Companion Animal Surgical Guidelines

Antimicrobial guidelines for surgical prophylaxis.

The surgical guidelines have been developed for all veterinarians, to inform clinical decisions, in response to a survey we completed in 2016 that identified a need for widely accessible antimicrobial guidelines for surgical prophylaxis.

The results of this survey have been published and the paper can be found at this link.

We suggest you download the VPG guidelines poster, display it in your clinic and record your protocols for surgical prophylaxis in the space provided.

Measuring compliance with the guidelines, or your clinic policy, is a powerful tool in improving appropriate antimicrobial use. Periodic review of clinical records, or review of surgical checklists, with regular reporting will motivate all staff to improve appropriate antimicrobial use for surgical prophylaxis.

Aim

To provide guidance on need for antimicrobials for surgical prophylaxis to mitigate the risk of surgical site infections and where antimicrobials are indicated, guidance on antimicrobial selection, timing and duration of therapy. We aim to provide guidance for common surgical conditions in dogs and cats, however, some conditions may not be covered and clinicians are advised to use their best judgement in these instances.

National Research Council’s risk index for surgical infection

Surgery classification

DescriptionExamples
CleanNon-traumatic, uninfected. No break in aseptic technique, no inflammation encountered. Elective, closed primarily and no drain used.

Eg Routine spey or castration

Exploratory laparotomy (not entering viscus)
Clean-contaminatedControlled entering of a hollow muscular viscus, minor break in aseptic techniqueEg Exploratory laparotomy for foreign body removal, cystotomy (no abdominal contamination)
ContaminatedOpen, fresh traumatic wound. Incision into a site with acute, non-purulent inflammation. Major break in aseptic technique.

Eg Cystotomy/laparotomy with significant abdominal contamination,

pyometra, closure of contaminated traumatic wound (<4h duration).
DirtyPus encountered during surgery. Perforated viscus found. Traumatic wound with devitalised tissue, foreign material or faecal contamination, or of more than 4-hour duration.Eg Peritonitis, necrotic traumatic wound (>4h duration) undergoing primary closure.

Guidelines for surgical prophylaxis in dogs and cats

Surgical contamination levelComplicating factorsLikely pathogensAntimicrobial recommendationDuration of therapyLevel of evidence
CleanNone1 N/ANoneStrong

If surgical site infection would be a major threat to the patient (ie central nervous system surgery)

Hypotension

Surgical duration >90 mins3,4

Obese dogs5

Endocrine disorder6

Bacterial dermatitis		 Amoxycillin or 1st generation cephalosporinStop within 24h*2Medium
Implant1,7Orthopaedic: Staphylococcus intermediusAmoxycillin or 1st generation cephalosporinPerioperative only**7 
Clean contaminatedGastrointestinalColiforms, anaerobes if caudal GI tractAmoxycillin or 1st generation cephalosporinStop within 24 hours*Medium
ContaminatedPyometra, prostatic abscessE. coli, Streptococcusspecies, AnaerobesAmoxycillin or 1st generation cephalosporin & gentamicin & metronidazoleNo evidence, 24-48 hours is common in human medicineWeak
Significant bowel leakageColiformsAmoxycillin & gentamicinNo evidence, 24-48 hours is common in human medicineWeak
Dirty  Choose appropriate for infection (ideally based on culture and susceptibility testing)Until clinical signs resolveWeak
DentalNoneNoneNoneN/AMedium

Geriatric patients

Heart disease

Systemic illness

Immunosuppression		 Bacteraemia expected for duration of procedure8, 9. If cannot tolerate this: clindamycin or amoxycillin.Stop within 24 hours*Weak

* Stop within 24 hours indicates administration prior to and during surgery, and doses after surgery up till 24 hours. Inter-dosing interval after surgery is described below.

**Perioperative only indicates administration prior to and during surgery, but no further doses after surgery

Timing of prophylactic antimicrobials

Tissue levels of antimicrobials are required at the time of first incision to confer protection from surgical site infection.

Intravenous antimicrobials: administer 30-60 mins prior to surgery

Subcutaneous amoxycillin / clavulanate: 2 hours prior to surgery

Tmax for individual drugs given by different routes can be used to assess optimal timing to achieve peak serum levels at the time of first incision.

Repeat dosing

Dosing interval should be measured from the time of the preoperative dose. The dosing interval during surgery can be calculated as twice the elimination half-life of the antimicrobial. For example, the dosing interval during surgery for common intravenous antimicrobials used in surgery for dogs and cats are:

Cefazolin: Maintains concentrations above MIC for common skin pathogens (Staphylococcal  & Streptococcal species) for 4 hours (10),however 2 hourly administration (twice elimination ½ life) may be required for E.coli. (11)

Amoxycillin: 2 hours

Following surgery, if antimicrobials continue to be indicated, the dosing interval returns to that used for non-surgical indications.

