Title:

Antibiotic Guidelines: Antibiotic

Prophylaxis in neurosurgery
Authors Name:

Antibiotic Steering Committee

Contact Name:

Christine Khan

Contact Phone No:

Departments/Groups This Document Applies
to:

All
Trustwide
Scope: Trustwide

Classification: Guideline

Keywords: Antibiotics,

Infection

Antibiotic
Prophylaxis in Neurosurgery
(December 2010)
Replaces:

To be read in conjunction with the following documents:

Trusts Medicines Policy

Trust Antibiotic Guidelines
Unique Identifier:

Review Date:

December 2012

144TD(C)25(F4)
Issue Status:

Approved

Issue No: 2

Issue Date: September

2011
Medicines
management Group
Authorised by:

Authorisation Date: 12

th

September 2011

Document for Public Display: Yes

Required NHSLA Evidence

Y/N

If this policy is required for NHSLA evidence, then this document must have been checked
against the current standards for compliance. If this is not known by the author, confirmation
should be sought from the Risk and Health and Safety Department.

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Policy Statement
This policy applies to all clinical staff involved the prescribing of
antimicrobials.
Antimicrobial agents are among the most commonly prescribed drugs and
account for 20% of the hospital pharmacy budget. Unfortunately, the benefits
of antibiotics to individual patients are compromised by the development of
bacterial drug resistance. Resistance is a natural and inevitable result of
exposing bacteria to antimicrobials.
Good antimicrobial prescribing will help to reduce the rate at which antibiotic
resistance emerges and spreads. It will also minimise the many side effects
associated with antibiotic prescribing, such as Clostridium difficile infection. It
should be borne in mind that antibiotics are not needed for simple coughs and
colds. In some clinical situations, where infection is one of several possibilities
and the patient is not showing signs of systemic sepsis, a wait and see
approach to antibiotic prescribing is often justified while relevant cultures are
performed.
This document provides treatment guidelines for the most common situations
in which antibiotic treatment is required. The products and regimens listed
here have been selected by the Trust's Medicines Management Group on the
basis of published evidence. Doses assume a weight of 60-80kg with normal
renal and hepatic function. Adjustments may be needed for the treatment of
some patients.
This document provides treatment guidelines for the appropriate use of
antibiotics. The recommendations that follow are for empirical therapy and do
not cover all clinical circumstances. Alternative antimicrobial therapy may be
needed in up to 20% of cases. Alternative recommendations will be made by
the microbiologist in consultation with the clinical team.
This document refers to the treatment of adult patients (unless otherwise
stated).

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Executive Summary

1. Roles and Responsibilities:

All clinical staff involved in the prescribing of antimicrobials to adhere to this
policy including full documentation on EPMAR as detailed.

2. Policy Implementation Plan

The guideline will form part of the Trust Antibiotic Policy and thus can be
accessed via the Antibiotic and Infection Control hotlinks area on the front
page of Synapse.
In addition, adherence to the policy will be encouraged through FY1 and FY2
teaching sessions.

3. Monitoring and Review

The guidelines will be reviewed on a two-yearly basis. Audits of compliance
with the guideline will be conducted on a regular basis.

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Surgical Prophylaxis Principles

Antimicrobial prophylaxis is indicated during selected clean surgical

procedures and during procedures which involve incision of non-sterile
mucosal surfaces (oral mucosa, respiratory tract, gastroinstestinal tract and
female genito-urinary tract). Local departmental protocols should be followed
where available. Prophylactic antibiotics should be prescribed on the single
dose/pre-medication section of the prescription chart.
Where a patient is at high risk of post-operative MRSA infection,
teicoplanin should be included in the prophylaxis regimen.
Patients at high risk of MRSA infection include:
Patient has a history of MRSA colonisation or infection
Prolonged pre-operative hospital inpatient stay
General Principles
1. The final decision regarding the benefits and risks of antibiotic
prophylaxis for an individual patient will depend on:
the patients risk of surgical site infection
the potential severity of the consequences of surgical site infection
the effectiveness of prophylaxis in that operation
the consequences of prophylaxis for that patient (e.g. increased risk
of C. difficile colitis)
2. Prophylaxis should be started preoperatively, ideally within 30 minutes
of the induction of anaesthesia and within 1 hour of the surgical
incision.
3. Penicillin Allergy: Patients with a history of anaphylaxis, rash or
urticaria occurring immediately after penicillin therapy are at increased
risk of immediate hypersensitivity to penicillins and should not receive
prophylaxis with a betalactam antibiotic (these include penicillins,
cephalosporins, monobactams and carbapenems).
4. An additional dose of prophylactic antibiotic during the operation is
indicated if:
there is major intra-operative blood loss blood loss of > 1500 ml
during surgery. In this case, additional dose of the prophylactic
antibiotic should be given after fluid replacement.
haemodilution up to 15ml/kg
surgery has lasted for more than 4 hours
These rules apply with the EXCEPTION of teicoplanin, gentamicin and
ciprofloxacin, where additional doses are not required.
5. Fluid replacement bags should not be primed with prophylactic
antibiotics because of the potential risks of contamination and
calculation errors
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Antibiotic prophylaxis in Neurosurgery

