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Home , Antibiotic prophylaxis, Aztreonam, Cefoxitin, Circumcision, Doxycycline, Piperacillin

SURGICAL PROPHYLAXIS RECOMMENDATIONS

I. TABLE OF CONTENTS Introduction & Considerations Introduction Considerations Dosing and Re-dosing Guidelines Patients >50 kg ( and Pediatric) Patients ≤50 kg (Adult and Pediatric) Surgical Antimicrobial Prophylaxis Guidelines by Procedure Breast and Axillary Cardiothoracic Gastrointestinal Genitourinary Head and Neck Neurosurgical Obstetrical and Gynecological Ophthalmic Orthopedic Plastic Solid Organ Transplant Thoracic (non-cardiac) Vascular Footnotes & References Footnotes References

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II. INTRODUCTION The use of peri-operative has become an essential component of the standard of care for certain surgical procedures and can result in a reduced risk of post-operative when sound and appropriate principles are utilized. However, the benefit of antimicrobial prophylaxis must be weighed against the risks of toxic and allergic reactions, emergence of resistant , drug interactions, super-infection, and cost.

III. CONSIDERATIONS FOR ANTIMICROBIAL PROPHYLAXIS Goal: Administer antimicrobial prophylaxis to achieve serum and tissue levels of antimicrobial at the time of incision and for the duration of the operation, that are in excess of the minimum inhibitory concentration (MIC) needed for organisms that may be encountered during the procedure. a. Antimicrobial prophylaxis should be administered if there is a risk of infection in the absence of a prophylactic agent; clean procedures rarely require prophylaxis unless high risk procedure, including implantation of prosthetic material. i. Clean procedures are defined as those with no acute inflammation or transection of gastrointestinal, oropharyngeal, genitourinary, biliary, or respiratory tracts (elective cases, no technique break). b. The activity of the chosen prophylactic agent(s) should encompass the most common associated with the surgical procedure and consider local susceptibility data, but need not cover every likely . c. The prophylactic agent must be administered in a dose which provides an effective tissue concentration prior to incision / intra-operative bacterial contamination. i. In most instances, a single intravenous dose of an antimicrobial agent provides adequate tissue concentrations around the time of induction and throughout the operation. 1. Antimicrobial agent infusion should begin 15-60 minutes before the incision with the exception of , levofloxacin, ciprofloxacin, , and fluconazole. These infusions should begin 45-90 minutes before the incision and infused over 60-120 minutes as indicated for and (See following tables). 2. In adult patients, (2 g if <120 kg, 3 g if ≥120 kg) and vancomycin (1 g if <80 kg, 1.5 g if ≥80 kg) dosing is based on weight. Adult patients <50 kg should refer to Patients <50 kg (Adult and Pediatric) Dosing recommendations for dosing. Weight-based dosing is recommended for all in patients <50 kg. 3. Infusion duration and time to redosing for recommended prophylactic antimicrobials are summarized for adults and pediatrics. 4. All prophylactic antimicrobials should be discontinued after the intra-operative period, unless otherwise specified. a. Data have not supported subsequent doses after surgical closure and may increase the risk of Clostridium difficile and . b. A longer duration of antimicrobials may be indicated if concomitant infection is present at the time of surgery.

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BREAST AND AXILLARY PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 Excisional biopsies None Not recommended Not recommended

Adult: Adult: Wire Localized Breast Biopsy, Re-excision Cefazolin lumpectomy, Sentinel (SLN) alone, Lumpectomy & S. aureus SLN, Axillary Lymph Node Dissection, Mastectomy S. epidermidis OR OR (Total or Modified Radical) Vancomycin

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CARDIOTHORACIC PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 Adults: Any to cefuroxime OR high-risk allergy2/contraindication3 to any beta-lactam4: Vancomycin + Gentamicin

Adults: Continue vancomycin post-op for 24-48 hours; Vancomycin Gentamicin redosing not recommended given + Cefuroxime decreased following cardiopulmonary bypass Continue post-op for 24-48 hours with implants Alternative if any allergy to cefuroxime OR high- • Aortic grafts Vancomycin dosing modification and risk allergy2/contraindication3 to any beta-lactam4 • Prosthetic valves duration: and SCr 2 mg/dL or CrCL <40 mL/min: S. aureus CrCl >50 mL/min regardless of weight: Vancomycin Deep Hypothermic Circulatory Arrest (DHCA) S. epidermidis Vancomycin 1,000 mg IV q12h x3 doses + Levofloxacin CrCl <50 mL/min and weight <80 kg: gram-negative bacilli (Some procedures may be included in SCIP, and Vancomycin 1,000 mg IV q24h x1 dose Continue vancomycin post-op for 24-48 hours; appropriate selection is linked to hospital CrCl <50 mL/min and weight >80 kg: Levofloxacin redosing not indicated given long reimbursement) Vancomycin 1,500 mg IV q24h x1 dose half-life, especially with renal impairment

Alternative to vancomycin if true vancomycin allergy (not Red-Man’s):

Continue post-op for 24-48 hours Pediatric: Pediatrics: Any allergy to cefazolin OR high-risk Cefazolin allergy2/contraindication3 to any beta-lactam4: Clindamycin

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CARDIOTHORACIC PROCEDURES

Adults: Any allergy to cefuroxime OR high-risk allergy2/contraindication3 to any beta-lactam4: Vancomycin + Gentamicin Adults: Vancomycin Continue vancomycin post-op for 24-48 hours; + Cefuroxime Gentamicin redosing not recommended given decreased excretion following cardiopulmonary Cardiac surgery without implants Continue post-op for 24-48 hours bypass • CABG alone S. aureus Vancomycin dosing modification and Alternative to gentamicin if SCr 2 mg/dL or CrCL (Some procedures may be included in SCIP, and S. epidermidis duration: <40 mL/min: appropriate antibiotic selection is linked to hospital CrCl >50 mL/min regardless of weight: Vancomycin reimbursement) Vancomycin 1,000 mg IV q12h x3 doses + Levofloxacin CrCl <50 mL/min and weight <80 kg: Vancomycin 1,000 mg IV q24h x1 dose Levofloxacin redosing not indicated given long CrCl <50 mL/min and weight >80 kg: half-life, especially with renal impairment Vancomycin 1,500 mg IV q24h x1 dose Alternative to vancomycin if true vancomycin allergy (not Red-Man’s): Daptomycin

Continue post-op for 24-48 hours

S. aureus Pediatric: Congenital heart repair procedures requiring an Pediatrics: Any allergy to cefazolin OR high-risk S. epidermidis open sternum postoperatively Cefazolin allergy2/contraindication3 to any beta-lactam4: gram-negative bacilli Clindamycin

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CARDIOTHORACIC PROCEDURES Adult: Any allergy to cefazolin OR high-risk allergy2/contraindication3 to any beta-lactam4 or history of MRSA infection or colonization: Adults: Vancomycin Cefazolin

Pacemaker or AICD placement or revision Alternative to vancomycin if true vancomycin Continue post-op for 24 hours S. aureus allergy (not Red-Man’s): (Some procedures may be included in SCIP, and Daptomycin appropriate antibiotic selection is linked to hospital S. epidermidis reimbursement) Continue post-op for 24-48 hours

Pediatric: Pediatrics: Any allergy to cefazolin OR high-risk Cefazolin allergy2/contraindication3 to any beta-lactam4: Clindamycin

Adults: Adults: Vancomycin Any allergy to cefuroxime OR high-risk + Cefuroxime allergy2/contraindication3 to any beta-lactam4:

Vancomycin Continue post-op for 48 hours. + Levofloxacin If definitive cultures are available,

continue antibiotics and tailor regimen Continue post-op for 48 hours.

