Antibiotic Prophylaxis for Surgical Procedures: Care of the Surgical Patient: Merck Manual Professional

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Antibiotic Prophylaxis for Surgical Procedures

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Antibiotic Prophylaxis for Surgical Procedures

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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 Table 2: Care of the Surgical Patient: 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.

Table 2

Antimicrobial Preoperative Prophylaxis Guidelines
Category	Procedure	Adult Dosage*
Abdominal	Gastroduodenal surgery in patients with hemorrhage, cancer, obstruction, or other high-risk features	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1–2 g IV preoperatively or ClindamycinSome Trade Names CLEOCIN Click for Drug Monograph 600 mg plus gentamicinSome Trade Names GARAMYCIN Click for Drug Monograph 120 mg IV preoperatively
	Gastric bypass	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1–2 g IV preoperatively
	Percutaneous gastrostomy	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 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	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1–2 g IV preoperatively or GentamicinSome Trade Names GARAMYCIN Click for Drug Monograph 80 mg IV preoperatively and q 8 h for 3 doses
	Appendectomy (without perforation)	CefoxitinSome Trade Names MEFOXIN Click for Drug Monograph , cefotetanSome Trade Names CEFOTAN Click for Drug Monograph , or cefmetazole 1–2 g IV preoperatively and q 6 h for 3 doses or MetronidazoleSome Trade Names FLAGYL Click for Drug Monograph 500 IV mg plus gentamicinSome Trade Names GARAMYCIN Click for Drug Monograph 1.5 mg/kg IV preoperatively
	Colorectal surgery, elective	NeomycinSome Trade Names NEO-FRADIN NEO-RX Click for Drug Monograph 1 g plus erythromycinSome Trade Names ERY-TAB ERYTHROCIN Click for Drug Monograph 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	CefoxitinSome Trade Names MEFOXIN Click for Drug Monograph , cefotetanSome Trade Names CEFOTAN Click for Drug Monograph , or cefmetazole 2 g IV preoperatively and q 4 h for 3 doses or MetronidazoleSome Trade Names FLAGYL Click for Drug Monograph 500 mg IV plus gentamicinSome Trade Names GARAMYCIN Click for Drug Monograph 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	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 2 g IV preoperatively and q 4–6 h intraoperatively or CefuroximeSome Trade Names CEFTIN ZINACEF Click for Drug Monograph 1.5 g IV preoperatively and q 4–6 h intraoperatively or VancomycinSome Trade Names VANCOCIN Click for Drug Monograph 1 g IV preoperatively
Neurosurgical	Craniotomy, high-risk only (eg, reexplorations, microsurgery, entry into sinuses or nasopharynx)	VancomycinSome Trade Names VANCOCIN Click for Drug Monograph 1g IV plus gentamicinSome Trade Names GARAMYCIN Click for Drug Monograph 1.5 mg/kg IV preoperatively or CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1 g IV preoperatively
Neurosurgical	CSF shunt placement—only in hospitals with high infection rates (15–20%)	TrimethoprimSome Trade Names PROLOPRIM TRIMPEX Click for Drug Monograph 160 mg IV plus sulfamethoxazole 800 mg IV preoperatively and q 12 h for 3 doses or VancomycinSome Trade Names VANCOCIN Click for Drug Monograph 10 mg plus gentamicinSome Trade Names GARAMYCIN Click for Drug Monograph 3 mg injected into a cerebral ventricle
Noncardiac thoracic	Pneumonectomy, lobectomy, other resections, or esophageal surgery	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1–2 g IV preoperatively and q 6 h for 24 h or VancomycinSome Trade Names VANCOCIN Click for Drug Monograph 1 g IV preoperatively
Obstetric-gynecologic	Cesarean delivery, high-risk only (eg, premature rupture of membranes)	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1 g IV after clamping cord and q 6 h for 2 doses
	Abortion, 2nd-trimester instillation	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 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 GSome Trade Names BICILLIN WYCILLIN Click for Drug Monograph 1–2 million units IV preoperatively and 3 h later or DoxycyclineSome Trade Names PERIOSTAT VIBRAMYCIN Click for Drug Monograph 100 mg po before the procedure and 200 mg ½ h afterward
	Hysterectomy, vaginal or abdominal	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1 g IV preoperatively and q 6 h for 2 doses or DoxycyclineSome Trade Names PERIOSTAT VIBRAMYCIN Click for Drug Monograph 200 mg IV preoperatively
Ophthalmic	Extraction of lens, with or without insertion of prosthesis	GentamicinSome Trade Names GARAMYCIN Click for Drug Monograph , tobramycinSome Trade Names NEBCIN TOBI TOBREX Click for Drug Monograph , or neomycinSome Trade Names NEO-FRADIN NEO-RX Click for Drug Monograph -gramicidin-polymyxin BSome Trade Names POLY-RX Click for Drug Monograph drops over 2–24 h plus cefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 100 mg subconjunctivally at the end of the procedure
Orthopedic	Arthroplasty, including replacements	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1–2 g IV preoperatively and q 6 h for 3 doses or VancomycinSome Trade Names VANCOCIN Click for Drug Monograph 1 g IV preoperatively
	Open reduction of fractures	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1 g IV preoperatively and as a single dose postoperatively
	Lower-extremity amputation (nonischemic)	CefoxitinSome Trade Names MEFOXIN Click for Drug Monograph 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	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1–2 g IV preoperatively and q 8 h for 2 doses or ClindamycinSome Trade Names CLEOCIN Click for Drug Monograph 600–900 mg IV ± gentamicinSome Trade Names GARAMYCIN Click for Drug Monograph 1.5 mg/kg IV preoperatively and q 8 h for 2 doses
Urologic	Prostatectomy if bacteriuria is present	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1 g IV preoperatively or another drug selected based on susceptibility tests
Urologic	Penile prosthesis insertion	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1 g IV preoperatively
Vascular	Lower-extremity or abdominal arterial surgery or lower- extremity amputation for ischemia	CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 1–2 g IV preoperatively and q 6 h for 24 h or VancomycinSome Trade Names VANCOCIN Click for Drug Monograph 1 g IV preoperatively and 12 h after the procedure
*Drugs, dosages, routes, and frequencies given represent recent expert recommendations. CefazolinSome Trade Names ANCEF KEFZOL Click for Drug Monograph 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.

Last full review/revision May 2009 by Robert G. Johnson, MD

Content last modified May 2009

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