Neurosurgical procedure
/ operation

Prophylaxis

Clean non implant and

Cranioplasty
(Procedure that does not
breach air sinuses,
mastoid air cells or
nasal or oral cavity)
Clean contaminated
(Procedures that breach
air sinuses, mastoid air
cells or nasal or oral
cavity)

Cefuroxime 1.5 gm IV at
induction and every 4 hours
during surgery

CSF shunt surgery

Primary shunt device
insertion or revision due
to malfunction WITHOUT
evidence of infection
CSF shunt surgery
For revision shunt
procedures FOLLOWING
infection

Cefuroxime 1.5 gm IV at
induction and vancomycin 10
mg intraventricular instillation

External ventricular
drain (EVD) insertion
Penetrating
craniocerebral injuries
and depressed skull
fractures

Cefuroxime 1.5 gm IV AND

metronidazole 500 mg IV at
induction and every 4 hours
during surgery

Prophylaxis if allergic to
penicillin or known to be
colonised or infected with
MRSA at any site
Teicoplanin 400 mg IV at
induction

Teicoplanin 400 mg IV,

Gentamicin 160 mg IV and
metronidazole 500 mg IV at
induction and ONLY IV
metronidazole 500 mg every 4
hours during surgery
Teicoplanin 400 mg IV at
induction and vancomycin 10 mg
intraventricular
instillation

Cefuroxime 1.5 gm IV at
induction and vancomycin 10
mg intraventricular and
gentamicin 5 mg
intraventricular
instillation
Cefuroxime 1.5 gm IV at
induction
Cefuroxime 1.5 gm IV 8
hourly and metronidazole 500
mg IV 8 hourly for 5 days

Teicoplanin 400 mg IV at
induction and vancomycin 10 mg
intraventricular and gentamicin 5
mg intraventricular
instillation

NB: Review tetanus status of

patient and consider
vaccination

NB: Review tetanus status of

patient and consider vaccination

Teicoplanin 400 mg IV at
induction
Discuss with Duty Microbiologist

Antibiotic prophylaxis NOT RECOMMENDED for:

Basal skull fractures
Traumatic CSF fistula
Post surgical CSF leak

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Antibiotic prophylaxis in Skull base surgery

Neurosurgical
procedure / operation

Prophylaxis

All lateral skull /

transmastoid skull base
surgery
Cochlear or brainstem
implant insertion

Cefuroxime 1.5 gm IV at
induction and every 4
hours during surgery
Cefuroxime 1.5 gm IV
and metronidazole 500
mg IV at induction.
Postoperatively give 2
more doses of both the
antibiotics 8 hourly

Extensive anterior
fossa cranio-facial
resections

Discuss with Duty

Microbiologist Depends
on extent of resection
and reconstruction

Prophylaxis if allergic to penicillin

or known to be colonised or
infected with MRSA at any site
Teicoplanin 400 mg IV and
Gentamicin 160 mg IV at induction
Teicoplanin 400 mg IV, Gentamicin
160 mg IV and metronidazole 500
mg IV at induction. Postoperatively
give 2 more doses of IV
metronidazole 8 hourly and one dose
of teicoplanin 400 mg IV after 12
hours
Discuss with Duty Microbiologist
Depends on extent of resection and
reconstruction

Protocol for CSF shunt surgery (internalisation) in patients with an EVD

Follow the following protocol:
v Collect CSF sample for culture 2 -3 days before the procedure from a
port or the Ommaya reservoir if fitted to ensure CSF is sterile
v Instil vancomycin 10 mg into the ventricles immediately after the above
sample is taken
v If the CSF is free flowing (> 100 ml/day) the dose should be repeated
daily until surgery. If the CSF flow is minimal only the first dose may be
necessary
v If surgery is delayed for 1 -2 days, continue vancomycin until surgery,
however if the surgery is delayed or postponed indefinitely, discontinue
vancomycin
v If CSF sample is confirmed to be sterile, no further vancomycin will be
required
v If CSF sample is culture positive, then surgery must be delayed until an
appropriate course of treatment has eradicated the infection

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Key References:
1. Infection in Neurosurgery Working Party of the British Society for
Antimicrobial Chemotherapy. Antimicrobial prophylaxis in neurosurgery
and after head injury. Lancet 1994; 344: 1547-1551.
2. Infection in Neurosurgery Working Party of the British Society for
Antimicrobial Chemotherapy. Use of antibiotics in penetrating
craniocerebral injuries. Lancet 2000; 355: 1813-1817.
3. Infection in Neurosurgery Working Party of the British Society for
Antimicrobial Chemotherapy. The management of neurosurgical
patients with post operative or aseptic meningitis or extended
ventricular drain associated ventriculitis. B J Neurosurg 2000; 14: 7-12.