If definitive cultures are available, continue Vancomycin dosing modification and antibiotics and tailor regimen S. aureus duration:

CrCl >50 mL/min regardless of weight: Heart transplant S. epidermidis Alternative to vancomycin if true vancomycin Vancomycin 1 g IV q12h x3 doses allergy (not Red-Man’s): gram-negative bacilli CrCl ≤50 mL/min and weight ≤80 kg: Daptomycin Vancomycin 1 g IV q24h x1 dose

CrCl ≤50 mL/min and weight ≥80 kg: Continue post-op for 24-48 hours Vancomycin 1.5 g IV q24h x1 dose

Pediatric: Pediatrics: Any allergy to cefazolin OR high-risk Cefazolin allergy2/contraindication3 to any beta-lactam4: Clindamycin

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CARDIOTHORACIC PROCEDURES Adults: Vancomycin + Cefuroxime Adults: Any allergy to cefuroxime OR high-risk Vancomycin dosing modification and allergy2/contraindication3 to any beta-lactam4: duration: Vancomycin CrCl >50 mL/min regardless of weight: + Levofloxacin Vancomycin 1 g IV q12h x3 doses CrCl <50 mL/min and weight <80 kg: Continue vancomycin for 48-hours post-op. Vancomycin 1 g IV q24h x1 dose CrCl < 50ml/min and weight >80 kg: Start rifampin 600 mg PO/IV q24h, levofloxacin Vancomycin 1.5 g IV q24h x1 dose 500 mg PO/IV q24h and fluconazole 400 mg S. aureus PO/IV q24h post-procedure and continue for 48 Continue vancomycin for 48-hours post-op. hours from OR or from chest closure in case of S. epidermidis delayed chest closure. Left Ventricular Assist Device (LVAD) Candida spp. Start rifampin 600 mg PO/IV q24h, levofloxacin 500 mg PO/IV q24h and If or intolerances to vancomycin, rifampin enteric gram-negatives fluconazole 400 mg PO/IV q24h post- or fluconazole, consultation with Infectious procedure and continue for 48 hours from Diseases is recommended. OR or from chest closure in case of delayed chest closure. If definitive cultures are available, continue antibiotics and tailor regimen If definitive cultures are available, continue antibiotics and tailor regimen

Pediatric: Pediatrics: Any allergy to cefazolin OR high-risk Cefazolin allergy2/contraindication3 to any beta-lactam4: Clindamycin

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GASTROINTESTINAL PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 Adults: Any allergy to cefazolin or OR high- risk allergy2/contraindication3 to any beta- lactam4: Clindamycin + Levofloxacin OR Adults: Cefazolin Clindamycin + + Enteric gram-negative bacilli OR Enterococci Reserve -based regimens for Appendectomy Cefoxitin patients with intolerance to alternative (non-perforated) anaerobes ( spp., Clostridia) recommendations or history of documented S. aureus multi-drug resistant pathogen. If risk factors for acute renal failure present, avoid if alternative options available: Clindamycin + Gentamicin Pediatrics: Cefoxitin Pediatrics: Clindamycin OR + Gentamicin - Colon and anorectal procedures NOT requiring antibiotic prophylaxis: • Evaluation under anesthesia, fulguration of warts, high resolution anoscopy, dilation of stricture, anal biopsy None Prophylaxis Not Recommended Prophylaxis Not Recommended • EUA for fistula placement of seton • Fistulotomy, simple (NOT a Surgisis plug or advancement flap) • Transanal resection of fibroepithelial or pedunculated polyp

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GASTROINTESTINAL PROCEDURES Adults: Adults: Cefazolin Clindamycin OR OR S. aureus Cefuroxime Vancomycin Splenectomy S. epidermidis Pediatrics: Cefuroxime Pediatrics: Cefazolin OR Vancomycin Adults: Adults: Any allergy to cefazolin OR high-risk Cefazolin allergy2/contraindication3 to any beta-lactam4: + Metronidazole Clindamycin + Levofloxacin OR Colorectal Procedures OR Cefoxitin Not limited to, but including the following: Clindamycin • Colon & rectal resection Optional oral regimens in combination + Aztreonam • High, complex fistula by Surgisis plug with IV : or advancement flap 1,000 mg PO + Reserve aminoglycoside-based regimens for • Lateral sphincterotomy for anal base 1,000 mg PO; patients with intolerance to alternative fissure Enteric gram-negative bacilli give at 19, 18, and 9h before surgery recommendations or history of documented • Hemorrhoidectomy multi-drug resistant pathogen. If risk factors Enterococci OR • Transanal resection for sessile polyp, for acute renal failure present, avoid villous adenoma, possible T1 anaerobes (Bacteroides spp., Clostridia) Neomycin 1,000 mg PO aminoglycosides if alternative options malignancy S. aureus + Metronidazole 500 mg PO; give at available: • Rectal prolapse procedure (Altmeier 19, 18, and 9 h before surgery Clindamycin or abdominal rectosigmoid + Gentamicin resection/rectopexy) Pediatrics: Cefoxitin Pediatrics: (Some procedures may be included in SCIP, and Cefazolin appropriate antibiotic selection is linked to Optional oral regimens: + Metronidazole hospital reimbursement) Neomycin 20 mg/kg/dose PO + Metronidazole 10 mg/kg/dose PO OR OR Clindamycin + Gentamicin Neomycin 20 mg/kg/dose + Erythromycin base 20 mg/kg/dose ,

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GASTROINTESTINAL PROCEDURES Esophageal, gastric surgery, Adults: G-tube; peg tube Clindamycin Adults: (See small bowel for gastric bypass and Cefazolin OR Upper airway flora (aerobic, anaerobic gastrectomy) Streptococci) Vancomycin

ADULTS - Prophylaxis recommended for high S. aureus risk patients, including diabetes, morbid Pediatrics: more rarely aerobic gram-negative obesity, cancer, gastric bleeding, gastric outlet Clindamycin bacilli Pediatrics: obstruction, gastroduodenal perforation, Cefazolin OR esophageal obstruction, decreased gastric acidity or gastrointestinal motility, morbid Vancomycin obesity Adults: Any allergy to cefazolin or cefoxitin OR high- risk allergy2/contraindication3 to any beta- lactam4: Clindamycin Adults: + Levofloxacin Cefazolin OR + Metronidazole Hepatic, biliary tract, pancreatic including Clindamycin OR cholecystectomy and procedures, + Aztreonam Enteric gram-negative bacilli (e.g., E. cystgastrostomy Cefoxitin coli, ) (excluding low-risk laparoscopic Reserve aminoglycoside-based regimens for cholecystectomy*) Enterococci Also option for Whipple patients with intolerance to alternative Pancreaticoduodenectomy with recommendations or history of documented S. aureus *ADULTS – Prophylaxis recommend for high biliary stents: / multi-drug resistant pathogen. If risk factors risk patients only, including age >70 years, anaerobes (Bacteroides spp., Clostridia) for acute renal failure present, avoid non-functioning gall bladder, emergency common with stents, biliary obstruction aminoglycosides if alternative options procedures, diabetes, acute , available: obstructive jaundice or common duct stones Clindamycin + Gentamicin Pediatrics: Cefoxitin Pediatrics: OR Clindamycin + Gentamicin Piperacillin-tazobactam (for biliary atresia repair) ,

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GASTROINTESTINAL PROCEDURES Adults: Any allergy to cefazolin OR high-risk allergy2/contraindicatio3 to any beta-lactam4: Clindamycin + Levofloxacin OR Adults: Clindamycin Cefazolin + Aztreonam + Metronidazole

Enteric gram-negative bacilli OR Reserve aminoglycoside-based regimens for patients with intolerance to alternative Enterococci Cefoxitin Small bowel, gastric bypass, gastrectomy recommendations or history of documented anaerobes (Bacteroides spp., Clostridia) multi-drug resistant pathogen. If risk factors S. aureus for acute renal failure present, avoid aminoglycosides if alternative options available: Clindamycin + Gentamicin Pediatrics: Cefoxitin Pediatrics: OR Clindamycin + Gentamicin Piperacillin-tazobactam (for biliary atresia repair) Adults: Clindamycin Adults: Cefazolin OR Hernia repair S. aureus Vancomycin (hernioplasty-prosthetic mesh repair of hernia; Pediatrics: herniorrhaphy-suture repair of hernia) S. epidermidis Clindamycin Pediatrics: Cefazolin OR Vancomycin

