• Information
  1. Principles
  2. Specific Indications

A. Principles

1. Antibiotic prophylaxis usually recommended only for procedures with high infection rates
2. Antibiotic usually given in single dose <1 hour prior to incision (operation)
3. If short half-life antibiotic used (eg. oxacillin, cefoxitin), intraoperative dose is given also
4. Antibiotics should almost always be used in patients with abnormal heart valves
   1. Prosthetic heart valves (natural and synthetic)
   2. Valvular abnormalities - especially rheumatic heart disease
5. In debilitated patients, lower threshhold for prophylaxis
6. In most cases, wound infections (gram positive cocci) are the major problem
   1. Cefazolin (Ancef®, Kefzol®) single 1-2gm IV dose preoperatively is usually adequate
   2. If methicillin-resistant staphylococci are a problem, use vancomycin 1gm IV
   3. Avoid 3rd-4th generation cephalosporins which may lead to resistance
7. In operations which are "dirty" or where an infection is already present, a full course of antibiotic therapy is given
8. Maintaining normothermia perioperatively significantly reduces wound infections [2]
9. Choice of antibiotic may depend on local flora and patterns of infection
10. Preoperative IgM anti-endotoxin core Abs correlated with adverse outcomes after cardiac surgery; IgG anti-endotoxin Ab level did not [3]
11. Supplemental 80% oxygen perioperatively reduces wound infections ~50% [4]
12. Intranasal Mupirocin (Bactroban® Nasal) [5]
    1. Reduces rate of nosocomial Staphylococcus aureus in S. aureus carriers by ~50%
    2. No effect on rate of S. aureus surgical wound infection

B. Specific Indications

1. Pulmonary Resection / Thoracostomy - cefuroxime 750-1500mg iv x 2 doses
2. Vascular Surgery
   1. Wound prophylaxis, particularly if synthetic graft material is used
   2. Cefazolin 1-2gm IV or vancomycin 1 gm IV
3. Orthopedic
   1. Anti-staphylococcal agents for orthopedic procedures are recommended
   2. Prosthetic joints may not need prophylaxis for other procedures (no good data)
   3. Cefazolin (Ancef®) 1-2gm IV or vancomycin 1 gm IV
4. Neurosurgical (craniotomy) - cefazolin 1-2gm IV or vancomycin 1 gm IV
5. Head and Neck - anaerobic coverage essential; ampicillin/sulbactam or clindamycin
6. Esophageal, Gastric, Duodenal - cefoxin or cefazolin 1-2gm IV
7. Abdominal Surgery
   1. Cephalosporins are usually recommended for prophylaxis (± oral antibiotics for bowel)
   2. Any evidence of perforation should prompt a full course of antibiotics
   3. For colorectal surgery, cefoxitin or cefotetan 1-2gm are used
   4. Cefoxitin and cefotetan doses should be repeated 1-2 times perioperatively
   5. Nonperforated appendectomy - cefoxitin or cefotetan 1-2gm IV
   6. Biliary tract - cefazolin or cefoxin 1-2gm IV
8. Invasive Procedures
   1. Angiography - prophylaxis not usually required
   2. Upper GI Endoscopy - prophylaxis only in patients on acid-blockers (H2- or H+ blockers)
   3. Endoscopic Retrograde Cholangiopancreatography (ERCP) - cephalosporin prophylaxis
   4. Thoracentesis / Paracentesis - not usually required
9. Gynecology / Obstetrics
   1. Recommended in (emergency) cesarean section
   2. Premature rupture of membranes
   3. After first or mid-trimester abortions
10. Urological
    1. Not required if urine is sterile; if not, prophylaxis recommended
    2. High risk (diabetes, catheter, prostate biopsy) - ciprofloxain 500mg po or 400mg IV
11. Ruptured Viscus
    1. Cefoxitin 1-2gm IV q6 hours or cefotetan 1-2gm IV q12 hours ± gentamicin 5mg/kg IV qd
    2. Alternative: clindamycin 600mg IV q6 hour + gentamicin 5mg/kg IV qd
12. Traumatic Wound - cefazolin 1-2gm IV q8 hours

References

1. Antimicrobial Prophylaxis for Surgery. 2001. Med Let. 43(1116):92
2. Kurz A, Sessler DI, Lenhardt R. 1996. NEJM. 334(19):1209
3. Bennett-Guerrero E, Ayuso L, Hamilton-Davies C, et al. 1997. JAMA. 277(8):646
4. Greif R, Akca O, Horn EP, et al. 2000. NEJM. 42(3):161
5. Perl TM, Cullen JJ, Wenzel RP, et al. 2002. NEJM. 346(24):1871