Antibiotic prophylaxis and

DVT prevention in a preoperative

patient

Chen Zhou Yue

Batch 5
0317302

Learning outcomes
Discuss antibiotic prophylaxis in a preoperative
patient.
Indications
Route and time of administration
Choice of antibiotics with dosage
Outline the measures used to prevent DVT in a
surgical patient.
Risk stratification
Non pharmacological methods
Drugs to prevent DVT

Indication of antibiotic
prophylaxis
Establishing a prophylaxis indicated status for a
given procedure requires consideration of the
likelihood of infection without antibiotics and the
morbidity and cost of an infectious complication.
Clean-contaminated, contaminated and dirty

Selection of antibiotics
Effective against microorganisms anticipated to
cause infection
Achieve adequate local tissue levels
Cause minimal side effects
Relatively inexpensive

Procedure-Specific Recommendations
for Prophylaxis

Aafp. Current Guidelines for Antibiotic Prophylaxis of Surgical Wounds

National Antibiotic Guidelines 2014

Route and Timing of

administration

Pre-operative dose timing: The optimal time for

administration of preoperative doses is within 60 minutes
before surgical incision.
Clindamycin, Fluoroquinolones, Gentamicin, Metronidazole
and Vancomycin, require administration over one to two
hours; therefore, the administration of these agents should
begin within 120 minutes before surgical incision (Reference:
Am J Health-Syst Pharm Vol 70: 195-283, 2013@IDSA.)

Ideally, the prophylaxis when given intravenously should be

given as soon as the patient is stabilized after induction.

DVT Prevention

Risk factors
Malignancy

Antiphospholipi
d syndrome

HRT

Pregnancy

Post
partum
(within 12
weeks)

Family
history

Recent leg
Trauma

Recent
abdominal /
pelvic
surgery

Bedridden
>3 days

Previous
VTE

Sickle cell
disease

Thalassemi
a

Inflammato
ry bowel
disease

Obesity

OCP

Smoking

Mechanical methods

Valuable adjunct to pharmacological

methods
Preferred alternative in ineligible
patients for pharmacological therapy

Graded Elastic Compression

Stockings (GECS)
Intermittent Pneumatic
Compression of calf or calf
and thigh
Venous Foot Pump

 Applicable pre and intraoperatively, continued

postoperatively until patient fully ambulating.
No clinically significant adverse effects, particularly
bleeding
IPC has relative contraindications:
- severe leg ischemia / peripheral artery disease
- acute superficial and deep vein thrombosis
- congestive cardiac failure
Home use is important, VTE reported to develop 8 days
after TKA and 21 days after THA.
Portable motorized mechanical compression devices are
available but are expensive.

Pharmacological Methods

Low molecular weight heparin (first line)

Fondaparinux
Unfractionated heparin
Newer anticoagulants (dabigatran, rivaroxaban,
apixaban)

Risk stratification
Risk category

Recommended
prophylaxis

Low risk Ambulatory patient < 40 years

without risk factors

Early aggressive
ambulation

Moderate Patient 40-60 years without risk

risk
Patient with an extra risk
Major surgery (>30 mins) for
benign disease

LMWH
Fondaparinux
LDUH, 12 hourly
GECS, IPC, VFP

High risk

Surgery in patient >60 years /

40-60years with an extra risk/
multiple risk factors
Major surgery for cancer
Major trauma, Spinal Cord Injury

LMWH
Fondaparinux
LDUH, 8 hourly
Warfarin INR 2-3
IPC or GECS

Highest
risk

Hip arthroplasty
Knee arthroplasty
Hip fracture surgery

LMWH >
Fondaparinux >
Warfarin and IPC
Rivaroxaban

References
1.
2.
3.
4.

5.
6.

7.
8.

Bailey & Loves Short Practice of Surgery 25th edition

Current Guidelines for Antibiotic Prophylaxis of Surgical Wounds. Available
from: http://www.aafp.org/afp/1998/0601/p2731.html#sec-2
Antibiotic Prophylaxis for Surgical Procedures. Available from:
https://www.merckmanuals.com/professional/special-subjects/care-of-the-sur
gical-patient/antibiotic-prophylaxis-for-surgical-procedures
Clinical Practice Guidelines Prevention and Treatment of Venous
Thromboembolism. Available from:
http://www.moh.gov.my/attachments/9005.pdf
Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery.
Available from: http://www.ashp.org/surgical-guidelines
Surgical Practice Guidelines HNEH. Available from:
https://www.safetyandquality.gov.au/wp-content/uploads/2012/02/3.8-Surgic
al-Antibiotic-Prophylaxis.pdf
SIGN 104 Antibiotic Prophylaxis in Surgery. Available from:
http://www.sign.ac.uk/pdf/sign104.pdf
MOH Malaysia. National Antibiotic Guideline 2014. Available from: http://
www.pharmacy.gov.my/v2/sites/default/files/document-upload/national-anti
biotic-guideline-2014-full-versionjun2015_1.pdf