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GENITOURINARY PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 Urinary Tract Instrumentation* Adults: TMP-SMX (Bactrim®) 1 DS PO, ideally 1-4 hrs prior Adults: Gentamicin 5 mg/kg IV x1 OR 120 mg IM OR OR Consider Prophylaxis ONLY in patients with risk factors: -clavulanate 875 mg PO, , urodynamic study, simple ideally 2-4 hrs prior Ciprofloxacin 500 mg PO 1-2 hrs prior or cystourethroscopy, shock wave OR 400 mg IV Risk Factors Include • Poor functional status/frailty Enteric gram-negative bacilli Cefazolin • anatomic anomalies of urinary tract Pediatrics: • chronic use Cefoxitin • immunocompromising condition or recent OR systemic chemotherapy Pediatrics: Gentamicin Cefazolin ± Ampicillin

OR

TMP-SMX (Bactrim®) Adults: Gentamicin 5 mg/kg IV x1 OR 120 mg IM Prophylaxis recommended for: +/-stent placement Adults: OR Cystourethroscopy with manipulation including: Cefazolin 2,000 mg IV/IM; • transurethral resection of bladder tumor and TMP-SMX (Bactrim®) 1 DS PO x1 , 3,000 mg IV/IM if ≥120 kg • any biopsy, resection, fulguration, foreign body OR

removal, urethral dilation or E. coli • any ureteral instrumentation including Ciprofloxacin 500 mg PO or 400 mg IV catheterization or stent placement/removal spp. Pediatrics: Cefoxitin • submucousal injection (e.g., Botulinum toxin) Klebsiella spp.

OR *The following procedures do not require infusion of IV antibiotics timed Pediatrics: for 15-30 min prior, but can be given directly before the procedure, as Gentamicin they are intended for prevention for post-procedural UTI: bladder biopsy; Cefazolin botox injection; cystolithalopaxy; with fulguration, ± Ampicillin microplastique, bladder neck incision or retrograde ; hydrodistention; ureteral stent placement and removal; ureteroscopy. OR

TMP-SMX (Bactrim®) ,

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GENITOURINARY PROCEDURES Adults w/o high risk features No antibiotics in days preceding PCNL Adults: Ampicillin-sulbactam prior to procedure Any allergy to OR high-risk Antibiotics should not be continued >24 allergy2/contraindication3 to any beta- Percutaneous nephrolithotomy (PCNL) hours unless there is concern for post- lactam4: procedural Vancomycin High risk features include: Adults w/high risk features: + Gentamicin • Positive urine culture within 2-4 weeks Recommend early ID consultation in • Residual stone with prior positive stone culture S. aureus OR anticipation of PCNL • Current indwelling ureteral stent or tube S. epidermidis Clindamycin • Severe hydronephrosis Tailored oral antibiotics 3-5 days prior to • Continuous intermittent catheterization enteric gram-negative bacilli PCNL, discuss w/ID if no oral option ± Gentamicin

• Renal transplant or other severe available Anaerobes immunocompromising condition If patient allergic to gentamicin or has Tailored IV antibiotic prophylaxis directly • Neurogenic bladder (with or without ) SCr >1.5 mg/mL, use Aztreonam instead prior to procedure • Urinary Diversion of gentamicin • Chronic indwelling (Foley or SP tube) Antibiotics only to continue >24 hrs after procedure for sepsis/complicated UTI due to residual infected stone Pediatrics : Pediatrics: Clindamycin Ampicillin-sulbactam + Gentamicin

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GENITOURINARY PROCEDURES Adults: S. aureus Any allergy to cefazolin OR high-risk allergy2/contraindication3 to any beta- Adults: Prostate S. epidermidis lactam4: Cefazolin Vancomycin Streptococci spp. OR Clindamycin Transperineal prostate biopsy None Prophylaxis Not Recommended Prophylaxis Not Recommended Adults: Rectal Swab Performed: Adults: Ciprofloxacin sensitive: Ciprofloxacin 500 mg PO 1 hour prior Rectal Swab Performed: to procedure and 500 mg PO 12 hours Allergic or resistant to , after the first dose cefazolin, ciprofloxacin, & TMP-SMX: OR Gentamicin 120 mg IM or 5 mg/kg IV Levofloxacin 750 mg PO 1 hour prior x1 (ideal body weight) to procedure

TMP-SMX (Bactrim™) sensitive: If isolated pathogen is resistant to TMP-SMX 1 DS PO 1 hour before ciprofloxacin, gentamicin, cefazolin, and procedure and 1 DS 12 hours after the ceftriaxone then antimicrobials should be first dose chosen based on organism susceptibilities Ciprofloxacin resistant and TMP-SMX E. coli resistant: Transrectal prostate biopsy Proteus spp. Cefazolin 2,000 mg IM; 3,000 mg IM if No Rectal Swab Performed: Klebsiella spp. ≥120 kg Cefazolin 2,000 mg IM; 3,000 mg IM if ≥120 kg Ciprofloxacin, TMP-SMX, and cefazolin + Ciprofloxacin 500 mg PO 1 hour prior resistant: to procedure and 500 mg PO 12 hours Ceftriaxone 1,000 mg IM after the first dose No Rectal Swab Performed: Gentamicin 120 mg IM OR

+ Ciprofloxacin 500 mg PO 1 hour prior Cefazolin 2,000 mg IM; 3,000 mg IM if to procedure and 500 mg PO 12 hours ≥120 kg after the first dose + Levofloxacin 750 mg PO 1 hour prior to OR procedure

Gentamicin 120 mg IM + Levofloxacin 750 mg PO 1 hour prior to procedure

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GENITOURINARY PROCEDURES OPEN, LAPAROSCOPIC, ROBOTIC SURGERY

S. aureus Adults: Adrenalectomy, Retroperitoneal/pelvic Any allergy to cefazolin OR high-risk Adults: lymphadenectomy S. epidermidis allergy2/contraindication3 to any beta- Cefazolin without entering the urinary tract lactam4: Streptococci spp. Vancomycin Adults: Adults: Any allergy to cefazolin OR high-risk None unless diabetes mellitus or allergy2/contraindication3 to any beta- other risk factors; then Cefazolin lactam4: Vancomycin Staphylococci Pediatrics: Pediatrics: Any allergy to cefazolin OR high-risk No antibiotic prophylaxis in healthy allergy3/contraindication4 to any beta- neonates; otherwise: lactam5: Cefazolin or Amoxicillin Clindamycin Adults: Adults: Any allergy to cefazolin OR high-risk Cefazolin 2,000 mg IV/IM; 3,000 mg allergy2/contraindication3 to any beta- if ≥120 kg lactam4: + Metronidazole 500 mg IV Levofloxacin 500 mg IV/PO + Metronidazole OR If history of MRSA infection or Cefoxitin colonization: S. aureus Vancomycin Genitourinary procedures involving small or large Optional oral antimicrobials in S. epidermidis + Gentamicin intestine combination with above prophylaxis Including urinary diversions, with small bowel Streptococci recommendations: Optional oral antimicrobials in conduit, uretero-pelvic junction repair, colon conduits, etc. neomycin sulfate + erythromycin combination with above prophylaxis Enteric gram-negative bacilli base recommendations: OR neomycin sulfate + erythromycin base neomycin sulfate + metronidazole OR neomycin sulfate + metronidazole Pediatrics: Ampicillin-sulbactam Pediatrics: OR Cefoxitin Clindamycin + Gentamicin ,

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GENITOURINARY PROCEDURES Adults: Cefazolin + Gentamicin Adults: + Fluconazole Any allergy to cefazolin OR high-risk

allergy2/contraindication3 to any beta- OR Staphylococci spp. lactam4 or if history of MRSA infection or

