Surgical Prophylaxis Antibiotic Recommendations Updated 2017
1. Prophylactic antibiotic is to be initiated within 1 hour prior to incision Exception: Due to the longer infusion time required, initiate vancomycin and ciprofloxacin within 2 hours prior to incision 2. Anesthesia to give preoperative antibiotic dose and document time on anesthesia record. Exception: Antibiotics in Endoscopy, Labor and Delivery and Birth Care Center 3. Chose alternative antibiotic if patient is allergic to recommended first line antibiotic. Avoid giving cefazolin or cefotetan if the patient has allergies to cephalosporins or a life- threatening allergy to penicillin (angioedema, bronchoconstriction, cardiac arrhythmias, hypotension, or respiratory distress) 4. Pediatric Patients: Maximum dose is dose listed for wt <80 kg. For pediatric patients >80 kg, follow adult dosing. 5. For patients colonized with MRSA: Give vancomycin as the pre-op antibiotics for cardiac, vascular, orthopedic, neurological, and head and neck surgeries. For all other surgeries, give vancomycin in addition to the antibiotics listed below. To determine if a patient is colonized with MRSA, please see flow sheet below. 6. Per Clinical Practice Restricted/High Risk Medications with Special Requirements Policy: Pre-operative antibiotics for prophylaxis in adult patients will be automatically substituted to the antibiotics listed on Adult Surgical Pre-Operative Antibiotic Prophylaxis order set #347. For surgeries/procedures not addressed on the order set, anesthesia is to discuss antibiotic selection with the surgeon. 7. Antibiotics listed below are listed in order of preference. The first line antibiotic has been designated with an asterisks(*).
Dose Surgical Procedure Drug Pediatrics (<80 kg), Wt <80 kg Wt 80-119 kg Wt ≥ 120 kg If applicable Coronary Artery Bypass Graft Cardiac Surgery cefazolin IV* 1 gm 2 gm 3 gm Vascular Surgery All CABG, Valves and other CV procedures Pacemakers, AICD’s, pocket vancomycin IV (MRSA or 1 gm 1.5 gm 2 gm relocation and lead revisions, allergy) generator replacements. Repair of the aorta Leg vessel bypasses Endarterectomy of the aorta clindamycin IV 900 mg Abdominal endarterectomy Abdominal vessel resection Intra-abdominal shunt Vascular shunt & bypass AV fistula daptomycin (MRSA or allergy) contact pharmacy
cefazolin IV* 1 gm 2 gm 3 gm
Hip Arthroplasty (full or partial) vancomycin IV (MRSA or 1 gm 1.5 gm 2 gm Knee Arthroplasty allergy)
All Orthopedic and Podiatry cases clindamycin IV 900 mg
daptomycin (MRSA or allergy) contact pharmacy 30 mg/kg cefazolin IV* 1 gm 2 gm 3 gm Neurological (max 1000 mg) Shunt insertion, replace or vancomycin IV (MRSA or 15 mg/kg revise 1 gm 1.5 gm 2 gm allergy) (max 1000 mg) Pain pumps 10 mg/kg Laminectomy clindamycin IV 900 mg Laminotomy (max 900 mg) Discectomy daptomycin (MRSA or allergy) contact pharmacy Head and Neck 30 mg/kg cefazolin IV* 1 gm 2 gm 3 gm (max 1000 mg) All jaw fracture repairs 15 mg/kg vancomycin IV (MRSA or 1 gm 1.5 gm 2 gm With or w/o interdental allergy) (max 1000 mg) fixation clindamycin IV PLUS 900 mg 900 mg PLUS
Diverticulectomy of gentamicin IV PLUS 80 mg 120 mg hypopharynx or esophagus with or w/o myotomy, daptomycin (MRSA or allergy) contact pharmacy cervical approach
Surgical Prophylaxis Antibiotic Recommendations Updated 2017
