Surgical Prophylaxis Recommendations

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

GENERAL PRINCIPLES 1. The goal of antimicrobial surgical prophylaxis is to achieve serum and tissue antibiotic concentrations that exceed the minimum inhibitory concentrations (MICs) of the majority of organisms likely to be encountered, at the time of the incision and for the duration of the procedure. a. Preoperative doses should be given within 60 minutes before incision. For exceptions and administration details, see Table 1. b. Intraoperative repeat dosing is recommended if prolonged surgical procedure (> 2 half-lives of the antimicrobial), or major blood loss (> 1.5L). See Table 2 for redosing interval. Patients receiving therapeutic antimicrobials for an infection before surgery should also be given antimicrobial prophylaxis pre-op to ensure adequate serum and tissue levels of antimicrobials with activity against likely pathogens at the time of incision. If the agents used for treatment are appropriate for surgical prophylaxis, administering an extra dose within 60 minutes prior to surgical incision is sufficient.

2. Dosing: Recommended adult doses for patients with normal weight and renal function. Refer to Table 1 for more information.

3. β-lactam allergy – use ALTERNATIVE REGIMENS if allergy to cefazolin, or severe non-IgE-mediated reaction to any β-lactam (specifically, interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. Stevens-Johnson syndrome, toxic epidermal necrolysis, drug rash with eosinophilia & systemic symptoms]). In the absence of these findings, cefazolin can be used as surgical prophylaxis. See β-lactam allergy assessment algorithm.

4. Postoperative doses for prophylaxis are not routinely indicated. If the surgery is contaminated, it should be indicated that the postoperative antibiotic orders are for treatment.

5. Drains: The practice of continuing antimicrobials started as prophylaxis until all drains/catheters (intravascular or urinary) are removed is not recommended due to lack of evidence, risk of development of antimicrobial resistance or superinfection, and drug toxicity.

6. MRSA: For patients with known methicillin resistant S. aureus (MRSA) colonization or past infection, consider adding vancomycin to the surgical prophylaxis regimen, particularly when prosthetic material/devices are implanted. Vancomycin alone is less effective than cefazolin for preventing surgical site infections due to methicillin susceptible S. aureus (MSSA).

7. Patients colonized with antibiotic-resistant organisms (other than MRSA), or immunosuppressed: Consider consultation with Infectious Diseases to tailor antimicrobial surgical prophylaxis.

8. Topical antimicrobials: With the exception of ophthalmic procedures, the safety and efficacy of topical antimicrobials* (irrigations, pastes, washes) have not been established, therefore routine use of topical antimicrobials is not recommended in any other surgical procedure. * This does not include topical antiseptics, e.g. chlorhexidine, isopropyl alcohol.

1 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

Table 1: Pre-Op Antibiotic Administration

Timely administration (within 60 minutes before initial skin incision) of antibiotic prophylaxis can significantly decrease the incidence of postoperative infections. The goal is to achieve optimal serum and tissue antibiotic concentrations at the time of the initial skin incision and for the duration of the procedure. To best achieve this, antibiotics can be given in the operating room (OR) by the anesthesiologist at induction of anesthesia, but depending on the circumstances of the procedure may also be given in the holding area, or on the patient care unit if prolonged infusion is necessary. Administering antibiotics “on call to the OR” is not recommended as it often results in suboptimal antibiotic concentrations due to surgery schedule changes or transport delays.

Prophylactic Recommended Recommended Administration Antibiotic Adult Dose Cefazolin IV 2g* IV push within 60 minutes before initial skin incision Cefuroxime IV 1.5g IV push within 60 minutes before initial skin incision Ceftriaxone IV 1g IV push within 60 minutes before initial skin incision Ciprofloxacin PO 500mg Administer 1-2 hours pre-op Clindamycin IV 600mg Administer over 20 minutes just prior to procedure Co-trimoxazole PO 1 DS tablet Administer 1-2 hours pre-op Gentamicin IV 1.5mg/kg** Administer over 30 minutes just prior to procedure or 5mg/kg** Administer over 60 minutes just prior to procedure Levofloxacin IV 500mg Administer over 60 minutes just prior to procedure Metronidazole IV 500mg Administer over 20 minutes just prior to procedure Vancomycin IV Administer ≤1g over at least 60 minutes, 15mg/kg*** > 1g- 1.5g over at least 90 minutes, and > 1.5g over 120 minutes just prior to procedure * Available evidence1-7 indicates that cefazolin 2g is sufficient, regardless of body mass index (BMI), including for patients 120kg or more. ** Use 5mg/kg single pre-op dose if: anticipated duration of surgery is greater than 5 hours. Gentamicin dose should be based on ideal body weight (IBW), or dosing weight (DW) if patient's actual body weight is > 20% above IBW, rounded to the nearest 20mg. *** Vancomycin dose should be based on total body weight, rounded to the nearest 250mg and to a maximum of 2g/dose.

