4.13.1 - Surgical

Principles of Surgical Prophylaxis:

The antimicrobial agent should be started within 30 - 60 minutes. Antibiotic administration must be completed before surgical incision (120 minutes for Vancomycin or Fluoroquinolones). 
While single-dose prophylaxis is usually sufficient, the duration of prophylaxis for all procedures should be less than 24 hours (48 hours for cardiac surgery) to minimize adverse effects, the development of resistance, and costs. 
Antimicrobial agents with the narrowest spectrum of activity required for efficacy in preventing infection to prevent resistance. 

Intraoperative redosing is needed if the duration of the procedure exceeds two half-lives of the drug (from the time of initiation of the preoperative dose [see Table], if prolonged or excessive bleeding occurs or if there are other factors that may shorten the half-life of the prophylactic agent (e.g. extensive burns). 

Intraoperative redosing may not be warranted in patients whom the half-life of the agent may be prolonged (e.g. patients with renal insufficiency or failure).  

MRSA decolonization is recommended in MRSA carriers.
For patients known to be colonized with methicillin-resistant Staphylococcus aureus, it is reasonable to add a single preoperative dose of Vancomycin 15 mg/kg to the recommended agent(s) 120 minutes before incision.

The use of antimicrobial agents for dirty procedures or established infections is classified as treatment of presumed infection, not prophylaxis. 

The predominant organisms causing SSIs after clean procedures are skin flora, including S. aureus and coagulase-negative staphylococci. In procedures involving the abdomen, heart, kidney, and liver, the predominant organisms are gram-negative rods and enterococci in addition to skin flora. 
Antimicrobial prophylaxis in gastroduodenal procedures should be considered for patients at highest risk for postoperative infections, including risk factors such as increased gastric pH (e.g. patients receiving acid-suppression therapy), gastroduodenal perforation, decreased gastric motility, gastric outlet obstruction, gastric bleeding, morbid obesity, ASA classification of ≥3, and cancer. 
For most patients undergoing colorectal surgery, a mechanical bowel preparation combined with oral Neomycin Sulfate plus oral Erythromycin base or with oral Neomycin Sulfate plus oral Metronidazole should be given in addition to IV prophylaxis. 

Antimicrobial

Half-life in Adults with Normal Renal Function (hours)

Recommended Redosing Interval (From Initiation of Preoperative Dose), (hours)

Cefuroxime

1 - 2

3 - 4

Clindamycin

2 - 4

6

Cefazolin

1.2 - 2.2

3 - 4

Co-amoxiclav

1

2.5

Gentamicin

2 - 3

N/A

Vancomycin

5 - 11

N/A

Ampicillin/Sulbactam

0.8 - 1.3

2

Fluconazole

30

N/A

Metronidazole

6 - 8

N/A
























Procedure

Preferred

Alternative

Comments

Cardiovascular Surgeries


Cardiac surgery including coronary artery bypass, reconstruction abdominal aorta, procedures on the leg that involves groin incision, any vascular procedure that inserts prosthesis / FB (e.g. pacemaker implantation, ventricular assist devices) and lower extremity amputation for ischemia.
    

Cefuroxime 1.5 gm IV q8H for 1 - 2 days

±

Vancomycin 15 mg/kg STAT, then q8 - 12H for 1 - 2 days if MRSA colonization is present

Clindamycin 600 mg IV 30 - 60 mins before procedure and q6H thereafter for 1 - 2 days

Thoracic Procedures


Non cardiac procedures (including lobectomy, pneumonectomy, lung resection, and thoracotomy), video-assisted thoracoscopic surgery


Cefazolin 2 gm IV 30 - 60 minutes prior to surgery.

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)


 
Clindamycin 600 mg IV
 

Gastroduodenal Procedures


Percutaneous Endoscopic Gastrostomy / Jejunostomy (high risk only)

Piperacillin / Tazobactam 4.5 gm IV

Clindamycin 600 mg IV 
+ Gentamicin 2 mg/kg IV at the time of induction

 

Biliary tract 
Gram +ve, gram -ve bacilli  
- Open procedure 
- Laparoscopic cholecestectomy

Co-amoxiclav 1.2 gm IV
 
OR
 
Cefazolin 2 gm IV

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)


Clindamycin 600 mg IV 
Gentamicin 5 mg/kg IV 


 

ERCP (controversial)

Without Obstruction


 


No antibiotics
   
 
With Obstruction

Co-amoxiclav 1.2 gm IV q8H (minimum 3 days) 

Clindamycin 600 mg IV 
+ Gentamicin 5 mg/kg IV 
± Vancomycin 25 mg/kg (max 2 gm) IV (for enterococcus)

 

Appendectomy for uncomplicated appendicitis

Cefazolin 2 gm IV 

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

+ Metronidazole 500 mg IV




Clindamycin 600 mg IV 
+ Gentamicin 5 mg/kg IV

 

Colorectal Surgeries


Small Intestine 

Non-Obstructed



Cefazolin 2 gm IV 

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

 


Clindamycin 600 mg IV 
+ Gentamicin 5 mg/kg IV

 

