.5g IV Teicoplanin single dose 800mg IV Teicoplanin single dose
shunts/EVDs) 800mg
(craniotomy, burr holes, tumours,
haematomas, shunt, EVDs, ommaya
reservoir)
Clean-contaminated IV Cefuroxime single dose 1.5g IV Cefuroxime single dose 1.5g plus IV IV Teicoplanin single dose
(trans-sphenoidal, Acoustic neuroma, Teicoplanin single dose 800mg 800mg + IV Gentamicin 2mg/kg
repair of CSF leak) single dose
Trauma Closed injury/no IV Cefuroxime single dose 1.5g IV Teicoplanin single dose 800mg IV Teicoplanin single dose
contamination 800mg
IV Cefuroxime 1.5g TDS + IV IV Teicoplanin 12mg/kg starting on induction then IV Teicoplanin 12mg/kg starting
Open injury/open Metronidazole 500mg TDS for 72 hrs every 12 hours for 3 doses then 12mg/kg on induction then every 12 hours
depressed (maximum 800mg) once daily + IV Cefuroxime for 3 doses then 12mg/kg
fracture 1.5g TDS + IV Metronidazole 500mg TDS all for (maximum 800mg) once daily +
elevation/retained 72hrs IV Metronidazole 500mg TDS
foreign body both for 72hrs + IV Gentamicin
2mg/kg single dose at induction
Spinal IV Flucloxacillin 2g single dose + IV IV Flucloxacillin 2g single dose + IV Gentamicin IV Teicoplanin 800mg single
(Laminectomy, discectomy, tumours, Gentamicin 2mg/kg single dose 2mg/kg single dose dose + IV Gentamicin 2mg/kg
dural patches, spinal cord tethers, or if mild allergy* IV Cefuroxime 1.5g or if mild allergy* IV Cefuroxime 1.5g single dose single dose
meningocoele repairs) single dose + IV Gentamicin 2mg/kg + IV Gentamicin 2mg/kg single dose
single dose
Special implants (excl IV Flucloxacillin 2g at induction, 3 further IV Flucloxacillin 2g at induction, 3 further doses of IV Teicoplanin 800mg single
shunts/EVDs) doses of 1g every 6 hours** + IV 1g every 6 hours** + IV Gentamicin 2mg/kg single dose + IV Gentamicin 2mg/kg
(any spinal implant/cage/disc Gentamicin 2mg/kg single dose dose single dose
replacement, Baclofen pumps, spinal or if mild allergy* IV Cefuroxime 1.5g at or if mild allergy* IV Cefuroxime 1.5g at induction
†
cord stimulators, cranioplasty, gliadel, induction then 2 further doses of 750mg then 2 further doses of 750mg every 8 hours + IV
deep brain stimulators) every 8 hours + IV Gentamicin single Gentamicin single dose 2mg/kg
dose 2mg/kg
* Mild allergy - mild penicillin allergy only (No urticarial rash within the first 72 hours, anaphylaxis or angioedema)
**Give the second dose early at 3 hours post induction if the patient is still intra-operative.
†
Give the second dose early at 4 hours post induction if the patient is still intra-operative.

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 Section 6.0: Summary Table for Neurosurgical Antibiotic Prophylaxis Regimens in Paediatric Patients (1 month to 18 years)

Procedure Standard Antibiotic Dose / Route If MRSA positive Severe Penicillin /

(if necessary) Cephalosporin Allergy
(NB will cover for MRSA)
Clean Neurosurgery (incl IV Cefuroxime single dose 50mg/kg (max IV Teicoplanin single dose 10mg/kg (max 800mg) IV Teicoplanin single dose
shunts/EVDs) 1.5g) 10mg/kg (max 800mg)
(craniotomy, burr holes, tumours,
haematomas, shunt, EVDs, ommaya
reservoir)
Clean, contaminated IV Cefuroxime single dose 50mg/kg (max IV Cefuroxime single dose 50mg/kg (max 1.5g) IV Teicoplanin single dose
(trans-sphenoidal, Acoustic 1.5g) plus IV Teicoplanin single dose 10mg/kg (max 10mg/kg (max 800mg) + IV
neuroma, repair of CSF leak) 800mg) Gentamicin 4mg/kg
Trauma Closed injury/no IV Cefuroxime single dose 50mg/kg (max IV Teicoplanin single dose 10mg/kg (max 800mg) IV Teicoplanin single dose
contamination 1.5g) 10mg/kg (max 800mg)
Open injury/open IV Cefuroxime 50mg/kg (max 1.5g) TDS + IV Teicoplanin 10mg/kg IV Teicoplanin 10mg/kg (max
depressed fracture IV Metronidazole 7.5mg/kg (max 500mg) (max 800mg) every 12 hours for 3 doses then 800mg) every 12 hours for 3
elevation/ retained TDS for 72 hrs 10mg/kg (max 800mg) once daily + IV Cefuroxime doses then 10mg/kg (max
foreign body 50mg/kg (max 1.5g) TDS + IV Metronidazole 800mg) once daily + IV
7.5mg/kg (max 500mg) TDS all for 72hrs Metronidazole 7.5mg/kg (max
500mg) TDS both for 72hrs + IV
Gentamicin 4mg/kg single dose
at induction
Spinal IV Flucloxacillin 50mg/kg (max 2g) + IV IV Flucloxacillin 50mg/kg (max 2g) + IV IV Teicoplanin single dose
(Laminectomy, discectomy, tumours, Gentamicin 4mg/kg** single dose Gentamicin 4mg/kg** single dose 10mg/kg (max 800mg) + IV
dural patches, spinal cord tethers, or if mild allergy* IV Cefuroxime 50mg/kg or if mild allergy* IV Cefuroxime single dose Gentamicin single dose
meningocoele repairs) (max 1.5g) single dose + IV Gentamicin 50mg/kg (max 1.5g) + IV Gentamicin single dose 4mg/kg**
single dose 4mg/kg** 4mg/kg**
Special implants (excl IV Flucloxacillin 50mg/kg at induction, IV Flucloxacillin 50mg/kg at induction, further IV Teicoplanin single dose
† †
shunts/EVDs) further doses of 25mg/kg every 6 hours + doses of 25mg/kg every 6 hours + IV Gentamicin 10mg/kg (max 800mg) + IV
(any spinal implant/cage/disc IV Gentamicin 4mg/kg** OD for 24 hours 4mg/kg for 24 hours Gentamicin 4mg/kg** single
replacement, Baclofen pumps, spinal or if mild allergy* IV Cefuroxime 50mg/kg or if mild allergy* IV Cefuroxime 50mg/kg (max dose
†† ††
cord stimulators, cranioplasty, (max 1.5g) every 8 hours + IV 1.5g) every 8 hours + IV Gentamicin 4mg/kg**
gliadel, deep brain stimulator) Gentamicin 4mg/kg** OD for 24 hours OD for 24 hours
* Mild allergy – mild penicillin allergy only (No urticarial rash within the first 72 hours, anaphylaxis or angioedema)
**Give the second dose early at 3 hours post induction if the patient is still intra-operative.
† ††
Give the second dose early at 4 hours post induction if the patient is still intra-operative. Give the second dose early at 4 hours post induction if the patient is still intra-operative

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