2 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

Table 2: Intraoperative Antibiotic Administration

Intraoperative repeat dosing is recommended if: • prolonged surgical procedure (> 2 half-lives of the antimicrobial), or • major blood loss (> 1.5L).

Prophylactic Antibiotic Recommended intraoperative redosing interval (from time of administration of pre-op dose): Cefazolin q4h (q3h with cardiopulmonary bypass8) Cefuroxime q4h Clindamycin q4h Levofloxacin q12h Metronidazole q8h Vancomycin q8h

3 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) GENERAL Gastroesophageal Prophylaxis not routinely indicated endoscopy NB: Patients with cirrhosis and ascites/GI bleed should be receiving medical prophylaxis for SBP.

Endoscopic ultrasound: • ceftriaxone 1g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV + • with drainage of clindamycin 600mg IV x 1 pre-op mediastinal cysts dose • for drainage of walled- off pancreatic necrosis/ cysts, biliary drainage, fine-needle injection of cysts, fiducial placement ERCP if biliary obstruction or • cefazolin 2g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV + known pancreatic pseudocyst clindamycin 600mg IV x 1 pre-op dose Percutaneous endoscopic • cefazolin 2g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV + gastrostomy (PEG) clindamycin 600mg IV x 1 pre-op dose

4 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) GENERAL Gastroduodenal surgery Duodenal/gastric resections • Enterobacteriaceae • cefazolin 2g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV + for ulcers/ cancer • Gram positive cocci clindamycin 600mg IV x 1 pre-op Perforated ulcer dose procedures Pre-op biliary stent in-situ, add: Pancreaticoduodenectomy • vancomycin 15 mg/kg IV x 1 pre-op Pre-op biliary stent in-situ, use: (Whipple’s) dose • gentamicin 1.5mg/kg IV + Bariatric surgical vancomycin 15 mg/kg IV x 1 pre- procedures (gastric op dose bypass, gastric banding, gastroplasty, biliopancreatic diversion) Gastroplasty – high risk only: gastric outlet obstruction, decreased gastric acidity or motility, morbid obesity, hemorrhage

5 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) GENERAL Hepatobiliary surgery High risk: open • Enterobacteriaceae • cefazolin 2g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV + cholecystectomy, emergency • Enterococcus spp clindamycin 600mg IV x 1 pre-op laparoscopic cholecyst- • Clostridium spp dose ectomy, insertion of • Streptococcus spp or prosthetic device, acute • Staphylococcus spp • gentamicin 1.5mg/kg IV + cholecystitis, biliary colic metronidazole 500mg IV x 1 pre- within 30 days, biliary op dose spillage, biliary obstruction, obstructive jaundice or common bile duct stones, non-functioning gallbladder, recent (within 1 month) biliary surgery, > 65 yrs old, diabetes, pregnancy, obesity, immunosuppression Liver resection Low risk: • elective laparoscopic Prophylaxis not routinely indicated cholecystectomy • liver biopsy Bowel surgery Small intestine - • Enterobacteriaceae • cefazolin 2g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV + nonobstructed clindamycin 600mg IV x 1 pre-op dose

