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Antibiotic Prophylaxis for Surgical Procedures

by Robert G. Johnson, MD

Most surgical procedures do not require prophylactic or postoperative antibiotics. However, certain patient-related and procedure-related factors alter the risk-benefit ratio in favor of prophylactic use.

Patient-related factors include certain valvular heart disorders and immunosuppression. Procedures with higher risk involve areas where bacterial seeding is likely:

  • Mouth

  • GI tract

  • Respiratory tract

  • GU tract

In so-called clean (likely to be sterile) procedures, prophylaxis generally is beneficial only when prosthetic material or devices are being inserted or when the consequence of infection is known to be serious (eg, mediastinitis after coronary artery bypass grafting).

Drug choice is based on the bacteria most likely to contaminate the wound during a specific procedure. For commonly recommended regimens by procedure, see Antimicrobial Preoperative Prophylaxis Guidelines. Prophylaxis requires that the appropriate antibiotic is given within 1 h before the procedure. Antibiotics may be given orally or IV, depending on the procedure. The need for additional doses after the procedure is controversial, but for clean operations, no additional doses are needed. Postoperative antibiotics are continued > 24 h only when an active infection is detected during surgery; antibiotics are then considered treatment, not prophylaxis.

Antimicrobial Preoperative Prophylaxis Guidelines

Category

Procedure

Adult Dosage*

Abdominal

Gastroduodenal surgery in patients with hemorrhage, cancer, obstruction, or other high-risk features

Cefazolin 1–2 g IV preoperatively

or

Clindamycin 600 mg plus gentamicin 120 mg IV preoperatively

Gastric bypass

Cefazolin 1–2 g IV preoperatively

Percutaneous gastrostomy

Cefazolin 1–2 g IV preoperatively

Biliary tract (including ERCP) in patients who have acute symptoms, jaundice, or other high-risk features or who have had previous surgery

Cefazolin 1–2 g IV preoperatively

or

Gentamicin 80 mg IV preoperatively and q 8 h for 3 doses

Appendectomy (without perforation)

Cefoxitin, cefotetan, or cefmetazole 1–2 g IV preoperatively and q 6 h for 3 doses

or

Metronidazole 500 IV mg plus gentamicin 1.5 mg/kg IV preoperatively

Colorectal surgery, elective

Neomycin 1 g plus erythromycin base 1 g po at 1, 2, and 11 pm on the day before surgery ± parenteral drugs listed below for colorectal surgery

Colorectal surgery, emergency

Cefoxitin, cefotetan, or cefmetazole 2 g IV preoperatively and q 4 h for 3 doses

or

Metronidazole 500 mg IV plus gentamicin 1.7 mg/kg IV preoperatively and q 8 h for 3 doses

Cardiac

Median sternotomy, coronary artery bypass graft surgery, valve surgery, or pacemaker insertion

Cefazolin 2 g IV preoperatively and q 4–6 h intraoperatively

or

Cefuroxime 1.5 g IV preoperatively and q 4–6 h intraoperatively

or

Vancomycin 1 g IV preoperatively

Neurosurgical

Craniotomy, high-risk only (eg, reexplorations, microsurgery, entry into sinuses or nasopharynx)

Vancomycin 1g IV plus gentamicin 1.5 mg/kg IV preoperatively

or

Cefazolin 1 g IV preoperatively

CSF shunt placement—only in hospitals with high infection rates (15–20%)

Trimethoprim 160 mg IV plus sulfamethoxazole 800 mg IV preoperatively and q 12 h for 3 doses

or

Vancomycin 10 mg plus gentamicin 3 mg injected into a cerebral ventricle

Noncardiac thoracic

Pneumonectomy, lobectomy, other resections, or esophageal surgery

Cefazolin 1–2 g IV preoperatively and q 6 h for 24 h

or

Vancomycin 1 g IV preoperatively

Obstetric-gynecologic

Cesarean delivery, high-risk only (eg, premature rupture of membranes)

Cefazolin 1 g IV after clamping cord and q 6 h for 2 doses

Abortion, 2nd-trimester instillation

Cefazolin 1 g IV preoperatively and q 6 h for 2 doses

Abortion, 1st trimester in patients with a history of pelvic inflammatory disease, gonorrhea, or multiple partners

Penicillin G 1–2 million units IV preoperatively and 3 h later

or

Doxycycline 100 mg po before the procedure and 200 mg ½ h afterward

Hysterectomy, vaginal or abdominal

Cefazolin 1 g IV preoperatively and q 6 h for 2 doses

or

Doxycycline 200 mg IV preoperatively

Ophthalmic

Extraction of lens, with or without insertion of prosthesis

Gentamicin, tobramycin, or neomycin-gramicidin-polymyxin B drops over 2–24 h plus cefazolin 100 mg subconjunctivally at the end of the procedure

Orthopedic

Arthroplasty, including replacements

Cefazolin 1–2 g IV preoperatively and q 6 h for 3 doses

or

Vancomycin 1 g IV preoperatively

Open reduction of fractures

Cefazolin 1 g IV preoperatively and as a single dose postoperatively

Lower-extremity amputation (nonischemic)

Cefoxitin 2 g IV preoperatively and q 6 h for 4 doses

Otolaryngologic

Major head and neck surgery involving mucosa of the oral cavity or pharynx

Cefazolin 1–2 g IV preoperatively and q 8 h for 2 doses

or

Clindamycin 600–900 mg IV ± gentamicin 1.5 mg/kg IV preoperatively and q 8 h for 2 doses

Urologic

Prostatectomy if bacteriuria is present

Cefazolin 1 g IV preoperatively or another drug selected based on susceptibility tests

Penile prosthesis insertion

Cefazolin 1 g IV preoperatively

Vascular

Lower-extremity or abdominal arterial surgery or lower- extremity amputation for ischemia

Cefazolin 1–2 g IV preoperatively and q 6 h for 24 h

or

Vancomycin 1 g IV preoperatively and 12 h after the procedure

*Drugs, dosages, routes, and frequencies given represent recent expert recommendations. Cefazolin remains highly favored because of its spectrum of bactericidal activity, long half-life, low cost, and low toxicity. Alternatives are primarily for patients with β-lactam allergies.

±= with or without.

Adapted from Kernodle DS, Kaiser AB: Postoperative infections and antimicrobial prophylaxis. In Principles and Practice of Infectious Diseases , ed 5, edited by GL Mandell, JE Bennett, and R Dolin. New York, Churchill Livingstone, 2000, pp. 3186–3187 and from Antimicrobial prophylaxis in surgery. The Medical Letter 37:79–82, 1995.

Resources In This Article

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • PERIOSTAT, VIBRAMYCIN
  • ERY-TAB, ERYTHROCIN
  • NEO-FRADIN
  • No US brand name
  • GENOPTIC
  • FLAGYL
  • VANCOCIN
  • MEFOXIN
  • CLEOCIN
  • CEFTIN, ZINACEF
  • ANCEF, KEFZOL
  • TOBI, TOBREX

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