[CG] Antibiotic Prophylaxis in Obstetric Procedures

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Objectives

NHS Greater Glasgow and Clyde recommendations for antibiotic prophylaxis in Obstetric Procedures

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Single dose, IV prophylaxis ≤ 60mins prior to skin incision/ intervention.

Gentamicin*

  • Please use the GGC gentamicin dose calculator to calculate the gentamicin dose. or use dose banding table in Appendix 1.
  • Doses of up to 400mg gentamicin can be given by slow IV injection over 3 – 5 minutes.
  • If subsequent treatment using gentamicin is required, measure gentamicin concentrations 6-14 hours post theatre gentamicin dose and follow GGC guidance on staffnet for gentamicin dosing. Calculate the dose using the online calculator. Discuss with pharmacy if further advice required (or if out of hours on call pharmacist).

If >1.5L blood loss: replace fluid and repeat antibiotic dose intra-operatively: benzyl penicillin, clindamycin, co-amoxiclav (with amoxicillin for weight >100kg) . Gentamicin should be re-dosed at half prophylaxis dose. Give half the original teicoplanin dose if ≥ 1.5L blood loss within the first hour of operation.

If surgery prolonged >4hrs post first antibiotic dose: repeat amoxicillin, benzyl penicillin, clindamycin, co-amoxiclav (with amoxicillin for weight >100kg); >8hrs post first antibiotic dose - repeat amoxicillin, benzyl penicillin, clindamycin, co-amoxiclav (with amoxicillin for weight >100kg), and if eGFR > 60mls/min/ 1.73m2 gentamicin (full prophylactic dose). No repeat dosing of teicoplanin if surgery prolonged.

MRSA: decolonise prior to procedure as per NHS GGC infection control guidelines and discuss with microbiology re antibiotic choice.

CPE carriers: For those patients who have been identified as CPE (carbapenemase producing enterobacteriaceae) carriers, contact microbiology

Weight > 80Kg
Increase the dose of antibiotic as below:

   >100 Kg
 Co-amoxiclav  add 1g IV amoxicillin to 1.2g IV co-amoxiclav
   >80 Kg  > 160 Kg
 Clindamycin  900mg  1200 mg

Recommended antibiotic regimens

Procedure

Recommended antibiotic regimen

Comments

Caesarean Section

 

Co-amoxiclav IV 1.2g 

or in penicillin allergy

Clindamycin IV 600 mg
And Gentamicin* IV 

 

>100 Kg

Co-amoxiclav

add 1g IV amoxicillin to 1.2g IV co-amoxiclav

 

>80 Kg

>160 Kg

Clindamycin

900mg

1200 mg

 

3rd Degree Tear

 

Co-amoxiclav IV 1.2g 

or in penicillin allergy

Clindamycin IV 600 mg
And Gentamicin* IV 

 

 

6 hours later second dose of  IV co-amoxiclav 1.2g  or in penicillin allergy
IV clindamycin 600mg 

  >100 Kg
Co-amoxiclav IV add 1g IV amoxicillin to
1.2g IV co-amoxiclav
  >80 Kg >160 Kg
Clindamycin IV 900mg 1200 mg

No repeat dosing of gentamicin.

4th Degree Tear

Co-amoxiclav IV 1.2g

or in penicillin allergy

Clindamycin IV 600 mg
And
Gentamicin* IV

6 hours later second dose of IV co-amoxiclav 1.2g or in penicillin allergy IV Clindamycin 600mg

Then Oral Co-amoxiclav 625mg 8 hourly for total duration (IV/oral) 5 days
or in penicillin allergy

Oral clindamycin 600mg 8 hourly for total duration (IV/oral) 5 days

  >100 Kg
Co-amoxiclav IV add 1g IV amoxicillin to
1.2g IV co-amoxiclav
  >80 Kg >160 Kg
Clindamycin IV 900mg 1200 mg

 

Manual removal of Placenta

Co-amoxiclav IV 1.2g

or in penicillin allergy

Clindamycin IV 600 mg
And
Gentamicin* IV

 

Specific antibiotic prophylaxis recommended for patients with proven Chlamydia or gonorrhoea

  >100 Kg
Co-amoxiclav IV add 1g IV amoxicillin to 1.2g IV co-amoxiclav
  >80 Kg >160 Kg
Clindamycin 900 mg 1200 mg

Pre-term, pre-labour rupture of membranes.