6 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) GENERAL Bowel surgery Elective colorectal surgery • Enterobacteriaceae • Optional: • Optional: • Anaerobes Mechanical bowel preparation then Mechanical bowel preparation neomycin* 1g PO + metronidazole 1g then neomycin* 1g PO + PO at 1300h, 1500h, 2000h day metronidazole 1g PO at 1300h, before surgery 1500h, 2000h day before surgery + + • cefazolin 2g IV + metronidazole • gentamicin 1.5mg/kg IV + 500mg IV x 1 pre-op dose clindamycin 600mg IV x 1 pre-op dose * Neomycin is not commercially available in or Canada but MAY be available through a retail • gentamicin 1.5mg/kg IV + compounding pharmacy. Confirm availability prior to prescribing. metronidazole 500mg IV x 1 pre- op dose Appendectomy • Enterobacteriaceae • cefazolin 2g IV + metronidazole • gentamicin 1.5mg/kg IV + Emergency bowel surgery • Anaerobes 500mg IV x 1 pre-op dose clindamycin 600mg IV x 1 pre-op Bowel obstruction dose Fistulas/Discontinuous or bowel segments • gentamicin 1.5mg/kg IV + metronidazole 500mg IV x 1 pre- op dose Perforated viscus, • Enterobacteriaceae Institute treatment for Peritonitis rather than prophylaxis (considered gangrene, peritonitis, or • Anaerobes contaminated) abscess • Enterococcus spp

7 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) GENERAL Anal surgery • Enterobacteriaceae Low risk: • Anaerobes Prophylaxis not routinely indicated • sigmoidoscopy • colonoscopy • fissurectomy • fistulectomy/fistulotomy • hemorrhoidectomy- ligation/banding • sphincterotomy High risk: • cefazolin 2g IV + metronidazole • gentamicin 1.5mg/kg IV + • sphincteroplasty 500mg IV x 1 pre-op dose clindamycin 600mg IV x 1 pre-op • rectovaginal fistula dose closure/repair or • proctocolectomy • gentamicin 1.5mg/kg IV + metronidazole 500mg IV x 1 pre-op dose Herniorrhaphy (suture • S. aureus • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op repair) • Coagulase negative If MRSA colonization/past infection, dose Hernioplasty (mesh staphylococcus add: If MRSA colonization/past infection, insertion) (CoNS) • vancomycin 15 mg/kg IV x 1 pre-op use: • Streptococcus spp dose1 • vancomycin 15 mg/kg IV x 1 pre-op 1 Evidence for adding vancomycin is based on dose bundled interventions.

8 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) GENERAL Splenectomy • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op dose or • vancomycin 15mg/kg IV x 1 pre- op dose Sclerotherapy Prophylaxis not routinely indicated

Insertion of long term/ tunneled central venous Prophylaxis not routinely indicated catheters • Hickman • Broviac Insertion of implantable vascular access devices • Port-a-Cath

9 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) OBSTETRICAL/GYNECOLOGICAL Therapeutic termination of • Enterobacteriaceae • doxycycline 100mg PO 1h pre-op + 200mg PO 1/2 h post-op pregnancy • Anaerobes or • Group B Streptococci • azithromycin 1g PO x 1 pre-op dose • Enterococcus spp Hysterosalpingogram • Enterobacteriaceae Chromotubation • Anaerobes Prophylaxis not routinely indicated unless high risk Sonohysterography • Group B Streptococci High risk: • Enterococcus spp High risk: • dilated fallopian tubes • If previous PID, give doxycycline 100mg PO x 1 pre-op dose and then • peritubal adhesions doxycycline 100mg PO bid x 5 days post-op • previous PID • If dilated fallopian tubes or peritubal adhesions seen, give doxycycline 100mg PO bid x 5 days post-op Caesarean section • Enterobacteriaceae • cefazolin 2g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV + elective • Anaerobes NB: Dosing prior to skin incision more clindamycin 600mg IV x 1 pre-op non-elective • Group B Streptococci effective than dosing after cord clamping. dose • Enterococcus spp NB: Dosing prior to skin incision more effective than dosing after cord clamping.