Obstructed 

Cefazolin 2 gm IV 

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

+ Metronidazole 500mg IV



 
Clindamycin 600 mg IV 
+ Gentamicin 5 mg/kg IV
 

Hernia Repair (Hernioplasty and Herniorrhaphy) 


Cefazolin 2 gm IV  

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

 
Clindamycin 600 mg IV 
 

Head and Neck Procedures

 
Clean

 
None
 
None
 

Clean with Placement of Prosthesis (Excludes Tympanostomy Tubes)
 
Cefazolin 2 gm IV


(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

 
Clindamycin 600 mg IV 
+ Gentamicin 5 mg/kg IV

 
 
Clean-contaminated procedure
 
Cefazolin 2 gm IV 

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

+ Metronidazole 500mg IV



 
Clindamycin 600 mg IV 
+ Gentamicin 5 mg/kg IV
 

Neurosurgery

 
Transnasal Surgery
 
Cefazolin 2 gm IV 

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)


OR Cefuroxime 1.5 gm IV


+ Metronidazole 500 mg IV




 
Clindamycin 600 mg IV
OR Vancomycin 15 mg/kg IV

 
 
Elective Craniotomy and Cerebrospinal Fluid-Shunting Procedures

 
Cefazolin 2 gm IV


(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

 
Clindamycin 600 mg IV
OR Vancomycin 15 mg/kg IV

 
 
Implantation of Intrathecal Pump

 
Cefazolin 2 gm IV

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

 
Clindamycin 600 mg IV
OR Vancomycin 15 mg/kg IV

 

 

Gynaecology Procedures

 
Cesarean Delivery

 
Cefazolin 2 gm IV


(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

 
Clindamycin 600 mg IV 
+ Gentamicin 5 mg/kg IV

 
 
Hysterectomy (Vaginal or Abdominal)
 
Co-amoxiclav 1.2 gm IV

 
Clindamycin 600 mg IV
+ Gentamicin 5 mg/kg IV

 
 
Repair of 3rd or 4th Degree Vaginal Laceration
 
Cefazolin 2 gm IV

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)


Metronidazole 500 mg IV


OR

Co-amoxiclav 1.2 gm IV

 
Clindamycin 600 mg IV
+ Gentamicin 5 mg/kg IV
 

Ophthalmic Procedures

 
Ophthalmic 

Topical Neomycin–Polymyxin B–Gramicidin or fourth-generation topical Fluoroquinolones (Gatifloxacin or Moxifloxacin) given as 1 drop every 5 –15 mins for 5 doses

 
None
 
Addition of Cefazolin 100 mg by subconjunctival injection or intracameral Cefazolin 1 – 2.5 mg or Cefuroxime 1 mg at the end of procedure is optional.

Orthopaedic Procedures 

 
Spinal Procedures With and Without Instrumentation
Hip Fracture Repair
Implantation of Internal Fixation Devices (e.g., nails, screws, plates, wires)
Total Joint Replacement

 
Cefazolin 2 gm IV

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)
 
Clindamycin 600 mg IV
 
 
Orthopedic
Clean operations involving hand, knee, or foot and not involving implantation of foreign materials

 
None
 
None
 

Urology Procedures

 
Urologic
Lower tract instrumentation :
Transrectal prostate biopsy
Cystoscopy
Urodynamic studies
Diagnostic ureteroscopy
TURP, TURB
ESWL (standard, no risk factors i.e. presence of stent or nephrostmy tube)
Ureteoscopy stone
Percutaneous stone management

 
Ampicillin / Sulbactam 1.5 gm IV
 
Clindamycin 600 mg IV 
+ Gentamicin 5 mg/kg IV
 
 
Clean with or without entry into urinary tract:
Nephrectomy, Scrotal Surgery, Prosthetic Implant, Nephroureterectomy, Ureteropelvic Junction Repair, Total Radical Prostectomy, Partial Bladder Resection, Involving Implanted Prosthesis

 
Cefazolin 2 gm IV

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

± 

Gentamicin 5 mg/kg IV (if involving implanted prosthesis)

 
Clindamycin 600 mg IV 
+ Gentamicin 5 mg/kg IV
 
 
Clean-contaminated:
Cystectomy with bladder deviation
 
Cefazolin 2 gm IV 

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

+ Metronidazole 500mg IV



 
Clindamycin 600 mg IV 
+ Gentamicin 5 mg/kg IV

 

Transplant

 
Vascular
Heart, lung, heart-lung transplantation

 
Cefazolin 2 gm IV

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

 
Clindamycin 600 mg IV
 
 
Pancreas and pancreas-kidney transplantation

 
Cefazolin 2 gm IV

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

±

Fluconazole (for patients at high risk of fungal infections)

 
Clindamycin 600 mg IV 
+ Gentamicin 2 mg/kg IV
 

Plastic Surgeries

 
Clean with risk factors or clean-contaminated

 
Cefazolin 2 gm IV

(Cefazolin 3 gm IV 30 - 60 minutes prior to surgery for patients weight > 120 kg)

 
Clindamycin 600 mg IV