Other factors to consider

Clip hair less than 4 hours before surgery4

Minimise number of people in surgical theatre5

Consider use of surgical safety checklist. Use of these tools has reduced surgical complications from 17% to 7% (SSIs from 5% to 1.4%).11

(Based on World Health Organisation surgical safety checklist)

A special mention – surgical treatment of Cranial Cruciate Ligament disease

  • Tibial tuberosity advancement (TTA): Peri-operative prophylaxis only, no evidence for post-operative therapy12.
  • Tibial plateau leveling osteotomy (TPLO): Peri-operative prophylaxis only13, 14. Studies that have shown reduced post-operative surgical site infections have had protocols that were unlikely to lead to necessary serum antimicrobial levels at the time of the first incision15, or did not report timing and in which antimicrobial therapy was given at the surgeons discretion16-18 thereby introducing unacceptable confounding bias. Careful attention should be paid to timing of prophylactic antimicrobial therapy.
  • TightRope: Peri-operative prophylaxis only14.

The evidence

These guidelines are designed to be evidence-based and transparent. As such, we’ve provided the evidence behind our recommendations.

A literature search was undertaken in PubMed using the following search terms:

(Dog OR Cat OR Canine OR Feline) AND Surg* AND (Antibiotic OR Antimicrobial OR Infection OR Complication)

Only research papers pertaining to species other than humans, with abstracts, and papers written in English were considered. No time limit was included.

In addition, guidelines from other professional organisations (restricted to those written in English) were reviewed and in particular, the reference lists of these guidelines. Only evidence-based recommendations were considered in constructing these guidelines. The guidelines were created by consensus by the development group.

The abstracts for all returned articles were examined. Articles were included if the title or abstract suggested that either surgical site infection or antimicrobial prophylaxis for surgery were discussed in the paper. In addition, articles were excluded if the sample size was insufficient to make appropriate inferences from the study. All study designs were considered as the literature is limited.

Research assessing risk of surgical site infection (SSI)

Research settingSSI Type of surgeryComments
Private practice, Canada19 1-4% OVH & castration  
University practice20 12.70% OVH  
University practice21 2.50% Elective  
University practice2 3.60% CCL  
University practice22 3.90% CCL Perioperative antimicrobials did not influence rate although only small number that didn’t get antimicrobials
University practice4 1.70% Minimally invasive  
University practice4 5.50% Open surgery Perioperative antimicrobials did not influence rate
University practice21 2.50% Clean  
University practice21 4.50% Clean-contaminated  
University practice21 5.80% Contaminated  
University practice21 18.10% Dirty  
University practice23 4.50% Clean  
University practice3 0.80% Clean  
University practice24 3.50% Elective joint surgery  
University practice25 9.0% External fixation in cats  

OVH, ovariohysterectomy; CCL, cranial cruciate ligament syndrome.

Quality of the evidence (Risk of Bias assessment)

Domains Confounding Selection bias Classification bias Deviation from intended intervention Missing dataMeasurementReporting Reason for non-inclusion
Aiken et.al. 20177 0 0 0 + 0  short and medium term ++ long term 0 0  
Andrade et.al. 201626 +++ + 0 N/A 0 0 0 Risk of confounding too high
Beal et.al., 200027 + + 0 NR 0 + 0  
Beever et.al., 201725 + 0 0 N/A + + 0  
Bergstrom et.al., 201611 + + 0 0 Not assessable + 0  
Billings et.al., 199024 +++ ++ 0 0 Not assessable Not assessable N/A Risk of confounding too high
Bristow et.al., 201528 ++ + 0 NR Not assessable   Not assessable   N/A Did not report length of antimicrobial therapy
Bowersock et.al., 20008 0 0 0 0 0 0 +  
Casale & McCarthy, 200922 + ++ 0 N/A NR + N/A  
Cook et.al., 201014 + + 0 0 Not assessable Not assessable 0  
Eugster et.al., 20045 0 0 0 N/A + + 0  
Fitzpatrick & Solano, 201015 +++ + 0 0 Not assessable + 0 Pre-operative antimicrobial therapy not given early enough
Frey et.al., 201018 + ++ 0 0 Not assessable Not assessable N/A Did not report length of antimicrobial therapy
Gatineau et.al., 201116 +++ +++ 0 N/A Not assessable Not assessable 0 Did not report timing of antimicrobial therapy, post-operative therapy given at the surgeon’s discretion
Heldmann et.al., 199923 ++ +++ 0 0 Not assessable Not assessable N/A Did not describe antimicrobial therapy
Jardel et.al., 201129 +++ +++ 0 0 Not assessable Not assessable N/A High risk of confounding and selection bias
Nazarali et.al., 201430 ++ +++ 0 N/A NR 0 ++ High risk of confounding, selection and reporting bias
Mayhew et.al., 20124 ++ ++ 0 N/A + 0 N/A  
Nicoll et.al., 201431 0 0 0 N/A 0 0 N/A  
Nicholson et.al., 20026 ++ ++ 0 N/A NR 0 +++ Limited data in paper to verify results. No reporting on effect of antimicrobials
Nieves et.al., 19979 0 0 0 N/A 0 0 +  
Pacchiana et.al., 200317 +++ + 0 N/A Not assessable Not assessable 0 Antimicrobial therapy given at the discretion of surgeon and not included as exposures variable
Pratesi et.al., 201532 0 0 0 + 0 0 +++  
Pollari & Bonnett, 199618 0 + + N/A 0 + 0  
Solano et.al., 201533 +++ +++ 0 NR NR 0 + Confounding and selection bias too high
Stauffer et.al., 200613 0 + 0 N/A NR 0 N/A  
Turk et.al., 20151 0 0 ++ N/A NR ++ 0  
Vasseur et.al., 19853 0 0 0 NR N/A 0 0  
Vasseur et.al., 198821 ++ 0 + N/A NR + N/A  
Weese & Halling, 20062 + + 0 N/A Not assessable 0 N/A  
Yap et.al., 201512 + + 0 N/A Not assessable Not assessable 0  