Dose Surgical Procedure Drug Pediatrics (<80 kg) Wt <80 kg Wt 80-119 kg Wt ≥ 120 kg If applicable vancomycin PLUS 15 mg/kg Colonized with MRSA 1 gm 1.5 gm 2 gm antibiotics listed below (max 1000 mg) 50 mg/kg ceftriaxone IV PLUS (max 1000 mg) 1 gm PLUS metronidazole IV* PLUS 15 mg/kg 500 mg (max 500 mg) 50 mg/kg cefotetan IV* 1 gm 2 gm 2 gm (max 1000 mg) During cefotetan shortage: 40 mg/kg Colon Surgery (open or lap) 2 gm Cecectomy cefoxitin (max 2000 mg) Hemicolectomy 10 mg/kg Sigmoidectomy ciprofloxacin IV PLUS (max 400 mg) 400 mg PLUS PLUS 15 mg/kg Anastomosis, including anal metronidazole IV 500 mg (max 500 mg) Resections, including rectal clindamycin IV PLUS 900 mg 900 mg PLUS Any laceration repair gentamicin IV PLUS 80 mg 120 mg Any intestinal/bowel incision clindamycin IV PLUS 900 mg PLUS aztreonam IV 2 gm clindamycin IV PLUS 900 mg PLUS ciprofloxacin IV 400 mg metronidazole IV PLUS 500 mg 500 mg PLUS gentamicin IV PLUS 80 mg 120 mg cefotetan IV* 1 gm 2 gm 2 gm During cefotetan shortage: 2 gm cefoxitin clindamycin IV PLUS 900 mg PLUS ciprofloxacin IV 400 mg ciprofloxacin IV PLUS 400 mg PLUS metronidazole IV 500 mg clindamycin IV PLUS 900 mg 900 mg PLUS Hysterectomy (any approach) gentamicin IV PLUS 80 mg 120 mg Hysterectomy (any approach) with colon clindamycin IV PLUS 900 mg PLUS procedure (any approach) aztreonam IV 2 gm 500 mg metronidazole IV PLUS 500 mg PLUS PLUS gentamicin IV 120 mg 80 mg vancomycin IV PLUS 1 gm PLUS 1.5 gm PLUS 2 gm PLUS gentamicin IV 80 mg 120 mg 120 mg vancomycin IV PLUS 1 gm PLUS 1.5 gm PLUS 2 gm PLUS aztreonam IV 2 gm 2 gm 2 gm Genitourinary cefazolin IV* 1 gm 2 gm 3 gm 500 mg ciprofloxacin PO (clearly document date/time taken if dose was taken PTA on day of surgery) Prostate biopsy sulfamethoxazole/ 800mg/160 mg Needle, punch or incisional (clearly document date/time taken if dose was trimethoprim PO approach taken PTA on day of surgery) gentamicin IV 80 mg 120 mg
aztreonam IV 2 gm cefazolin IV PLUS 1 gm PLUS 2 gm PLUS 3 gm PLUS gentamicin IV* 80 mg 120 mg 120 mg vancomycin IV PLUS 1 gm PLUS 1.5 gm PLUS 2 gm PLUS gentamicin IV 80 mg 120 mg 120 mg gentamicin IV PLUS 80 mg PLUS 120 mg PLUS clindamycin IV 900 mg 900 mg Penile prosthesis aztreonam IV PLUS 2 gm PLUS Insertion, removal, revision clindamycin IV 900 mg aztreonam IV PLUS 2 gm PLUS 2 gm PLUS 2 gm PLUS vancomycin IV 1 gm 1.5 gm 2 gm
aztreonam IV PLUS 2 gm PLUS 2 gm PLUS 2 gm PLUS cefazolin IV 1 gm 2 gm 3 gm Surgical Prophylaxis Antibiotic Recommendations Updated 2017
Dose Surgical Procedure Drug Pediatrics (<80 kg) Wt <80 kg Wt 80-119 kg Wt ≥ 120kg If applicable vancomycin PLUS 15 mg/kg Colonized with MRSA 1 gm 1.5 gm 2 gm antibiotics listed below (max 1000 mg) Gastric/Biliary 30 mg/kg cefazolin IV* 1 gm 2 gm 3 gm (max 1000 mg) 10 mg/kg (max 400 mg) ciprofloxacin IV PLUS 400 mg PLUS PLUS clindamycin IV 900 mg 10 mg/kg (max 900 mg) PEG placement clindamycin IV PLUS 900 mg 900 mg PLUS gentamicin IV PLUS 80 mg 120 mg vancomycin IV PLUS 1 gm PLUS 1.5 gm PLUS 2 g PLUS gentamicin IV 80 mg 120 mg 120 mg vancomycin IV PLUS 1 gm PLUS 1.5 gm PLUS 2 gm PLUS ciprofloxacin IV 400 mg 400 mg 400 mg cefotetan IV* 1 gm 2 gm 2 gm During cefotetan shortage: 2 gm cefoxitin clindamycin IV PLUS 900 mg PLUS ciprofloxacin IV 400 mg Pubovaginal Sling clindamycin IV PLUS 900 mg 900 mg PLUS gentamicin IV PLUS 80 mg 120 mg Sling operation for stress clindamycin IV PLUS 900 mg PLUS incontinence (fascia or aztreonam IV 2 gm synthetic) metronidazole IV PLUS 500 mg PLUS Paravaginal defect repair aztreonam IV 2 gm (including repair of 500 mg metronidazole IV PLUS 500 mg PLUS cystocele) PLUS gentamicin IV 120 mg 80 mg vancomycin IV PLUS 1 gm PLUS 1.5 gm PLUS 2 gm PLUS gentamicin IV 80 mg 120 mg 120 mg vancomycin IV PLUS 1 gm PLUS 1.5 gm PLUS 2 gm PLUS aztreonam IV 2 gm 2 gm 2 gm vancomycin IV PLUS 1 gm PLUS 1.5 gm PLUS 2 gm PLUS gentamicin IV 80 mg 120 mg 120 mg cefazolin IV once 1 GM 2 GM 3 GM 900 mg 900 mg Cesarean Delivery clindamycin IV once PLUS 900 mg PLUS PLUS PLUS gentamicin IV once 120 mg 120 80 mg mg Urologic 30 mg/kg Urologic without entry into