Penile prosthesis insertion, removal, & revision colonization AND SCr >1.5 mg/dL: Enteric gram-negative bacilli Vancomycin Vancomycin + Gentamicin + Aztreonam + Fluconazole + Fluconazole

Antibiotics should not be continued >24 hours post-operatively unless there is concern for sepsis Adults: Adults: Cefazolin Any allergy to cefazolin OR high-risk + Gentamicin allergy2/contraindication3 to any beta- Staphylocci spp. Testicluar implants lactam4 or if history of MRSA infection OR Enteric gram-negative bacilli or colonization AND SCr >1.5

mg/dL:Vancomycin Vancomycin + Aztreonam + Gentamicin Adults: Cefazolin + Gentamicin Adults: Vancomycin OR + Aztreonam Vancomycin + Gentamicin Implanted prosthetic devices Staphylococci Pediatrics: Cefoxitin Artificial urinary sphincter and sacral nerve stimulators enteric gram-negative bacilli OR Pediatrics: Ampicillin-sulbactam

Cefazolin Any allergy to cefoxitin or penicillins OR + Gentamicin high-risk allergy2/contraindication3 to any beta-lactam4: Vancomycin + Gentamicin

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GENITOURINARY PROCEDURES Adults: Any allergy to cefazolin OR high-risk allergy2/contraindication3 to any beta- Vaginal urologic surgery Enterococci spp. lactam4: Including urethral sling, fistulae repair, urethral Adults: Levofloxacin 500 mg IV/PO diverticulectomy, Enteric gram-negative bacilli. Cefazolin If history of MRSA infection or Open or laparoscopic procedure involving entry into the S. aureus colonization: urinary tract Vancomycin Including ; stricture repair including S. epidermidis + Aztreonam . , partial or otherwise, Pediatrics: urethrectomy, pyeloplasty, radical , partial Streptococci spp. (vaginal surgery Cefoxitin cystectomy mostly) Pediatrics: Cefazolin OR

Ciprofloxacin

NOTE: Some experts do not recommend prophylaxis for all Adults: cases. Prophylaxis may be Any allergy to cefazolin OR high-risk considered based on complexity of allergy2/contraindication3 to any beta- Staphylococci spp. procedure and comorbidities of Vasectomy lactam4 or if history of MRSA infection or patient. Enteric gram-negative bacilli colonization:

Vancomycin Adults: + Aztreonam Cefazolin

Adults: Any allergy to cefazolin OR high-risk allergy2/contraindication3 to any beta- Adults: lactam4 or if history of MRSA infection or Cefazolin colonization: Inguinal and scrotal cases Staphylococci spp. Including radical , reversals, variocelectomy, Vancomycin hydrocelectomy Enteric gram-negative bacilli + Aztreonam

Pediatrics: Pediatrics: Cefazolin Clindamycin

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GENITOURINARY PROCEDURES

S.aureus Adults: Adults: Medoidioplasty Cefazolin Clindamycin

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OBSTETRICAL AND GYNECOLOGICAL PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 Any allergy to cefazolin OR high-risk allergy2/contraindication3 to any beta-lactam4: Not in Labor: GBS screen negative or GBS screen positive and clindamycin sensitive: Clindamycin + Gentamicin 5 mg/kg IV x1 (adjusted body weight) GBS screen positive and clindamycin resistant: Adult: Vancomycin Enteric gram-negative bacilli Not in Labor: + Gentamicin 5 mg/kg IV x1 (adjusted Cefazolin body weight) Anaerobes Cesarean section Group B Streptococci In Labor (contractions with cervical In Labor (contractions with cervical dilation or dilation or membrane rupture): membrane rupture): Enterococci Cefazolin GBS screen negative, or GBS screen positive + Azithromycin 500 mg IV and clindamycin sensitive, or GBS unknown: Clindamycin + Azithromycin 500 mg IV + Gentamicin 5 mg/kg IV x1 (adjusted body weight) GBS screen positive and clindamycin resistant: Vancomycin + Azithromycin 500 mg IV + Gentamicin 5 mg/kg IV x1 (adjusted body weight) Vaginal hysterectomy Adult: Any allergy to cefazolin OR high-risk Abdominal hysterectomy allergy2/contraindication3 to any beta-lactam4: Enteric gram-negative bacilli Clindamycin Laproscopic or robotic hysterectomy Adult: Anaerobes + Gentamicin 5 mg/kg IV x1 (if pregnant, use (including supracervical hysterectomy) Cefazolin Group B Streptococci adjusted body weight; otherwise, use ideal + Metronidazole procedures including those body weight) Enterococci involving mesh OR Clindamycin Enterocele repair + Aztreonam ,

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OBSTETRICAL AND GYNECOLOGICAL PROCEDURES No history of PID: Hysterosalpingogram or Chromotubation No antibiotics (In patients with no history of PID, HSG can be History of PID: performed without prophylactic antibiotics. If HSG Doxycycline 100 mg PO x1 shows dilated fallopian tubes, antibiotic prophylaxis Dilated fallopian tubes: should be given) Doxycycline 100 mg PO BID x5 days Adult: MVA Doxycycline 100 mg PO one hour

before procedure Suction D&C procedures Anaerobes OR D&E procedures Azithromycin 1 g prior to procedure Low/medium-risk5 allergy: Emergent: Cefazolin

Enteric gram-negative bacilli Any allergy to penicillins and cefazolin OR high-risk allergy2/contraindication3 to any beta-lactam4: Planned: Anaerobes Emergent: Prophylaxis Not Recommended Cerclage Clindamycin Emergent: Group B Streptococci + Gentamicin 5 mg/kg IV x1 (if pregnant, use Ampicillin-sulbactam adjusted body weight; otherwise, use ideal Enterococci body weight) OR Clindamycin + Aztreonam Laparoscopy or laparotomy that is not accompanied by hysterectomy

Conization of cervix

Vulvectomy (simple) None Prophylaxis Not Recommended Prophylaxis Not Recommended

Laser treatment to vulva or perineum

Cystocele and rectocele repair

Perineorraphy WITHOUT mesh

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HEAD AND NECK PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 Clean, non-contaminated procedures None Not recommended Not recommended (i.e., thyroidectomy, lymph node excision) Adults: Low/medium-risk5 penicillin allergy: Cefazolin

Oral anaerobes + Metronidazole Adults: Clean contaminated head and neck surgery enteric gram-negative bacilli Ampicillin-sulbactam Any allergy to penicillins and cefazolin OR 6 (incision through oral, pharyngeal, or nasal mucosa) 2 3 S. aureus high-risk allergy /contraindication to any beta-lactam4: S. epidermidis Levofloxacin viridans streptococci + Metronidazole Pediatrics: Pediatrics: Ampicillin-sulbactam Clindamycin

Adults: Clindamycin Adults: Cefazolin OR Clean procedure with insertion of a prosthesis S. aureus Vancomycin (including BAHA hearing device) S. epidermidis Pediatrics: Clindamycin Pediatrics: Cefazolin OR Vancomycin Adults: Cefuroxime Adults: S. aureus Skull base, lateral or posterior approach OR Clindamycin procedures S. epidermidis Ampicillin-sulbactam (including cochlear implants) S. pneumoniae Pediatrics: Pediatrics: Cefuroxime Clindamycin

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HEAD AND NECK PROCEDURES Adults: Low/medium-risk5 penicillin allergy: Ceftriaxone + Metronidazole

Adults: If history of MRSA infection or Ampicillin-sulbactam colonization:

+ Vancomycin If history of MRSA infection or

colonization: S. aureus Any allergy to penicillins and cefazolin OR + Vancomycin 2 3 Skull base, anterior approach including high-risk allergy /contraindication to any S. epidermidis 4 transphenoidal surgery for pituitary tumors beta-lactam : gram-negative bacilli Vancomycin + Aztreonam + Metronidazole

