Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Fundamentals of Surgical Practice
The Surgical Patient
Approach to the surgical patient
The paediatric patient
Surgical Techniques
Tissue Handling
Suture and suture technique
Prophylaxis
Basic Surgical Procedures
Wound management
Specific lacerations and wounds
Burns
Foreign bodies
Cellulitis and abscess
Excision and biopsies
Prophylaxis
 



ANTIBIOTIC PROPHYLAXIS

Antibiotic prophylaxis is different from antibiotic treatment. Prophylaxis is intended to prevent infection or to decrease the potential for infection. It is not intended to prevent infection in situations of gross contamination. Use therapeutic doses if infection is present or likely:

:: Administer antibiotics prior to surgery, within the 2 hours before the skin is cut, so that tissue levels are adequate during the surgery
:: More than one dose may be given if the procedure is long (>6 hours) or if there is significant blood loss.

The use of topical antibiotics and washing wounds with antibiotic solutions are not recommended.
Use antibiotic prophylaxis in cases where there are:

:: Biomechanical considerations that increase the risk of infection:
– Implantation of a foreign body
– Known valvular heart disease
– Indwelling prosthesis
:: Medical considerations that compromise the healing capacity or increase the infection risk:
– Diabetes
– Peripheral vascular disease
– Possibility of gangrene or tetanus
– Immunocompromise
:: High-risk wounds or situations:
– Penetrating wounds
– Abdominal trauma
– Compound fractures
– Wounds with devitalized tissue
– Lacerations greater than 5 cm or stellate lacerations
– Contaminated wounds
– High risk anatomical sites such as hand or foot
– Biliary and bowel surgery.


Consider using prophylaxis:

:: For traumatic wounds which may not require surgical intervention
:: When surgical intervention will be delayed for more than 6 hours.


Use intravenous (IV) antibiotics for prophylaxis in clean surgical situations to reduce the risk of postoperative infection, since skin and instruments are never completely sterile.

For the prophylaxis of endocarditis in patients with known valvular heart disease:

:: Oral and upper respiratory procedures: give amoxycillin 3 g orally, 1 hour before surgery and 1.5 g, 6 hours after first dose
:: Gastrointestinal and genitourinary procedures: give ampicillin 3 g, 1 hour before surgery and gentamicin 1.5 mg/kg intramuscularly (IM) or IV (maximum dose 80 mg), 30 minutes before surgery.


Antibiotic treatment

When a wound is extensive and more than 6 hours old, you should consider it to be colonized with bacteria, and use therapeutic doses and regimens. Penicillin and metronidazole provide good coverage and are widely available.

Monitor wound healing and infection regularly. Make use of culture and sensitivity findings if they are available. Continue therapeutic doses of antibiotics for 5–7 days.

Tetanus prophylaxis

Active immunization with tetanus toxoid (TT) prevents tetanus and is given together with diphtheria vaccine (TD). Women should be immunized during pregnancy to prevent neonatal tetanus. Childhood immunization regimes include diphtheria, pertussis and tetanus. Individuals who have not received three doses of tetanus toxoid are not considered immune and require immunization.

A non-immune person with a minor wound can be immunized if the wound is tetanus prone; give both TT or TD and tetanus immune globulin (TIG). A non-immunized person will require repeat immunization at six weeks and at six months to complete the immunization series.

Examples of tetanus prone wounds include:

:: Wounds contaminated with dirt or faeces
:: Puncture wounds
:: Burns
:: Frostbite
:: High velocity missile injuries.

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  Kep Points  
Give prophylactic antibiotics in cases of wound contamination


Immunize the non-immune patient against tetanus with tetanus toxoid and give immune globulin if the wound is tetanus prone.