| Procedure
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Causative etiologies
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Recommended antimicrobials
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Usual adult dosage
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Comments
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| Cardiovascular
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Staphylococcus aureus, Staphylococcus epidermidis
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Cefazolin
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1-2 g IV
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Antibiotic prophylaxis has been proved beneficial in the following patients: reconstruction of abdominal aorta, procedures on the leg that involve a groin incision, any vascular procedure that inserts prosthesis/foreign body, lower extremity amputation for ischemia, cardiac surgery, permanent pacemakers, heart transplant. The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses. Some experts recommend an additional dose when patients are removed from bypass during open-heart surgery.
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Cefuroxime
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1.5 g IV
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Some experts recommend an additional dose when patients are removed from bypass during open-heart surgery.
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Vancomycin
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1 g IV
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Vancomycin is preferable in hospitals with high frequency of MRSA, high risk patients, those colonized with MRSA or for pen-allergic patients. Clindamycin 900 mg IV is another alternative for pen-allergic or vanco-allergic patients. Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with Diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of Vancomycin to patients weighing more than 751<g, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (Gentamicin, Tobramycin or Amikacin), Aztreonam or a fluoroquinolone.
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Mupirocine
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Consider intranasal Mupirocine evening before, day of surgery and bid for 5 days post-op in patients with positive nasal culture for S. aureus. Mupirocine resistance has been encountered.
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| Gastrointestinal
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| Esophageal, gastroduodenal (includes percutaneous endoscopic gastrostomy - high risk only)
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Enteric gram-negative bacilli, gram-positive cocci
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High-risk only: Cefazolin, Cefoxitin, Ceftriaxone
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Single-dose: 2 g IV
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The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses. PEG placement: high-risk is marked obesity, obstruction, reduced gastric acid or reduced motility.
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| Biliary tract
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Enteric gram-negative bacilli, enterococci, clostridia
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High-risk only: Cefazolin, Cefoxitin or Cefotetan
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1-2 g IV
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High risk: age >70, acute cholecystitis, non-functioning gallbladder, obstructive jaundice or common duct stones. With cholangitis, treat as infection, not prophylaxis. The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses. Low-risk, laparoscopic: no prophylaxis.
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OR Ampicillin/Sulbactam
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3 g IV
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| Endoscopic retrograde cholangiopancreatography
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Ciprofloxacin
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500 - 750 mg PO OR 400 mg IV 2 hours before procedure
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Only needed if there is obstruction. Greatest benefit of prophylaxis occurs when complete drainage cannot be achieved.
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OR Piperaciline-Tazobactam
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4.5 g IV 1 hour before procedure
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Only needed if there is obstruction.
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| Colorectal
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Enteric gram-negative bacilli, anaerobes, enterococci
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Oral: Neomycin PLUS Erythromycin bases OR Metronidazole
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In addition to mechanical bowel preparation, 1 g of Neomycin PLUS 1 g of Erythromycin at 1 PM, 2 PM and 11 PM or 2 g of Neomycin PLUS 2 g of Metronidazole at 7 PM and 11 PM the day before an 8 AM operation.
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Parenteral: Cefoxitin or Cefotetan
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1-2 g IV
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OR Cefazolin
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1-2 g IV
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The recommended dose of cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
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PLUS Metronidazole
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0.5 g IV
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Ampicillin/Sulbactam
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3 g IV
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Ertapenem
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1 g IV
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Ertapenem can be used if there is beta-lactam allergy. Other regimens include: Clindamycin 900 mg IV PLUS Gentamycin 5mg/kg OR Aztreonam 2 g IV OR Ciprofloxacin 400 mg IV.
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| Appendectomy, non-perforated
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Same as for colorectal
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Cefoxitin OR Cefotetan
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1-2 g IV
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For patients allergic to penicillins and cephalosporins, Clindamycin OR Vancomycin with either Gentamicin, Ciprofloxacin, Levofloxacin or Aztreonam is a reasonable alternative. Fluoroquinolones should not be used for prophylaxis in cesarean section.