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Endorsed by:
Name of Lead Clinician/Manager or
Committee Chair

Position of Endorser or Name of

Endorsing Committee

Date

Dr Paul Chadwick

Antibiotic Steering Committee

August 2011

Dr Paul Chadwick

Medicines Management Committee

September 2011

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Record of Changes to Document - Issue number: 3

Changes approved in this document by - Corporate Governance and Risk Management
Section
Amendment (shown in bold
Deletion
Addition
Number

italics)
Antibiotic prophylaxis in
Neurosurgery

Issue [2]
[Sept 2011]

NOT RECOMMENDED

Cefuroxime 1.5 gm IV at induction or

Teicoplanin 400 mg IV at induction for
penicillin allergy or MRSA colonisation

Antibiotic Guidelines: Antibiotic Prophylaxis in Neurosurgery

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Date: 7/7/05

Page 9 of 11

Reason
Change of guidelines

Screening Equality Analysis Outcomes (Policies/Procedures)

The Trust is required to ensure that all our policies/procedures meet the
requirements of its service users, that it is accessible to all relevant groups
and furthers the aims of the Equality Duty for all protected groups by
age, religion/belief, race, disability, sex, sexual orientation, martial
status/civil partnership, pregnancy/maternity, gender re-assignment.
Due consideration may also be given to carers & socio/economic.
Have you been trained to carryout this assessment? YES
If 'no' contact Equality Team 62598 for details.

This Section must be completed

Name of policy or document : Antibiotic Prophylaxis in Neurosurgery
Key aims/objectives of policy/document
(impact on both staff & service users): Good antimicriobial prescribing to reduce
the emergence of resistance and healthcare associated infections

1) a) Whom is this document or policy

aimed at?

1a)

2) a) Is there any evidence to suggest

that your end users have different
needs in relation to this policy or
document; (e.g.health/employment
inequality outcomes) (NB If you do not

2a)
No

Trustwide policy aimed at all medical,

pharmacy and nursing staff.

have any evidence you should put in

section 8 how you will start to review
this data)

3) a) Does the document require any

decision to be made which could
result in some individuals receiving
different treatment, care, outcomes to
other groups/individuals?
b) If yes, on what basis would this
decision be made? (It must be

3a)
No

3b)

objectively justified)

4) a) Have you included where you may

need to make reasonable adjustments
for disabled users or staff to ensure
they receive the same outcomes to
other groups ?

4a)
N/A

5) a) Have you undertaken any

consultation/involvement with service
users or other groups in relation to this
document?

5a)
Yes

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b) If yes, what format did this take?

face/face or questionnaire? (please
provide details of this)

5b)

c)Has any amendments been made

as a result?

5c)
Yes

6) a) Are you aware of any complaints

from service users in relation to this
policy?

6a)
No

b) If yes, how was the issue resolved?

Has this policy been amended as a
result?

It has been discussed with the neurosurgeons

and at the EVD group

6b)

7) a) To summarise; is there any evidence to indicate that any groups listed below
receive different outcomes in relation to this document?
Yes
Positive

No

unsure

Negative*

Age

Disability

Sex

Race

Religion & Belief

Sexual orientation

Pregnancy & Maternity

Marital status/civil partnership

Gender Reassignment

Carers *1

Socio/economic**2

1: That these two categories are not classed as protected groups under the Equality Act.
2: Care must be taken when giving due consideration to socio/economic group that we do
not inadvertently discriminate against groups with protected characteristics

Negative Impacts
*If any negative impacts have been identified you must either a) state below how you
have eliminated these within the policy or b) conduct a full impact assessment:
8) How will the future outcomes of this policy be monitored?
Regular audits

9) If any negative impact has been highlighted by this assessment, you will
need to undertake a full equality impact assessment:
Will this policy require a full impact assessment? Yes/No (delete)
(if yes please contact Equality Team, 62598/67204, for further guidance)
High/Medium/Low signed___________________________
date:
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Page 11 of 11