Pediatrics: Pediatrics: Clindamycin Vancomycin + Cefuroxime

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NEUROSURGICAL PROCEDURES Nature of operation Likely pathogens Recommended regimenα Alternative regimenα Craniotomy Adults: Adults: VP shunts & other prosthetic material Cefazolin Vancomycin Spine implantable devices S. aureus Pediatrics: Cefazolin Pediatrics: (Some procedures may be included in SCIP, and S. epidermidis TMP-SMX (Bactrim ™) OR appropriate antibiotic selection is linked to hospital reimbursement) Vancomycin Adults: Any allergy to cefazolin OR high-risk allergy2/contraindication3 to any beta-lactam4: Adults: Clindamycin Discography Cefazolin

S. aureus (Intradiscal antimicrobial prophylaxis is not If history of MRSA infection or colonization: endorsed by the UMHS and S. epidermidis Vancomycin Therapeutics Committee and should not be used.) Pediatrics: Pediatrics: Clindamycin Cefazolin OR Vancomycin Adults: Low/medium-risk5 penicillin allergy: Ceftriaxone + Metronidazole

Adults: If history of MRSA infection or colonization: Ampicillin-sulbactam + Vancomycin

S. aureus If history of MRSA infection or Skull base, anterior approach including Any allergy to penicillins and S. epidermidis colonization: transphenoidal surgery for pituitary tumors ceftriaxone/// + Vancomycin gram-negative bacilli OR high-risk allergy2/contraindication3 to any beta-lactam4: Vancomycin + Aztreonam + Metronidazole Pediatrics: Pediatrics: Clindamycin Vancomycin + Cefuroxime

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NEUROSURGICAL PROCEDURES Adults: Ampicillin-sulbactam Adults: OR Clindamycin Skull base, lateral or posterior approach S. aureus Cefuroxime procedures S. epidermidis Pediatrics: Pediatrics: Clindamycin Vancomycin + Cefuroxime

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OPHTHALMIC PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 Gentamicin OR OR S. aureus Ciprofloxacin Minimal evidence supporting routine S. epidermidis OR use of prophylactic antibiotics for Ophthalmic procedures Streptococci ophthalmic surgery. Discretion advised Gatifloxacin regarding drug choice, duration, or enteric gram-negative bacilli OR . spp. Levofloxacin OR Neomycin--Polymixin B

Administer multiple drops topically over 2- 72 hrs

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ORTHOPEDIC PROCEDURES Nature of operation Likely Recommended regimen1 Alternative regimen1 pathogens Adults: S. aureus nasal screen: - Negative for MRSA - Positive for MSSA - Not performed and in the absence of history of MRSA Adults: carriage or infection Any allergy to cefazolin OR high-risk Cefazolin allergy2/contraindication3 to any beta-lactam4: Vancomycin S. aureus nasal screen: - Positive for MRSA Alternative to vancomycin if true vancomycin Total joint replacement (Arthroplasty) - Not performed, but patient has history of MRSA allergy (not Red-Man’s): carriage or infection Daptomycin Implantation of prosthetic material S. aureus Vancomycin (e.g., intramedullary nails, screw, plates, wires) S. epidermidis + Cefazolin

Hip fracture repair Antibiotic prophylaxis should be discontinued within 24 hours following sugery Pediatrics: History of MRSA carriage or infection AND any Pediatrics: allergy to cefazolin OR high-risk Cefazolin allergy2/contraindication3 to any beta-lactam4: Vancomycin History of MRSA carriage or infection: Vancomycin Allergy as above without history of MRSA + Cefazolin carriage or infection: Clindamycin

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ORTHOPEDIC PROCEDURES

Adults: Grade I or II open fracture with any allergy to Adults: cefazolin OR high-risk allergy2/contraindication3 Grade I or II open fracture: to any beta-lactam4: Cefazolin Clindamycin Extensive soil exposure (e.g., farming accident) + Metronidazole Grade III open fracture with any allergy to ceftriaxone/cefotaxime/cefpodoxime/cefepime Grade III open fracture: OR high-risk allergy2/contraindication3 to any Ceftriaxone beta-lactam4: Extensive soil exposure (e.g., farming accident) Clindamycin + Metronidazole + Aztreonam

Antibiotic prophylaxis should be discontinued within 48 hours Antibiotic prophylaxis should be discontinued within 48 hours S. aureus Open Fracture Repair Streptococcus (Includes upper and lower extremity open fractures) gram-negative rods Pediatrics: Grade I or II open fracture with any allergy to Pediatrics: cefazolin OR high-risk allergy2/contraindication3 Grade I or II open fracture: to any beta-lactam4: Cefazolin Clindamycin Extensive soil exposure (e.g., farming accident)

+ Metronidazole Grade III open fracture with any allergy to

ceftriaxone/cefotaxime/cefpodoxime/cefepime Grade III open fracture: OR high-risk allergy2/contraindication3 to any Ceftriaxone beta-lactam4: Extensive soil exposure (e.g., farming accident) Clindamycin + Metronidazole + Aztreonam

Antibiotic prophylaxis should be discontinued within 48 hours Antibiotic prophylaxis should be discontinued within 48 hours

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ORTHOPEDIC PROCEDURES Adults: S. aureus nasal screen: - Negative for MRSA - Positive for MSSA - Not performed and in the absence of history of MRSA carriage or infection Adults: Cefazolin Any allergy to cefazolin OR high-risk 2 3 4 S. aureus nasal screen: allergy /contraindication to any beta-lactam : - Positive for MRSA Vancomycin

- Not performed, but patient has history of MRSA carriage S. aureus or infection Alternative to vancomycin if true vancomycin Coagulase Vancomycin allergy (not Red-Man’s): Spinal procedure, with or without negative + Cefazolin Daptomycin instrumentation staphylococci Patients without instrumentation or drains: Gram negative Post-operative antibiotics are unnecessary bacilli Patients with instrumentation or drains: Antibiotics should be discontinued within 24 hours of surgery Pediatrics: Pediatrics: History of MRSA carriage or infection AND any Cefazolin allergy to cefazolin OR high-risk 2 3 4 allergy /contraindication to any beta-lactam : Vancomycin History of MRSA carriage or infection:

Vancomycin Allergy as above without history of MRSA + Cefazolin carriage or infection: Clindamycin Adults: Adults: Any allergy to cefazolin OR high-risk Cefazolin allergy2/contraindication3 to any beta-lactam4:

Sports History of MRSA infection or colonization: Clindamycin OR (Orthopaedic ) + Vancomycin S. aureus Vancomycin

Pediatrics: Implantation of interference screws, suture Streptococcus Any allergy to cefazolin OR high-risk anchors, permanent sutures, etc. Pediatrics: allergy2/contraindication3 to any beta-lactam4: Cefazolin Clindamycin OR Vancomycin REFERENCES 1. Bratzler DW, et al. Am J Health-Syst Pharm 2013; 70:195-283. 2. Schweizer ML et al. JAMA 2015; 313:2162-2171. 3. Rodriguez L et al. J Trauma Acute Care Surg 2013;77:400-408. ,

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SURGICAL ANTIMICROBIAL PROPHYLAXIS RECOMMENDATIONS

PLASTIC SURGERY PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 Adults: Any allergy to cefazolin OR high-risk Breast reconstruction (without implants), cosmetic Adults: allergy2/contraindication3 to any beta- procedures (excluding blepharoplasty), large hand Cefazolin lactam4: dissections*, phalloplasty, vaginoplasty, and S. aureus Clindamycin general reconstructive procedures involving Pediatrics: medium/large flaps or tissue expanders S. epidermidis Any allergy to cefazolin OR high-risk Pediatrics: allergy2/contraindication3 to any beta- *Open fractures: see guidelines Cefazolin lactam4: Clindamycin Adults: Adults: Cefazolin Any allergy to cefazolin OR high-risk

allergy2/contraindication3 to any beta- If history of MRSA infection or lactam4: colonization: S. aureus Vancomycin Breast procedures with implants + Vancomycin S. epidermidis Pediatrics: Any allergy to cefazolin OR high-risk Pediatrics: allergy2/contraindication3 to any beta- Cefazolin lactam4: Clindamycin Adults: Low/medium-risk5 penicillin allergy: Cefazolin + Metronidazole