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OR Cefazolin
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1-2 g IV
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PLUS Metronidazole
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0.5 g IV
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| Genitourinary
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| Cystoscopy alone
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Enteric gram-negative bacilli, enterococci
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High-risk only: Ciprofloxacin
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500 mg PO OR 400 mg IV
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Due to increasing resistance of E. coli to fluoroquinolones and Ampicillin/Sulbactam, local sensitivity profiles should be reviewed prior to use. AUA recommends prophylaxis for those with several potentially adverse host factors (e.g. advanced age, immunocompromised state, anatomic abnormalities, etc.).
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OR Trimethoprim-Sulfamethoxazole
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1 DS tablet
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| Cystoscopy with manipulation or upper tract instrumentation
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Enteric gram-negative bacilli, enterococci
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Ciprofloxacin
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500 mg PO OR 400 mg IV
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Due to increasing resistance of E. coli to fluoroquinolones and Ampicillin/Sulbactam, local sensitivity profiles should be reviewed prior to use.
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OR Trimethoprim-Sulfamethoxazole
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1 DS tablet
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Viable alternative in populations with low rates of resistance.
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| Transrectal prostate biopsy
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Enteric gram-negative bacilli, enterococci
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Ciprofloxacin
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500 mg PO 12 hours before biopsy and 12 hours after first dose.
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| Open or laparoscopic surgery
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Enteric gram-negative bacilli, enterococci
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Cefazolin
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1-2 g IV
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The recommended dose of cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
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| Gynecologic and Obstetric
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| Vaginal, abdominal or laparoscopic hysterectomy
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Enteric gram-negative bacilli, anaerobes, Gp B strep, enterococci
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Cefazolin OR Cefoxitin OR Cefotetan
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1-2 g IV
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The recommended dose of cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses. For patients allergic to penicillins and cephalosporins, Clindamycin OR Vancomycin with either Gentamicin, Ciprofloxacin, Levofloxacin or Aztreonam is a reasonable alternative. Fluoroquinolones should not be used for prophylaxis in cesarean section. Due to increasing resistance of E. coli to fluoroquinolones and Ampicillin/Sulbactam, local sensitivity profiles should be reviewed prior to use.
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OR Ampicillin/Sulbactam
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3 g IV
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For patients allergic to penicillins and cephalosporins, Clindamycin OR Vancomycin with either Gentamicin, Ciprofloxacin, Levofloxacin or Aztreonam is a reasonable alternative. Fluoroquinolones should not be used for prophylaxis in cesarean section. Due to increasing resistance of E. coli to fluoroquinolones and Ampicillin/Sulbactam, local sensitivity profiles should be reviewed prior to use.
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| Cesarean section
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Same as for hysterectomy
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Cefazolin
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1-2 g IV
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The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses. For patients allergic to penicillins and cephalosporins, Clindamycin OR Vancomycin with either Gentamicin, Ciprofloxacin, Levofloxacin or Aztreonam is a reasonable alternative. Fluoroquinolones should not be used for prophylaxis in cesarean section. Due to increasing resistance of E. coli to fluoroquinolones and Ampicillin/Sulbactam, local sensitivity profiles should be reviewed prior to use.
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Clindamycin
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900 mg IV
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Use as alternative method to Cefazolin and associated with Gentamicin 5 mg/kg IV OR Tobramycin 5 mg/kg IV single dose.
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| Abortion, surgical
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Same as for hysterectomy
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Doxycycline
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300 mg PO
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Divided into 100 mg before the procedure and 200 mg after.
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| Head and Neck Surgery
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| Incisions through oral or pharyngeal mucosa
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Anaerobes, enteric gram-negative bacilli, S. aureus
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Clindamycin
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600 mg - 900 mg IV
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Clean, uncontaminated head and neck surgery does not require prophylaxis. If using Clindamycin, consider associating Gentamicin 5 mg/kg IV single dose.
