Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Benefits and Risks of Antibiotic Prophylaxis
Risks of Prophylaxis
C: Patients with a history of anaphylaxis, laryngeal oedema, bronchospasm, hypotension, local swelling, urticaria or pruritic rash, occurring immediately after a penicillin therapy are potentially at increased risk of immediate hypersensitivity to beta-lactams and should not receive prophylaxis with a beta-lactam antibiotic.
D: The duration of prophylactic antibiotic therapy should be single dose except in special circumstances (for example, prolonged surgery, major blood loss or as indicated in sections 5.2, 5.3 and 6.4 in the original guideline document).
Indications for Surgical Antibiotic Prophylaxis
See sections 5.2 and 5.3 in the original guideline document for recommended indications for surgical antibiotic prophylaxis to prevent surgical site infection (SSI) and recommended indications for surgical antibiotic prophylaxis to prevent SSI in children.
Antibiotic Prophylaxis to Prevent Chest or Urinary Tract Infection
A: Prophylactic antibiotic treatment during surgery solely for the prevention of urinary or respiratory tract infection is not recommended.
Administration of Prophylactic Antibiotics
Choice of Antibiotic
C: The antibiotics selected for prophylaxis must cover the expected pathogens for that operative site.
B: Intranasal mupirocin should be used prophylactically for adult patients undergoing surgery with a high risk of major morbidity who are identified with Staphylococcus aureus (S. aureus) or meticillin-resistant S. aureus (MRSA).
A: A glycopeptide should be considered for antibiotic prophylaxis in patients undergoing high risk surgery who are MRSA positive.
Timing of Administration
B: Intravenous prophylactic antibiotics should be given ≤30 minutes before the skin is incised.
Duration of Prophylaxis
B: A single dose of antibiotic with a long enough half-life to achieve activity throughout the operation is recommended.
B: Up to 24 hours of antibiotic prophylaxis should be considered for arthroplasty.
C: An additional intraoperative dosage of antibiotic is recommended for cardiac surgery longer than four hours when using an antibiotic with pharmacokinetics equivalent to cefazolin.
Route of Administration
B: Intranasal mupirocin should be used prophylactically for patients undergoing high risk surgery who are identified with S. aureus or meticillin-resistant S. aureus.
B: A single dose of topical antibiotic is recommended for insertion of grommets.
Other Routes of Administration
B: In addition to intravenous antibiotics, impregnated cement is recommended for cemented joint replacements.
A: Intracameral antibiotic prophylaxis is recommended for cataract surgery.
Penetrating Eye Injuries
B: Intracameral or intravitreal intraocular antibiotic prophylaxis is recommended at completion of surgery for penetrating eye injuries (dependent on extent of injury and the presence or absence of an intraocular foreign body).
Antibiotic Impregnated Devices in Neurosurgery
C: Routine use of impregnated devices in neurosurgery is not recommended.
Antimicrobial-Impregnated Central Venous Catheters
A: Routine use of antimicrobial-impregnated central venous catheters is not recommended.
Implementing the Guideline
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g., case reports, case series)
4: Expert opinion
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4 or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group