Oral anaerobes Adults: Low/medium-risk5 penicillin allergy PLUS enteric gram-negative bacilli Ampicillin-sulbactam cefazolin allergy, OR high-risk Cleft lip and palate repair, or facial procedures that allergy2/contraindication3 to any beta- transect oral, nasal (see rhinoplasty below), or S. aureus lactam4: pharyngeal mucosa S. epidermidis Levofloxacin + Metronidazole viridans streptococci Pediatrics: Any allergy to penicillins OR high-risk Pediatrics: allergy2/contraindication3 to any beta- Ampicillin-sulbactam lactam4: Clindamycin Table of Contents

PLASTIC SURGERY PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 NOTE: Some experts do not recommend prophylaxis for all procedures. Prophylaxis may be considered based on complexity of Adults: procedure and comorbidities of Low/medium-risk5 penicillin allergy PLUS patient. cefazolin allergy, OR high-risk allergy2/contraindication3 to any beta- S. aureus Adults: lactam4: Rhinoplasty/Septorhinoplasty S. epidermidis Ampicillin-sulbactam Clindamycin OR C. acnes Cefazolin

Pediatrics: Pediatrics: Any allergy to penicillins OR high-risk Ampicillin-sulbactam allergy2/contraindication3 to any beta- OR lactam4: Cefazolin Clindamycin Pediatrics: S. aureus Any allergy to penicillins OR high-risk Pediatrics: allergy2/contraindication3 to any beta- S. epidermidis Pre-operative: lactam4: Open cranial vault reconstruction Oral flora Piperacillin-tazobactam Pre-operative: Post-operative: Clindamycin P. aeruginosa Ampicillin-sulbactam + Gentamicin Post-operative: Clindamycin Pediatrics: Any allergy to cefazolin OR high-risk Endoscopic craniofacial procedures and strip S. aureus Pediatrics: allergy2/contraindication3 to any beta- craniectomy Cefazolin S. epidermidis lactam4: Clindamycin

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RADIOLOGY PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 Adults: Clindamycin Adults: ± Gentamicin Ceftriaxone OR If the patient allergic to gentamicin or has S. aureus SCr >1.5 mg/dL: T-tube cholangiogram, Diagnostic PTC, PTC tube Ampicillin-sulbactam S. epidermidis Clindamycin placement/check/change, TIPS + Aztreonam enteric gram-negative bacilli Pediatrics: Pediatrics: Clindamycin Ampicillin-sulbactam + Gentamicin

Adults: Clindamycin ± Gentamicin S. aureus Adults:

S. epidermidis Ampicillin-sulbactam If the patient allergic to gentamicin or has tube SCr >1.5 mg/dL: change/check/placement enteric gram-negative bacilli Clindamycin anaerobes (Bacteroides spp., Clostridia + Aztreonam spp.) Pediatrics: Pediatrics: Clindamycin Ampicillin-sulbactam + Gentamicin

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SOLID ORGAN TRANSPLANT PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 Adults: Adults: S. aureus Vancomycin Cefazolin + Aztreonam transplant S. epidermidis Pediatrics: Pediatrics: enteric gram-negative bacilli Vancomycin Cefazolin + Aztreonam Adults: Enteric gram-negative bacilli (e.g., E. coli, Adults: Vancomycin Klebsiella) Piperacillin-tazobactam + Aztreonam Liver transplant Enterococci Pediatrics: Pediatrics: S. aureus Vancomycin Piperacillin-tazobactam anaerobes (Bacteroides, Clostridia) + Aztreonam

Enteric gram-negative bacilli (e.g., E. coli, Klebsiella) Adults: Adults: Pancreas transplant and Pancreas-Kidney Cefoxitin Vancomycin Transplant S. aureus + Fluconazole + Aztreonam anaerobes (Bacteroides, Clostridia)

Staphylococci Adults: Adults: Laparoscopic Living Donor Nephrectomy Cefazolin 2,000 mg IV/IM; 3,000 mg if Vancomycin enteric gram-negative bacilli ≥120 kg + Aztreonam

Enteric gram-negative bacilli (e.g., E. coli, Klebsiella) Adults: Enterococci Adults: Living Donor Liver Clindamycin Cefoxitin S. aureus + Aztreonam anaerobes (Bacteroides, Clostridia) common with stents, biliary obstruction For Heart Transplant see Cardiothoracic guideline

For Lung Transplant see Thoracic (non- cardiac) guideline

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THORACIC (NON-CARDIAC) PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 Adults: Adults: Cefazolin Vancomycin S. aureus Pediatrics: Esophagectomy Clindamycin S. epidermidis Pediatrics: Cefazolin OR Vancomycin Adults: Adults: Vancomycin Vancomycin S. aureus + Cefepime + Aztreonam Lung transplant aerobic gram-negative bacilli All antimicrobials should be All antimicrobials should be discontinued discontinued 48 hours post-operatively 48 hours post-operatively or until cultures or until cultures are available are available Adults: Adults: Cefazolin Vancomycin S. aureus Pediatrics: Misc. thoracic procedures Clindamycin S. epidermidis Pediatrics: Cefazolin OR Vancomycin

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VASCULAR PROCEDURES Nature of operation Likely pathogens Recommended regimen1 Alternative regimen1 Adults: Cefazolin

Adults: Open, repair If history of MRSA infection or Clindamycin colonization or if severe β-lactam Aortic and peripheral aneurysm repair with S. aureus allergy: endovascular stent graft S. epidermidis Vancomycin Pediatrics: Arterial bypass with prosthetic graft Clindamycin Pediatrics: Cefazolin OR Vancomycin Adults: Cefazolin

Adults: If history of MRSA infection or Clindamycin colonization or if severe β-lactam

S. aureus allergy: AV grafts (with prosthetic) & fistulas (no prosthetic) Vancomycin with skin flap for vein transposition S. epidermidis Pediatrics: Clindamycin Pediatrics: Cefazolin OR Vancomycin Adults: Adults: Cefazolin Clindamycin

If history of MRSA infection or OR colonization: Vancomycin Carotid endarterectomy with prosthesis or patch Staph. aureus, Staph. epidermidis Vancomycin Pediatrics: Clindamycin Pediatrics: Cefazolin OR Vancomycin Carotid endarterectomy without prosthesis or None Not recommended Not recommended patch

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VASCULAR PROCEDURES Fistulas (no prosthetic) without skin flaps for vein transposition

None Not recommended Not recommended Varicose vein ablation (laser or radio frequency)

Vena cava filter placement Adults: Clindamycin Adults: Lower extremity for ischemia S. aureus Cefazolin OR

S. epidermidis Vancomycin Phlebectomy of varicose veins, stripping of Pediatrics: varicose veins, ligation of varicose veins (e.g., enteric gram-negative bacilli Clindamycin Saphenous Vein stripping or ligation) Clostridia spp. Pediatrics: Cefazolin OR Vancomycin Adults: Cefazolin Adults: Clindamycin If history of MRSA infection or OR colonization or if severe β-lactam Thromboendarterectomy without bypass S. aureus allergy: Vancomycin

Vancomycin Arterial bypass with vein graft S. epidermidis Pediatrics: Clindamycin Pediatrics: Cefazolin OR Vancomycin

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PATIENTS >50 kg (ADULT AND PEDIATRIC) PRE-OP AND INTRAOPERATIVE ANTIBIOTIC DOSING RECOMMENDATIONS7,8,9