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OR Cefazolin
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2 g IV
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The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
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PLUS Metronidazole
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0.5 g IV
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OR Ampicillin/Sulbactam
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3 g IV
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| Neurosurgery
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S. aureus, S. epidermidis
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Cefazolin
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1-2 g IV
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The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
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OR Vancomycin
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1 g IV
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Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with Diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of Vancomycin to patients weighing more than 751<g, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (Gentamicin, Tobramycin or Amikacin), Aztreonam or a fluoroquinolone.
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Clindamycin
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900 mg IV
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Clindamycin can be used in clean, contaminated surgeries (cross sinuses, or naso/oropharynx). British recommend Amoxicilin-clavulanate 1.2 g IV OR Cefuroxime 1.5 g IV PLUS Metronidazole 0.5 mg g IV.
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| Ophthalmic
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S. aureus, S. epidermidis, streptococci, enteric gram-negative bacilli, Pseudomonas spp.
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Gentamicin, Tobramycin, Ciprofloxacin, Gatifloxacin, Levofloxacin, Moxifloxacin, Ofloxacin OR Neomycin-gramicidin-polymyxin B
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Multiple drops topically over 2 to 24 hours
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OR Cefazolin
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100 mg subconjunctivally
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| Orthopedic
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| Hip arthroplasty, spinal fusion
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S. aureus, S. epidermidis
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Same as cardiac surgery
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| Total joint replacement (other than hip)
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S. aureus, S. epidermidis
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Cefazolin
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1-2 g IV
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The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
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OR Vancomycin
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1 g IV
|
Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with Diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of Vancomycin to patients weighing more than 751<g, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (Gentamicin, Tobramycin or Amikacin), Aztreonam or a fluoroquinolone. If a tourniquet is to be used in the procedure, the entire dose of antibiotic must be infused prior to its inflation. For patients weighing >90 kg use Vancomycin 1.5 g IV as single dose OR Clindamycin 900 mg IV.
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| Open reduction of closed fracture with internal fixation
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S. aureus, S. epidermidis
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Ceftriaxone
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2 g IV single dose
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| Thoracic (non-cardiac)
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S. aureus, S. epidermidis, enteric gram-negative bacilli, streptococci
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Cefazolin
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1-2 g IV
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The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
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OR Vancomycin
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1 g IV
|
Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with Diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of Vancomycin to patients weighing more than 751<g, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (Gentamicin, Tobramycin or Amikacin), Aztreonam or a fluoroquinolone.
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OR Ampicillin/Sulbactam
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3 g IV
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Due to increasing resistance of E. coli to fluoroquinolones and Ampicillin/Sulbactam, local sensitivity profiles should be reviewed prior to use.
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| Vascular
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| Arterial surgery involving· a prosthesis, the abdominal aorta, or a groin incision
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S. aureus, S. epidermidis, enteric gram-negative bacilli
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Cefazolin
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1-2 g IV
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The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
|
|
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OR Vancomycin
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1 g IV
|
Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with Diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of Vancomycin to patients weighing more than 751<g, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (Gentamicin, Tobramycin or Amikacin), Aztreonam or a fluoroquinolone.
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| Lower extremity amputation for ischemia
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S. aureus, S. epidermidis, enteric gram-negative bacilli, clostridia
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Cefazolin
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1-2 g IV
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The recommended dose of Cefazolin is 1 g for patients who weigh <80 kg and 2 g for those ~80 kg. Morbidly obese patients may need higher doses.
|
|
|
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OR Vancomycin
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1 g IV
|
Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with Diphenhydramine (Benadryl, and others) and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of Vancomycin to patients weighing more than 751<g, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (Gentamicin, Tobramycin or Amikacin), Aztreonam or a fluoroquinolone.
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