Erythromycin oral 250mg 6 hourly for 10 days

Prophylaxis only required if no evidence of chorioamnionitis

Erythromycin serious drug interations (see BNF Appendix 1) and QTc prolongation

Group B streptococcus prophylaxis (specific)

Benzylpenicillin IV 3g
Then
Benzylpenicillin IV 1.8g every 4 hours until delivery

or in penicillin allergy
Teicoplanin#12mg/Kg 12 hourly for 3 doses then 24 hourly until delivery

 

Always give IAP however soon the lady is likely to deliver.
Know that it is more effective the earlier it is started (at least more than 2-4hr before delivery) and if it is continued without interruption until delivery. For benzylpenicillin given > 1 hour late a further loading dose of 3g is required.

Teicoplanin# based on most recent body weight - round to nearest 100mg (max dose 800mg)
See Dosing table, Appendix 2

Operative Vaginal Births (To be given ASAP after delivery, and no more than 6 hours after delivery)

Co-amoxiclav IV 1.2g

or in penicillin allergy

Clindamycin IV 600 mg
And
Gentamicin* IV
  > 100 Kg
Co-amoxiclav IV  add 1g IV amoxicillin to 1.2g IV co-amoxiclav
  > 80 Kg > 160 Kg
Clindamycin  900mg 1200 mg

Appendix 1: Gentamicin* Surgical Prophylaxis Dosing Guidelines

  • Prophylactic gentamicin dosing is based on patient height and approximates to 5mg/kg/ideal body weight, capped at 400mg.
  • Doses of gentamicin can be given by slow IV injection over 3-5 minutes.
  • Patients receiving aminoglycosides as a slow IV bolus should be closely monitored for other signs of extravasation or infiltration e.g. swelling, redness, coolness or blanching at the cannula insertion site.
  • Avoid gentamicin if eGFR< 20mls/min/1.73m2: seek advice on alternative from microbiology. In renal transplant patients avoid gentamicin and seek advice from microbiology or renal team.

 Height ranges

 (cm)

 Gentamicin Dose (mg)

Females

142 - 146

200

147 - 154

240

155 - 164

280

165 - 174

320

≥ 175

400

Appendix 2: Teicoplanin# Dose Banding for GBS Prophylaxis

Most recent weight Dose (mg)
Less than 36kg 400mg
36 - 45.9 kg 500mg
46 - 53.9 kg 600mg
54 - 61.9 kg 700mg
62kg or above 800mg
References
  1. Janson B & Thursky K. Dosing of antibiotics in Obesity, Current Opinion Infectious diseases December 2012 Vol 25:6:634-649.
  2. www.medscape.com/viewarticle/742992
  3. Knight M et al. Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial, The
    Lancet 393:10189:P2395-2403, June 2019.
  4. Bratzler DW et al. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery, Am J Health-Sys Pharmacy 2013; 70:195-283.

Last reviewed: 01 February 2020

Next review: 30 November 2022

Author(s): Dr Julie Murphy, Consultant Obstetrician, RAH; Dr. Mairi Macleod, Consultant Medical Microbiologist, Microbiology, GRI, GG&C; Ysobel Gourlay Lead Pharmacist GG&C Antimicrobial Management Team; Dr Andrew Seaton, Lead Physician GG&C Antimicrobial Management team; Mrs June Grant, Lead Clinical Pharmacist, W & C, GG&C

Version: 2

Approved By: Obstetric Governance Group