Risk of bias was assessed using the ROBINS-I assessment tool28.

NR, not reported; N/A, not applicable

Manuscripts in red were not considered for recommendations.

Range 0 (no bias detected) to +++ (major bias detected)

References

    1. Turk R, Singh A, Weese JS. Prospective surgical site infection surveillance in dogs.Vet Surg2015;44:2-8.
    2. Weese JS, Halling KB. Perioperative administration of antimicrobials associated with elective surgery for cranial cruciate ligament rupture in dogs: 83 cases (2003-2005). JAVMA2006;229:92-95.
    3. Vasseur PB, Paul HA, Enos LR, Hirsch DC. Infection rates in clean surgical procedures: a comparison of ampicillin prophylaxis vs a placebo. JAVMA1985;187:825-827.
    4. Mayhew PD, Freeman L, Kwan T, Brown DC. Comparison of surgical site infection rates in clean and clean-contaminated wounds in dogs and cats after minimally invasive versus open surgery: 179 cases (2007-2008). JAVMA2012;240:193-198.
    5. Eugster S, Schawalder P, Gaschen F, Boerlin P. A prospective study of postoperative surgical site infections in dogs and cats. Vet Surg2004;33:542-550.
    6. Nicholson M, Beal M, Shofer F, Brown DC. Epidemiologic Evaluation of Postoperative Wound Infection in Clean-Contaminated Wounds: A Retrospective Study of 239 Dogs and Cats. Veterinary Surgery2002;31:577-581.
    7. Aiken MJ, Hughes TK, Abercromby RH, Holmes MA, Anderson AA. Prospective, Randomized Comparison of the Effect of Two Antimicrobial Regimes on Surgical Site Infection Rate in Dogs Undergoing Orthopedic Implant Surgery. Vet Surg2015;44:661-667.
    8. Bowersock TL, Wu CC, Inskeep GA, Chester ST. Prevention of bacteremia in dogs undergoing dental scaling by prior administration of oral clindamycin or chlorhexidine oral rinse. J Vet Dent2000;17:11-16.
    9. Nieves MA, Hartwig P, Kinyon JM, Riedesel DH. Bacterial isolates from plaque and from blood during and after routine dental procedures in dogs. Vet Surg1997;26:26-32.
    10. Gonzalez OJ, Renberg WC, Roush JK, KuKanich B, Warner M. Pharmacokinetics of cefazolin for prophylactic administration to dogs. Am J Vet Res2017;78:695-701.
    11. Marcellin-Little DJ, Papich MG, Richardson DC, DeYoung DJ. Pharmacokinetic model for cefazolin distribution during total hip arthroplasty in dogs. Am J Vet Res1996;57:720-723.
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    13. Yap FW, Calvo I, Smith KD, Parkin T. Perioperative risk factors for surgical site infection in tibial tuberosity advancement: 224 stifles. Vet Comp Orthop Traumatol2015;28:199-206.
    14. Stauffer KD, Tuttle TA, Elkins AD, Wehrenberg AP, Character BJ. Complications associated with 696 tibial plateau leveling osteotomies (2001-2003). J Am Anim Hosp Assoc2006;42:44-50.
    15. Cook JL, Luther JK, Beetem J, Karnes J, Cook CR. Clinical comparison of a novel extracapsular stabilization procedure and tibial plateau leveling osteotomy for treatment of cranial cruciate ligament deficiency in dogs. Vet Surg2010;39:315-323.
    16. Fitzpatrick N, Solano MA. Predictive variables for complications after TPLO with stifle inspection by arthrotomy in 1000 consecutive dogs. Vet Surg2010;39:460-474.
    17. Gatineau M, Dupuis J, Plante J, Moreau M. Retrospective study of 476 tibial plateau levelling osteotomy procedures. Rate of subsequent ‘pivot shift’, meniscal tear and other complications. Vet Comp Orthop Traumatol2011;24:333-341.