Pre-operative dose10 Intraoperative re-dosing11 Pre-operative dose does not Antimicrobial Omit second re-dose in those with IV push Infusion require adjustment for renal CrCl <50 ml/min or on hemodialysis dysfunction

Ampicillin 2 g 2 g every 2 hours for 2 re-doses 3-5 min12 30 min13

Ampicillin/sulbactam 3 g 3 g every 2 hours for 2 re-doses 3-5 min12 30 min13

Aztreonam 2 g 2 g every 4 hours for 2 re-doses 3-5 min12 30 min13 2 g if <120 kg, 2 g (3 g if ≥120 kg) every 4 hours Cefazolin 3-5 min12 30 min13 3 g if ≥120 kg for 2 re-doses Cefuroxime 1.5 g 1.5 g every 4 hours for 2 re-doses 3-5 min12 30 min13

Cefoxitin 2 g 2 g every 2 hours for 2 re-doses 3-5 min12 30 min13

Cefepime 2 g 2 g every 4 hours for 2 re-doses 3-5 min12 30 min13

Clindamycin 900 mg 900 mg every 6 hours for 2 re-doses Not Recommended 30 min13

Daptomycin 6 mg/kg14 Not Recommended 2 min 30 min13

Piperacillin/tazobactam 4.5 g 4.5 g every 2 hours for 2 re-doses Not Recommended 30 min13

Metronidazole 500 mg Not Recommended Not Recommended 30 min13

Ceftriaxone 2 g Not Recommended 3-5 min12 30 min13 5 mg/kg15 Gentamicin Not Recommended Not Recommended 30 min - 60 min (ideal body weight) 1 g if <80 kg, 1 g (1.5 g if ≥80 kg) every 8 hours Vancomycin Not Recommended 60 – 120 min 1.5 g if ≥80 kg for 2 doses Levofloxacin 500 mg Not Recommended Not Recommended 60 min13

Ciprofloxacin 400 mg Not Recommended Not Recommended 60 min13

Fluconazole 400 mg Not Recommended Not Recommended 120 min13

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8,9 PATIENTS ≤50 kg (ADULT AND PEDIATRIC) PRE-OP AND INTRAOPERATIVE ANTIBIOTIC DOSING RECOMMENDATIONS Recommended Infusion Patient Weight in kg Intraoperative Antibiotic Dose Concentration Time <2.5 2.5-4.9 5-7.49 7.5-9.9 10-14.9 15-19.9 20-24.9 25-29.9 30-34.9 35-39.9 40-44.9 45-50 >50 Redosing Interval Ampicillin 50 mg/kg Maximum (Ampicillin/Sulbactam dosed 1 g/10 mL of 200 250 mg 375 mg 500 mg 750 mg 1000 mg 1250 mg 1500 mg 1750 mg 2000 mg 2000 mg 2000 mg q2h x2 redoses on ampicillin) mg/min

max: 2000 mg

Aztreonam IVP 30 mg/kg 1 g/10 mL 3-5 150 mg 225 mg 300 mg 450 mg 600 mg 750 mg 750 mg 1000 mg 1000 mg 1000 mg 1500 mg q4h x2 redoses max: 2000 mg minutes

Cefazolin IVP (non-cardiac/redoses) 1 g/10 mL 3-5 150 mg 225 mg 300 mg 450 mg 600 mg 750 mg 750 mg 1000 mg 1000 mg 1000 mg 1500 mg q4h x2 redoses 30 mg/kg minutes max: 2000 mg

Cefazolin11 q4h x2 redoses IVP (cardiac/SBE16) w/non-cardiac 1 g/10 mL 3-5 250 mg 375 mg 500 mg 750 mg 1000 mg 1250 mg 1500 mg 1750 mg 2000 mg 2000 mg 2000 mg 50 mg/kg redose value minutes max: 2000 mg (30 mg/kg) Cefepime 3-5 50 mg/kg 1 g/10 mL 250 mg 375 mg 500 mg 750 mg 1000 mg 1250 mg 1500 mg 1750 mg 2000 mg 2000 mg 2000 mg q4h x2 redoses minutes max: 2000 mg Cefotaxime 3-5 50 mg/kg 1 g/10 mL 250 mg 375 mg 500 mg 750 mg 1000 mg 1250 mg 1500 mg 1750 mg 2000 mg 2000 mg 2000 mg q3h x2 redoses minutes max: 2000 mg

Cefoxitin RECOMMENDATIONS DOSING 3-5 40 mg/kg 1 g/10 mL 200 mg 300 mg 400 mg 600 mg 800 mg 1000 mg 1250 mg 1500 mg 1500 mg 2000 mg 2000 mg q2 x2 redoses minutes max: 2000 mg Ceftriaxone 3-5 50 mg/kg 40 mg/mL 250 mg 375 mg 500 mg 750 mg 1000 mg 1250 mg 1500 mg 1750 mg 2000 mg 2000 mg 2000 mg None

minutes kg >50 max: 2000 mg Cefuroxime 3-5 50 mg/kg 1 g/10 mL TRADITIONAL USE MG/KG DOSING 250 mg 375 mg 500 mg 750 mg 1000 mg 1500 mg 1500 mg 1500 mg 1500 mg 1500 mg 1500 mg q4h x2 redoses minutes max: 1500 mg Ciprofloxacin Minimum 10 mg/kg 2 mg/mL of 60 50 mg 75 mg 100 mg 150 mg 200 mg 250 mg 300 mg 350 mg 400 mg 400 mg 400 mg None max: 400 mg minutes TO REFER Clindamycin Maximum (non-cardiac/redoses) 20 mg/mL of 30 50 mg 75 mg 100 mg 150 mg 200 mg 250 mg 300 mg 350 mg 400 mg 450 mg 500 mg q6h x2 redoses 10 mg/kg mg/min max: 900 mg

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8,9 PATIENTS ≤50 kg (ADULT AND PEDIATRIC) PRE-OP AND INTRAOPERATIVE ANTIBIOTIC DOSING RECOMMENDATIONS Recommended Infusion Patient Weight in kg Intraoperative Antibiotic Dose Concentration Time <2.5 2.5-4.9 5-7.49 7.5-9.9 10-14.9 15-19.9 20-24.9 25-29.9 30-34.9 35-39.9 40-44.9 45-50 >50 Redosing Interval

Clindamycin11 Q6h x2 redoses Maximum (cardiac/SBE16 in PCN w/non-cardiac 20 mg/mL of 30 100 mg 150 mg 200 mg 300 mg 400 mg 500 mg 600 mg 700 mg 800 mg 900 mg 900 mg allergy) redose value mg/min

20 mg/kg max: 900 mg (10 mg/kg)

80 mg SMX: 16 Co-trimoxazole mg TMP/mL Minimum 5 mg/kg TMP 5 ml vial of 30 25 mg 37.5 mg 50 mg 75 mg 100 mg 125 mg 150 mg 160 mg 160 mg 160 mg 160 mg Q6h x2

Not in <2 months Maximum conc. minutes max: 160 mg TMP 1:10 Fluconazole Maximum 6 mg/kg 2 mg/mL of 200 25 mg 40 mg 50 mg 75 mg 100 mg 135 mg 165 mg 200 mg 225 mg 250 mg 285 mg None max: 400 mg mg/hour Gentamicin/ Minimum Tobramycin 10 mg/mL of 30 12.5 mg 20 mg 25 mg 40 mg 50 mg 60 mg 75 mg 90 mg 100 mg 100 mg 100 mg Q8h x2 redoses 2.5 mg/kg minutes max: 100 mg Levofloxacin Minimum 10 mg/kg 5 mg/mL of 60 50 mg 75 mg 100 mg 150 mg 200 mg 250 mg 300 mg 350 mg 400 mg 450 mg 500 mg None max: 750 mg minutes Metronidazole

15 mg/kg Minimum DOSINGRECOMMENDATIONS

(dosing rounded to be 5 mg/mL of 30 75 mg 100 mg 150 mg 200 mg 300 mg 375 mg 450 mg 500 mg 500 mg 500 mg 500 mg None divisible by 5) minutes max: 500 mg Piperacillin/