10 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) OBSTETRICAL/GYNECOLOGICAL Hysterectomy • Enterobacteriaceae • cefazolin 2g IV +/- metronidazole • gentamicin 1.5mg/kg IV + abdominal • Anaerobes 500mg IV x 1 pre-op dose clindamycin 600mg IV x 1 pre-op laparoscopic • Group B Streptococci dose vaginal • Enterococcus spp Note: Treat bacterial vaginosis pre-operatively if present. If found incidentally at time of surgery, treat immediately intra-op and for 4 days post-operatively. Adnexal procedures that • Enterobacteriaceae • cefazolin 2g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV + enter uterus or vagina • Anaerobes clindamycin 600mg IV x 1 pre-op (including vaginal repair/ • Group B Streptococci If entry into rectum, add: dose vaginal sling/transvaginal • Enterococcus spp • metronidazole 500mg IV x 1 pre-op tape/bladder repair/ dose cystocele/rectocele/pelvic organ prolapse +/- graft/mesh) Note: Treat bacterial vaginosis pre-operatively if present. If found incidentally at time of surgery, treat immediately intra-op and for 4 days post-operatively.

11 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) OBSTETRICAL/GYNECOLOGICAL Endometrial ablation Endometrial biopsy Prophylaxis not routinely indicated Cervical tissue excision Intrauterine device Insertion Dilatation and curettage • postpartum Prophylaxis not routinely indicated • menorrhagia • missed abortion Laparoscopic procedures that do not enter uterus Prophylaxis not routinely indicated and/or vagina Hysteroscopy

12 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if allergy to (See General Principles and ceFAZolin, or severe non-IgE-mediated Table 1 and Table 2) reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) UROLOGY Note: If positive urine culture pre-operatively, institute treatment according to culture and susceptibility results. Open or laparoscopic • Enterobacteriaceae • cefazolin 2g IV x 1 pre-op • gentamicin 1.5mg/kg IV + procedures with: • Enterococcus spp dose clindamycin 600mg IV x 1 pre-op dose • entry into urinary tract • Staphylococcus spp • entry into vagina • Streptococcus spp If entry into rectum, add: (including vaginal repair/ • metronidazole 500mg IV x 1 vaginal sling/transvaginal pre-op dose tape/bladder repair/ cystocele/rectocele/pelvic organ prolapse +/- graft/mesh) • percutaneous renal surgery Open or laparoscopic • Enterobacteriaceae • cefazolin 2g IV +/- • vancomycin 15mg/kg IV + procedures with placement • Enterococcus spp gentamicin 1.5mg/kg IV x 1 gentamicin 1.5mg/kg IV x 1 pre-op of prosthetic material • Staphylococcus spp pre-op dose dose (penile implant, artificial • Streptococcus spp sphincters) Adrenalectomy • S. aureus • cefazolin 2g IV x 1 pre-op • clindamycin 600mg IV x 1 pre-op dose Nephrectomy • Streptococcus spp dose

13 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if allergy to (See General Principles and ceFAZolin, or severe non-IgE-mediated Table 1 and Table 2) reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) UROLOGY Note: If positive urine culture pre-operatively, institute treatment according to culture and susceptibility results. Urodynamic studies and: Oral regimens: (give 1-2 h pre- Oral regimens: (give 1-2 h pre-op) • neurogenic bladder op) • co-trimoxazole 1 DS tablet PO x 1 • bladder outlet obstruction • co-trimoxazole 1 DS tablet dose • elevated residual volume PO x 1 dose • > 70 yrs old Alternative: Alternative: • immunodeficiency/chronic • ciprofloxacin 500mg PO x 1 • ciprofloxacin 500mg PO x 1 dose corticosteroid use dose • chronic urinary catheterization

14 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) UROLOGY Note: If positive urine culture pre-operatively, institute treatment according to culture and susceptibility results. Cystoscopy, no risk factors • Enterobacteriaceae • Pseudomonas spp Prophylaxis not routinely indicated unless risk factors • Enterococcus spp

Cystoscopy with risk • Enterobacteriaceae Oral regimens: (give 1-2 h pre-op) Oral regimens: (give 1-2 h pre-op) factors: • Pseudomonas spp • ciprofloxacin 500mg PO • ciprofloxacin 500mg PO • prolonged indwelling • Enterococcus spp or or catheter • co-trimoxazole 1 DS tablet PO • co-trimoxazole 1 DS tablet PO • intermittent catheterization or or • urinary retention Parenteral regimens*: Parenteral regimen*: • previous urinary tract • ceftriaxone 1g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV x 1 pre- infection or op dose • neutropenia • gentamicin 1.5mg/kg IV x 1 pre-op dose Cystourethroscopy with: manipulation, dilatation, *Note: consider parenteral regimen for *Note: consider parenteral regimen biopsy, fulguration, resection patients who have received multiple for patients who have received or ureteral instrumentation previous antibiotic courses. multiple previous antibiotic courses.