    18. Pacchiana PD, Morris E, Gillings SL, Jessen CR, Lipowitz AJ. Surgical and postoperative complications associated with tibial plateau leveling osteotomy in dogs with cranial cruciate ligament rupture: 397 cases (1998-2001). J Am Vet Med Assoc2003;222:184-193.
    19. Frey TN, Hoelzler MG, Scavelli TD, Fulcher RP, Bastian RP. Risk factors for surgical site infection-inflammation in dogs undergoing surgery for rupture of the cranial cruciate ligament: 902 cases (2005-2006). J Am Vet Med Assoc2010;236:88-94.
    20. Pollari FL, Bonnett BN. Evaluation of postoperative complications following elective surgeries of dogs and cats at private practices using computer records. Canadian veterinary journal1996;37:672-678.
    21. Dorn AS, Swist RA. Complications of Canine Ovariohysterectomy. Journal of the American Animal Hospital Association1977;13:720-724.
    22. Vasseur PB, Levy J, Dowd E, Eliot J. Surgical wound infection rates in dogs and cats. Data from a teaching hospital.Vet Surg1988;17:60-64.
    23. Casale SA, McCarthy RJ. Complications associated with lateral fabellotibial suture surgery for cranial cruciate ligament injury in dogs: 363 cases (1997-2005). JAVMA2009;234:229-235.
    24. Heldmann E, Cimino Brown D, Shofer F. The assocation of propofol usage with postoperative wound infection rate in clean wounds: A retrospective study. Veterinary Surgery1999;28:256-259.
    25. Billings L, Vasseur PB, Fancher C, Miller M, Nearenberg D. Wound infection rates in dogs and cats after use of cotton muslin or disposable impermeable fabric as barrier material: 720 cases (1983-1989). JAVMA1990;197:889-892.
    26. Beever L, Giles K, Meeson R. Postoperative complications associated with external skeletal fixators in cats. J Feline Med Surg2017;19:727-736.
    27. Andrade N, Schmiedt CW, Cornell K et al. Survey of Intraoperative Bacterial Contamination in Dogs Undergoing Elective Orthopedic Surgery. Vet Surg2016;45:214-222.
    28. Beal MW, Brown DC, Shofer F. The effects of perioperative hypothermia and the duration of anaesthesia on postoperative wound infection rate in clean wounds: a retrospective study. Veterinary Surgery2000;29:123-127.
    29. Bristow PC, Meeson RL, Thorne RM et al. Clinical comparison of the hybrid dynamic compression plate and the castless plate for pancarpal arthrodesis in 219 dogs. Vet Surg2015;44:70-77.
    30. Jardel N, Hidalgo A, Leperlier D et al. One stage functional end-to-end stapled intestinal anastomosis and resection performed by nonexpert surgeons for the treatment of small intestinal obstruction in 30 dogs. Vet Surg2011;40:216-222.
    31. Nazarali A, Singh A, Weese JS. Perioperative administration of antimicrobials during tibial plateau leveling osteotomy. Vet Surg2014;43:966-971.
    32. Nicoll C, Singh A, Weese JS. Economic impact of tibial plateau leveling osteotomy surgical site infection in dogs. Vet Surg2014;43:899-902.
    33. Pratesi A, Moores AP, Downes C, Grierson J, Maddox TW. Efficacy of Postoperative Antimicrobial Use for Clean Orthopedic Implant Surgery in Dogs: A Prospective Randomized Study in 100 Consecutive Cases. Vet Surg2015;44:653-660.
    34. Solano MA, Danielski A, Kovach K, Fitzpatrick N, Farrell M. Locking plate and screw fixation after tibial plateau leveling osteotomy reduces postoperative infection rate in dogs over 50 kg. Vet Surg2015;44:59-64.
    35. Sterne JA, Hernan MA, Reeves BC et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions.BMJ2016;355:i4919.

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