Tazobactam Minimum >50kg 100 mg/kg based on 100 mg/mL of 30 500 mg 750 mg 1000 mg 1500 mg 2000 mg 2500 mg 3000 mg 3000 mg 3000 mg 3000 mg 3000 mg Q2h x2 redoses Piperacillin minutes max: 3000 mg TRADITIONAL USE DOSING MG/KG Vancomycin Minimum (cardiac) 1 g/100 mL of 60 50 mg 75 mg 100 mg 150 mg 200 mg 250 mg 300 mg 350 mg 400 mg 450 mg 500 mg Q12h x2 redoses 10 mg/kg

minutes TO REFER max: 1000 mg Vancomycin Minimum (non-cardiac) 1 g/100 mL of 60 75 mg 100 mg 150 mg 225 mg 300 mg 375 mg 450 mg 500 mg 500 mg 750 mg 750 mg Q8h x2 redoses 15 mg/kg minutes max: 1000 mg

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IV. FOOTNOTES 1 Refer to Pre-op and Intraoperative Antibiotic Dosing Recommendations Guidelines • Guideline includes infusion duration and time to intra-operative redosing • All prophylactic antimicrobials should be discontinued after the intra-operative period, unless otherwise specified • Adult patients <50 kg should receive antibiotic dosing based on ≤50 kg guideline • Pediatrics patients >50 kg should receive antibiotic dosing based on >50 kg guideline • Patients <2.5 kg, use traditional mg/kg dosing • SIP operative pediatrics procedures include: cardiac, ventriculoperitoneal shunts, and spinal surgery 2 High-risk allergies include: respiratory symptoms (chest tightness, bronchospasm, wheezing, cough), angioedema (swelling, throat tightness), cardiovascular symptoms (hypotension, dizzy/lightheadedness, syncope/passing out, arrhythmia), . If a patient has a high-risk allergy to penicillins, , or , the only beta-lactam antibiotic that can be safely used without Allergy consult is aztreonam (if the allergy is to or aztreonam, aztreonam should be avoided as well). See β-lactam allergy evaluation and empiric guidance for further information. 3 Previous reactions that are contraindications to further beta-lactam use (except aztreonam, which can be used unless the reaction was to ceftazidime or aztreonam) unless approved by Allergy: organ damage (kidney, liver), drug-induced immune-mediated /thrombocytopenia/leukopenia, rash with mucosal lesions (Stevens Johnson Syndrome/Toxic Epidermal Necrosis), rash with pustules (acute generalized exanthematous pustulosis), rash with eosinophils and organ injury (DRESS – drug rash and systemic symptoms), rash with joint , fever, and myalgia (Serum Sickness). See β-lactam allergy evaluation and empiric guidance for further information. 4 Beta-lactam antibiotics include the following antibiotic classes: penicillins, cephalosporins, carbapenems, aztreonam 5 Low-risk allergies include: pruritus without rash, remote (>10 years) unknown reaction, patient denies allergy but is on record, mild rash with no other symptoms (mild rash: non-urticarial rash that resolves without medical intervention). Medium-risk allergies include: urticaria/hives with no other symptoms, severe rash with no other symptoms (severe rash: requires medical intervention [, anti-histamines] and/or ER visit or hospitalization). See β-lactam allergy evaluation and empiric guidance for further information. 6 Deviations may be appropriate for staged procedures. For example, in TMJ replacement cases, ampicillin-sulbactam prior to the oral portion of the procedure followed by cefazolin prior to the neck incision. 7 Adapted from Clinical Infectious Diseases 2004;38:1706-15 and Am J Health-Syst Pharm 2013;70. 8 Patients receiving systemic antibiotics prior to procedure should still receive the standard pre-operative antimicrobial prophylaxis with appropriate timing of administration as outlined in the UMHS surgical antimicrobial prophylaxis guidelines. Given the risk of nephrotoxicity, in patients receiving vancomycin or aminoglycosides prior to procedure who need these agents for pre-operative antimicrobial prophylaxis, please consult pharmacy to see if treatment doses can be rescheduled such that administration begins 45-90 minutes prior to incision. 9 In patients with known colonization or infection with drug-resistant pathogens, the standard pre-operative antimicrobial prophylaxis should generally still be administered unless otherwise specified in procedure-specific guidelines. Please contact the ID approval pager (adults: 30780; pediatrics: 36149) to discuss the case if concerned about: history of a multidrug-resistant organism (e.g., ESBL- producing organism, -resistant Enterobacteriaceae, etc.) at the site of the procedure in the previous year OR history of MRSA colonization in the previous year. 10 Infusion Timing: • Infusions should begin 15-60 minutes prior to incision for all antimicrobial agents unless listed below: o Levofloxacin, ciprofloxacin, vancomycin, gentamicin, azithromycin, and fluconazole, which should begin 45-90 minutes prior to incision. • If pre-operative antibiotics have already been administered but incision has been delayed more than 60 minutes beyond the maximum dosing window (i.e., beta-lactam antibiotics started >2 hours prior to incision), consider pre-operative re-dosing for all antibiotics except vancomycin and aminoglycosides. For vancomycin and aminoglycosides, please contact pharmacy to determine if re-dosing is appropriate. 11 Redosing should occur with the same initial dose, with the exception of cefazolin and clindamycin when used in cardiac/SBE prophylaxis 12 Reconstituted dose injected directly into vein or via running IV fluids (only if IV piggyback not available). 13 Intermittent IV infusion 14 Daptomycin should be dosed on actual body weight except in patients with BMI ≥35 kg/m2, in which case adjusted body weight should be used. 15 Gentamicin dose should be based on ideal body weight unless actual body weight is less than ideal body weight. Consult pharmacy if patient has severe renal dysfunction. 16 SBE prophylaxis, ACC/AHA 2008 guideline update on valvular heart disease

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V. ADDITIONAL REFERENCES • Milstone A. et al. Timing of Preoperative Antibiotic Prophylaxis: A modifiable risk factor for deep surgical site after pediatric spinal fusion. Pediatr Infect Dis J. 2008 Aug;27(8):704-8. • Kids’ Campaign 2007 Pediatric Webcast Series: Reduce Surgical Complications and Prevent Surgical Site Infections. 5 Million lives Campaign. • Bratzler DW., Houch PM. Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project. Am J Surg. 2005 Apr;189(4):395-404. • American Academy of Pediatrics: Antimicrobial Prophylaxis in Pediatric Surgical Patients. Pediatrics. 1984 Sep;74(3):437-9. • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013 Feb 1;70(3):195-283.

Antimicrobial Subcommittee Approval: 08/18, 07/20, 10/20 Originated: 04/09 P&T Approval: 10/18, 08/20, 11/20, 04/21, Last Revised: 07/21 06/21, 07/21 Revision History: 08/2020: Revised OB/GYN section 10/2020: Revised section 11/2020: Revised Gastrointestinal section 03/2021: Revised allergy wording, Orthopedic, Plastics, and Cardiothoracic sections. 04/2021: Adjusted rhinoplasty/septorhinoplasty and vasectomy recommendations. 07/2021: Revised Spinal Surgergy prophylaxis, reorganized footnotes, added staged procedures comment. The recommendations in this guide are meant to serve as treatment guidelines for use at Michigan Medicine facilities. If you are an individual experiencing a medical emergency, call 911 immediately. These guidelines should not replace a provider’s professional medical advice based on clinical judgment, or be used in lieu of an Infectious Diseases consultation when necessary. As a result of ongoing research, practice guidelines may from time to time change. The authors of these guidelines have made all attempts to ensure the accuracy based on current information, however, due to ongoing research, users of these guidelines are strongly encouraged to confirm the information contained within them through an independent source.

If obtained from a source other than med.umich.edu/asp, please visit the webpage for the most up-to-date document.

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