Ureteroscopy ± stent

15 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) UROLOGY Note: If positive urine culture pre-operatively, institute treatment according to culture and susceptibility results. Shock-wave lithotripsy, no • Enterobacteriaceae risk factors • Pseudomonas spp Prophylaxis not routinely indicated unless risk factors • Enterococcus spp

Shock-wave lithotripsy with • Enterobacteriaceae Oral regimens: (give 1-2 h pre-op) Oral regimens: (give 1-2 h pre-op) risk factors: • Pseudomonas spp • ciprofloxacin 500mg PO • ciprofloxacin 500mg PO • large stone burden • Enterococcus spp or or • proximal stone • co-trimoxazole 1 DS tablet PO • co-trimoxazole 1 DS tablet PO • stone ≥ 2 cm or or • associated pyuria Parenteral regimens*: Parenteral regimen*: • history of pyelonephritis • ceftriaxone 1g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV x 1 pre- • stent in place or op dose • gentamicin 1.5mg/kg IV x 1 pre-op dose

*Note: consider parenteral regimen *Note: consider parenteral regimen for patients who have received for patients who have received multiple previous antibiotic courses. multiple previous antibiotic courses.

16 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) UROLOGY Note: If positive urine culture pre-operatively, institute treatment according to culture and susceptibility results. Percutaneous nephro- • Enterobacteriaceae Oral regimens: (give 1-2 h pre-op) Oral regimens: (give 1-2 h pre-op) lithotomy • Pseudomonas spp • ciprofloxacin 500mg PO • ciprofloxacin 500mg PO Nephrostomy insertion • Enterococcus spp or or Nephrostomy tube change – • co-trimoxazole 1 DS tablet PO • co-trimoxazole 1 DS tablet PO high risk: or or • advanced age Parenteral regimens*: Parenteral regimen*: • anatomical abnormality of • ceftriaxone 1g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV x 1 pre- urinary tract or op dose • immunodeficiency/chronic • gentamicin 1.5mg/kg IV x 1 pre-op corticosteroid use dose • prolonged hospitalization • externalized catheter *Note: consider parenteral regimen for *Note: consider parenteral regimen • prolonged indwelling patients who have received multiple for patients who have received catheter previous antibiotic courses. multiple previous antibiotic • poor nutritional status courses. • smoking

17 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if allergy PATHOGENS (See General Principles and Table 1 to ceFAZolin, or severe non-IgE- and Table 2) mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) UROLOGY Note: If positive urine culture pre-operatively, institute treatment according to culture and susceptibility results. Transrectal prostatic biopsy • Enterobacteriaceae Oral regimens: (give 1-2 h pre-op) Oral regimens: (give 1-2 h pre-op) • Pseudomonas spp • ciprofloxacin 500mg PO x 1 dose • ciprofloxacin 500mg PO x 1 dose Transurethral prostatectomy • Enterococcus spp or or (TURP) • co-trimoxazole 1 DS tablet PO x 1 • co-trimoxazole 1 DS tablet PO x 1 dose dose Transurethral resection of bladder tumour Moderate risk: antibiotic therapy in last Moderate risk: antibiotic therapy in 6 months, chronic indwelling urinary last 6 months, chronic indwelling catheter, diabetes mellitus, chronic urinary catheter, diabetes mellitus, corticosteroid use, immunodeficiency, chronic corticosteroid use, prostate volume ≥ 75mL/severe immunodeficiency, prostate volume ≥ voiding disturbance, recent (6 months) 75mL/severe voiding disturbance, international travel (other than to South recent (6 months) international travel Asia), previous urine culture with (other than to South Asia), previous ciprofloxacin or co-trimoxazole- urine culture with ciprofloxacin or co- resistant organism, previous sepsis trimoxazole-resistant organism, following prostate biopsy) previous sepsis following prostate Oral regimens: (give 1-2 h pre-op) biopsy) • ciprofloxacin 500mg PO x 1 dose Oral regimens: (give 1-2 h pre-op) or • ciprofloxacin 500mg PO x 1 dose • co-trimoxazole 1 DS tablet PO x 1 or dose • co-trimoxazole 1 DS tablet PO x 1 PLUS dose

