Antibiotic Prophylaxis in Surgery

Timing

To achieve adequate drug concentrations at the onset and throughout the operative procedure the initial dose must be given intravenously in the immediate pre-operative period (within 60 minutes for most antibiotics; 120 minutes for vancomycin and fluoroquinolones).

If surgery is longer than 4-6 hours a second intra-operative dose is advisable for some antibiotic regimens. (ceFAZolin: re-dose at 4 hours intra-op; clindamycin: re-dose at 6 hours intra-op; metroNIDAZOLE: re-dose at 8 hours intra-op; vancomycin: re-dose at 12 hours intra-op).

Duration

A single dose of preoperative antibiotics is sufficient for most surgical procedures. In general, post-operative doses should not exceed 24 hours.

Choice of Antibiotics

Surgical Specialty	Patient Selection	Antibiotic Regimens
Surgical Specialty	Patient Selection	Recommended Regimen	Anaphylaxis to β-lactams	MRSA Positive
General Surgery	Laparoscopic cholecystectomy For high risk only: >70 years Obstructive jaundice Diabetes Acute inflammation	ceFAZolin^* 2 g IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV pre-op
	Biliary, pancreas, liver	ceFAZolin^* 2 g IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV pre-op
	Colorectal surgery	ceFAZolin^* 2 g IV + metroNIDAZOLE 500 mg IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV + metroNIDAZOLE 500 mg IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV + metroNIDAZOLE 500 mg IV pre-op
	Appendectomy	ceFAZolin^* 2 g IV + metroNIDAZOLE 500 mg IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV + metroNIDAZOLE 500 mg IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV + metroNIDAZOLE 500 mg IV pre-op
	Gastroduodenal/esophageal (including bariatric)	ceFAZolin^* 2 g IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV pre-op
	Anorectal procedures Hemorrhoidectomy Fistulotomy Sphincterotomy for fissure	None required	None required	None required
Gynecological and Obstetric	Emergency or elective C-section	ceFAZolin^* 2 g IV pre-op	clindamycin 900 mg IV + tobramycin^‡ 5 mg/kg IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV pre-op
Gynecological and Obstetric	Hysterectomy or surgery for pelvic organ prolapse/stress urinary incontinence surgery	ceFAZolin^* 2 g IV pre-op	clindamycin 900 mg IV pre-op + tobramycin^‡ 5 mg/kg IV pre-op	vancomycin^† 15 mg/kg IV pre-op + tobramycin^‡ 5 mg/kg IV pre-op
Head and Neck Surgery, Plastic Surgery	Breast, thyroid, parathyroid	ceFAZolin^* 2 g IV pre-op	vancomycin 15 mg/kg IV pre-op	vancomycin^† 15 mg/kg IV pre-op
	Head and neck surgery involving incision of oral, pharyngeal or nasal mucosa	ceFAZolin^* 2 g IV pre-op	clindamycin 900 mg IV pre-op	vancomycin 15 mg/kg IV + metroNIDAZOLE 500 mg IV pre-op
	Minor plastic surgery or no incision of mucosa	None required	None required	None required
	Ocular surgery	Eye drops pre-op as per protocol	Eyedrops pre-op as per protocol	Eyedrops pre-op as per protocol
Orthopedic	Total joint replacement, hip fracture	ceFAZolin^* 2 g IV pre-op and then 1g IV q8h x 24h post-op	vancomycin^† 15 mg/kg IV pre-op and then q12h x 24 h post-op^§	vancomycin^† 15 mg/kg IV pre-op and then q12h x 24 h post-op^§
Thoracic/ Vascular/ Pacemaker^¶	All except carotid or brachial	ceFAZolin^* 2 g IV pre-op	vancomycin^† 15 mg/kg IV pre-op	vancomycin^† 15 mg/kg IV pre-op
Urology^#	Lower Tract
	Cystoscopy with manipulation	ceFAZolin^* 2 g IV pre-op	ciprofloxacin 400 mg IV or 500 mg PO pre-op	N/A as no skin breach
	Transrectal ultrasound (TRUS) with prostate biopsy	ciprofloxacin 400 mg IV or 500 mg PO pre-op	ciprofloxacin 400 mg IV or 500 mg PO pre-op	N/A as no skin breach
	Upper Tract
	Shock wave lithotripsy or ureteroscopy^¥	ceFAZolin^* 2 g IV pre-op	ciprofloxacin 400 mg IV or ciprofloxacin 500 mg PO pre-op	N/A as no skin breach
	Open or Laparoscopic
	Not entering GU or GI tract (e.g. radical nephrectomy, laparoscopic nephrectomy)	ceFAZolin^* 2 g IV pre-op	vancomycin^† 15 mg/kg IV pre-op	vancomycin^† 15 mg/kg IV pre-op
	Entering GU tract (e.g. radical prostatectomy)	ceFAZolin^* 2 g IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV pre-op
	Entering GU and GI tract (e.g. radical cystectomy with ileoconduit, ileoconduit construction)	ceFAZolin^* 2 g IV pre-op + metroNIDAZOLE 500 mg IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV + metroNIDAZOLE 500 mg IV pre-op	vancomycin^† 15 mg/kg IV + tobramycin^‡ 5 mg/kg IV + metroNIDAZOLE 500 mg IV pre-op

^* If patient weight ≥120kg, use ceFAZolin 3 IV pre-op.

^† Vancomycin dosing is based on actual body weight.

^‡ Tobramycin dosing based on Ideal Body Weight (IBW) or Adjusted Body Weight (AdjBW) if weight is greater than 20% of IBW [AdjBW = IBW + 0.4 × (actual body weight - IBW)].

^§ Dosing depends on renal function.

^¶ Prophylaxis should be provided for all pacemaker insertions.

^# Prophylaxis should be targeted to preoperative urinary cultures. For assistance with prophylaxis for resistant organisms, consult Infectious Diseases.

^¥ If high risk features: immunosuppression, > 70 years of age, diabetes mellitus, active infection/infected stone/obstructive pyelonephritis.

References

Bratzler DW. Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004;38:1706-15.
American Academy of Orthopaedic Surgeons Advisory statement – Recommendations for the use of intravenous antibiotic prophylaxis in primary total joint arthroplasty.
American College of Obstetricians and Gynecologists (ACOG). Antibiotic prophylaxis for gynecologic procedures. 2001.
Society of Obstetrics and Gynecology of Canada (SOGC). Antibiotic Prophylaxis is Obstetric Procedures. 2010.
American Urological Association. Best Practice Policy Statement on Urological Surgery Antimicrobial Prophylaxis, updated 2008.
Best Practices in General Surgery. Strategies to prevent Surgical Site Infections. June 2012
Bratzler DW et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 2013;70:195-283.