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Antibiotic Prophylaxis for Surgical Procedures

by Paul K. Mohabir, MD, Jennifer Gurney, 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 risk factors suggesting need for antibiotics include

  • Certain valvular heart disorders

  • 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).

Choice of antibiotics is based on the Surgical Care Improvement Project (SCIP) guidelines (see Perioperative Management). There is strong evidence that standardizing antibiotic choices and adhering to SCIP protocols or another standardized and validated protocol reduce the risk of surgical infection. Some regions of the US that followed SCIP guidelines were able to decrease surgical site infections by 25% from 2006 to 2010. Drug choice is based on the drug's activity against the bacteria most likely to contaminate the wound during the specific procedure (see Table: Antibiotic Regimens for Certain Surgical Procedures). The antibiotic is given within 1 h before the surgical incision (2 h for vancomycin and fluoroquinolones). Antibiotics may be given orally or IV, depending on the procedure. For most cephalosporins, another dose is given if the procedure lasts > 4 h. For clean procedures, no additional doses are needed, but, for other cases, it is unclear whether additional doses are beneficial. Antibiotics are continued > 24 h postoperatively only when an active infection is detected during surgery; antibiotics are then considered treatment, not prophylaxis.

Antibiotic Regimens for Certain Surgical Procedures

Surgical Procedure

Approved Antibiotics

Cardiac or vascular

Cefazolin, cefuroxime, or vancomycin

If β-lactam allergy: Vancomycin or clindamycin

Hip/knee arthroplasty

Cefazolin, cefuroxime, or vancomycin

If β-lactam allergy: Vancomycin or clindamycin

Colon

Cefotetan, cefoxitin, ampicillin/sulbactam, or ertapenem or cefazolin plus Metronidazole or cefuroxime plus metronidazole or ceftriaxone plus metronidazole

If β-lactam allergy: Clindamycin plus gentamicin or clindamycin plus ciprofloxacin or clindamycin plus aztreonam or metronidazole plus gentamicin or metronidazole plus ciprofloxacin

Hysterectomy

Cefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin/sulbactam

If β-lactam allergy: Clindamycin plus gentamicin or clindamycin plus ciprofloxacin or clindamycin plus aztreonam or metronidazole plus gentamicin or metronidazole plus ciprofloxacin or vancomycin plus aminoglycoside or vancomycin plus aztreonam or vancomycin plus quinolone

Adapted from the Specifications Manual for National Hospital Inpatient Quality Measures, Section 2.4 Surgical Care Improvement Project (SCIP), version 4.3:38–39, 2014. Available at QualityNet .

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Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • ROCEPHIN
  • No US brand name
  • GENOPTIC
  • FLAGYL
  • VANCOCIN
  • MEFOXIN
  • CILOXAN, CIPRO
  • CLEOCIN
  • CEFTIN, ZINACEF
  • ANCEF, KEFZOL
  • INVANZ
  • AZACTAM

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