the urinary cefazolin IV* 1 gm 2 gm 3 gm (max 1000 mg) tract 10 mg/kg clindamycin IV 900 mg (max 900 mg) 50 mg/kg cefotetan IV* 1 gm 2 gm 2 gm (max 1000 mg) Urologic involving entry into the urinary During cefotetan shortage: 40 mg/kg 2 gm tract or involving intestines cefoxitin (max 2000 mg) Bladder resections 10 mg/kg Gastrointestinal fistulas ciprofloxacin IV PLUS (max 400 mg) 400 mg PLUS metronidazole IV PLUS 15 mg/kg 500 mg (max 500 mg) Special Considerations: The only operations for which oral antibiotics alone are acceptable are the Prostate biopsy and Pubovaginal sling procedures. The only operations for which intramuscular antibiotics alone are acceptable are the Prostate biopsy procedures. For urologic and pubovaginal sling procedures only: If the patient took an oral antibiotic prior to arrival on the date of surgery – please clearly document name of drug, date and time taken.
Surgical Prophylaxis Antibiotic Recommendations Updated 2017
Patient arrives in pre-op clinic or pre-op holding Do not swab; standard precautions; standard antibiotics No Has the Does Does patient had a patient meet No patient have a Yes positive MRSA culture surveillance policy history of at WMC or criteria? MRSA? Yes Yes WW?
No
Has the patient had a surveillance culture w/in last When Yes 30 days? No was culture >3 obtained? <3 yrs yrs
Do not swab; Obtain a standard precautions; surveillance swab; Are Is there a standard antibiotics antibiotic selection there 3 negative based on results negative culture >3 yrs cultures (at least 30 Yes since the last positive days apart) since the culture? No last positive No culture?
Remove from contact precautions; Yes notify Infection Prevention at WQA.IP; standard antibiotics
Has patient received Mupirocin within 14 Yes days? Do not swab; No contact precautions; Swab; vancomycin contact precautions
Remain in contact precautions; Are vancomycin Is it there results No > 3 yrs since the Yes available? last positive culture? Yes Are the results No negative? Remove from contact precautions; Yes notify Infection Prevention at WQA.IP; standard antibiotics No
Notify surgeon; notify nursing management; initiate #599 orderset; initiate contact precautions; place pink flag on outside of chart; place pink armband on patient; place pink laminate on inside of chart; vancomycin Surgical Prophylaxis Antibiotic Recommendations Updated 2017
Cefazolin Cefotetan Cefoxitin* Ceftriaxone 1 gm if <80 kg 1 gm 2 gm if 80-119 kg 2 gm 1 gm Dose 2 gm ≥ 80 kg 3 gm if ≥ 120 kg Peds: 40 mg/kg Peds: 50 mg/kg Peds: 50 mg/kg Peds: 30 mg/kg Infusion time 3-5 min per 1 gm 3-5 min 3-5 min 3-5 min Redose if blood loss >1500 ml or 3 hr 6 hr 2 hr Do not redose case is longer than:
*** Ampicillin/Sulbactam Ciprofloxacin Metronidazole Gentamicin Clindamycin ** Vancomycin 1 gm if <80 kg 3 gm 80 mg if <80 kg 400 mg 500 mg 900 mg 1.5 gm if 80-119 kg Dose Peds: 50 mg/kg ampicillin 120 mg if ≥ 80 kg Peds: 10 mg/kg Peds: 15 mg/kg Peds: 10 mg/kg 2 gm if ≥ 120 kg component Peds: 2.5 mg/kg Peds: 15 mg/kg 1 gm: 60 min 30 min Infusion time 30 min 1 hr 15 min 30 min 1.5 gm: 90 min
2 gm: 120 min Redose if blood loss >1500 ml 2 hr 10 hr 8 hr Do not redose 6 hr 12 hr or case is longer than:
Preferred Agents for most cases * May be used in place of cefotetan in times of shortage ** May be used in place of cefazolin in patients with cephalosporin allergy *** May be used in place of cefazolin in patients with cephalosporin allergy or in certain high-risk patients.
Prophylactic antibiotics are to be initiated within 1 hour prior to incision. Vancomycin and fluoroquinolones may be initiated within 2 hours prior to incision.
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