18 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

• ceftriaxone 1g IV x 1 pre-op dose PLUS or • ceftriaxone 1g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV x 1 pre-op or dose • gentamicin 1.5mg/kg IV x 1 pre-op dose High risk: recent (6 months) travel to South Asia, previous urine/blood High risk: recent (6 months) travel to culture with ESBL or AmpC organism South Asia, previous urine/blood Oral regimens: (give 1-2 h pre-op) culture with ESBL or AmpC • ciprofloxacin 500mg PO x 1 dose Oral regimens: (give 1-2 h pre-op) or • ciprofloxacin 500mg PO x 1 dose • co-trimoxazole 1 DS tablet PO x 1 or dose • co-trimoxazole 1 DS tablet PO x 1 PLUS: dose • meropenem 500 mg IV x 1 pre-op PLUS: dose • meropenem 500 mg IV x 1 pre-op dose

19 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) UROLOGY Note: If positive urine culture pre-operatively, institute treatment according to culture and susceptibility results. Prostatectomy: • Enterobacteriaceae • cefazolin 2g IV x 1 pre-op dose • gentamicin 1.5mg/kg IV + - radical • Staphylococcus spp clindamycin 600mg IV x 1 pre-op - suprapubic • Streptococcus spp dose Cystectomy Cystectomy with ileal • Enterobacteriaceae • cefazolin 2g IV + metronidazole • gentamicin 1.5mg/kg IV + conduit/urinary diversion • Anaerobes 500mg IV x 1 pre-op dose clindamycin 600mg IV x 1 pre-op • Staphylococcus spp dose • Streptococcus spp Vasectomy Prophylaxis not routinely indicated

20 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if allergy (See General Principles and Table to ceFAZolin, or severe non-IgE- 1 and Table 2) mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) CARDIAC - Preoperative assessment of nasal culture for S. aureus carriage should be considered. • If nasal S. aureus (MSSA or MRSA) carrier, suggest intranasal mupirocin 2% bid for 4 days prior to surgery ± chlorhexidine 4% body wash the day prior to surgery. NB: No evidence of benefit if not nasal S. aureus carrier. - The safety and efficacy of topical antibiotics applied to the sternum has not been established and is currently not recommended. - Vancomycin alone should be restricted to true cefazolin allergy as it is associated with a higher frequency of postoperative infections (including Gram positive infections). - For patients with known MRSA colonization or past infection, add vancomycin to surgical prophylaxis regimen. (NB: Evidence for adding vancomycin is based on bundled interventions.) Open heart surgery Prosthetic valve • S. aureus • cefazolin 2g IV x 1 pre-op dose • vancomycin 15mg/kg IV x 1 pre-op Coronary artery bypass • Coagulase negative dose Other open heart surgery staphylococcus (CoNS) If MRSA colonization/past infection, • If patient hospitalized > 3 days prior • Corynebacterium spp add: to surgery, or saphenous vein • Enterobacteriaceae • vancomycin 15 mg/kg IV x 1 pre- procedure, add gentamicin 5mg/kg op dose1 IV x 1 pre-op dose 1 Evidence for adding vancomycin is based on bundled interventions.

