Hospital Infection Control
KEIT DAY HOSPITAL
Surgical antibiotic prophylaxis protocol
| Document Code | KEIT-SOP-05 | Version | 2.0 |
|---|---|---|---|
| Revision | 02 | Status | Official |
| Issue Date | 28/03/2026 | Next Review | 28/03/2027 |
| Prepared by | Medical Directorate / Quality | Approved by | |
| Signature and Date | Distribution | Controlled - Internal Use |
1. Document Control Information
| Application | All clinical, nursing, technical and organizational personnel involved in the described process. |
|---|---|
| Archiving | KEIT internal document management system and controlled copy in the relevant areas. |
| Review | At least annually or earlier in the event of regulatory, organizational or technological updates. |
2. Scope of Application
This protocol applies to surgical procedures for which antibiotic prophylaxis is indicated or considered appropriate according to the procedure, patient risk and specialist clinical judgment.
3. Responsibilities
- Operating surgeon: clinical indication and selection of prophylaxis in accordance with the protocol.
- Anesthesiologist and operating room nurse: verification of administration timing before the incision.
- Ward physician: reassessment of any postoperative continuation when clinically indicated.
4. Operating Procedure
- Verify allergies, body weight, renal function and previous adverse reactions.
- Confirm the indication for prophylaxis based on the procedure and infection risk.
- Administer the antibiotic at the appropriate time before the surgical incision.
- Assess the need for intraoperative redosing in the event of a prolonged procedure or significant blood loss.
- Avoid unnecessary continuation; when postoperative coverage is planned, provide clinical justification and document it in the medical record.
- Monitor side effects, allergic reactions and compliance with the protocol.
- Periodically review the antimicrobial agents used and internal microbiological patterns.
5. KEIT Operational Standards
- KEIT applies preoperative antibiotic prophylaxis according to the procedure and the individual clinical plan.
- Any postoperative therapy is defined and documented by the surgeon and the Clinical Directorate as a justified, non-automatic decision.
- In protocols involving implants, particular attention is maintained toward the prevention of perioperative contamination.
6. Records and Documentation
- Prescription and administration record.
- Adverse event reporting.
- Antibiotic appropriateness audit.
7. Review and Updates
Update at least annually or earlier if changes emerge in antimicrobial resistance, regulations or scientific literature.
This document is an internal operational draft. Before final adoption, review by the Medical Directorate, Clinical Directorate, Legal Advisor and the relevant department managers is recommended.
8. Related Attachments and Forms
- Operational checklists, recording forms, audit sheets and maintenance registers applicable to this protocol.
- Any department-specific or equipment-specific technical attachments are referenced in the relevant local operating instructions.
9. Final Approval
| Position | Name and Signature | Date |
|---|---|---|
| Medical Directorate |
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