21 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if allergy (See General Principles and Table to ceFAZolin, or severe non-IgE- 1 and Table 2) mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) CARDIAC - Preoperative assessment of nasal culture for S. aureus carriage should be considered. • If nasal S. aureus (MSSA or MRSA) carrier, suggest intranasal mupirocin 2% bid for 4 days prior to surgery ± chlorhexidine 4% body wash the day prior to surgery. NB: No evidence of benefit if not nasal S. aureus carrier. - The safety and efficacy of topical antibiotics applied to the sternum has not been established and is currently not recommended. - Vancomycin alone should be restricted to true cefazolin allergy as it is associated with a higher frequency of postoperative infections (including Gram positive infections). - For patients with known MRSA colonization or past infection, add vancomycin to surgical prophylaxis regimen. (NB: Evidence for adding vancomycin is based on bundled interventions.) Placement of electrophysio- • S. aureus • cefazolin 2g IV x 1 pre-op dose • vancomycin 15mg/kg IV x 1 pre-op logic devices (e.g. • Coagulase negative dose pacemaker, implantable staphylococcus (CoNS) If MRSA colonization/past infection, cardioverter-defibrillator • C. acnes add: (ICD), ventricular assist • vancomycin 15 mg/kg IV x 1 pre- devices) op dose1 Transcatheter aortic valve 1 Evidence for adding vancomycin is based implantation (TAVI) on bundled interventions. Left atrial occlusion devices Ventriculoatrial shunts Arterial patches Cardiac catheterization including angioplasty +/- stenting Prophylaxis not routinely indicated Transesophageal echocardiogram

22 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) THORACIC Esophageal procedures • S. aureus • cefazolin 2g IV + metronidazole • clindamycin 600mg IV + WITH mucosal breach, • Coagulase negative 500mg IV x 1 pre-op dose gentamicin 5mg/kg IV x 1 pre-op including laparoscopic staphylococcus (CoNS) dose • Streptococcus spp • Enterobacteriaceae • Oral anaerobes Excision of Zenker’s • cefazolin 2g IV + metronidazole • clindamycin 600mg IV + diverticulum 500mg IV x 1 pre-op dose gentamicin 5mg/kg IV x 1 pre-op dose Esophageal procedures • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV + withOUT mucosal breach, gentamicin 5mg/kg IV x 1 pre-op e.g. anti-reflux surgery, Heller dose myotomy Radical thymectomy, open or • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV + VATS gentamicin 5mg/kg IV x 1 pre-op dose

23 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any SURGERY COMMON PATHOGENS β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) THORACIC Pneumonectomy • S. aureus • cefazolin 2g IV x 1 pre-op dose • [vancomycin 15mg/kg IV or Lobectomy (complete or • Coagulase negative or clindamycin 600mg IV] +/- partial) staphylococcus (CoNS) • cefuroxime 1.5g IV x 1 pre-op dose gentamicin* 5mg/kg IV x 1 pre-op Thoracotomy • Streptococcus spp dose Thorascopy, including video- • Enterobacteriaceae * Consider adding gentamicin if: assisted thoracoscopic • Oral anaerobes • patient hospitalized ≥ 3 days surgery (VATS) prior to surgery and/or Mediastinoscopy • chronic obstructive pulmonary disease with Gram negative colonization. Thoracentesis Chest tube insertion for Prophylaxis not routinely indicated spontaneous pneumothorax Closed chest tube insertion • S. aureus • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV +/- for chest trauma with • Streptococcus spp gentamicin 5mg/kg IV x 1 pre-op hemo/pneumothorax • Enterobacteriaceae dose Chest wall resection with • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op mesh insertion dose or • vancomycin 15mg/kg IV x 1 pre- op dose

24 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any SURGERY COMMON PATHOGENS β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) VASCULAR Arterial surgery involving the • S. aureus • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV + abdominal aorta or a groin • Coagulase negative gentamicin 5mg/kg IV x 1 pre-op incision staphylococcus (CoNS) If MRSA colonization/past infection, dose • Enterobacteriaceae add: or • vancomycin 15 mg/kg IV x 1 pre-op • vancomycin 15mg/kg IV + dose1 gentamicin 5mg/kg IV x 1 pre-op 1 Evidence for adding vancomycin is based on dose bundled interventions.

Arterial surgery involving • S. aureus • cefazolin 2g IV • clindamycin 600mg IV x 1 pre-op placement of prosthetic • Coagulase negative dose material staphylococcus (CoNS) If MRSA colonization/past infection, or • Enterobacteriaceae add: • vancomycin 15mg/kg IV x 1 pre- • vancomycin 15 mg/kg IV x 1 pre-op op dose dose1 1 Evidence for adding vancomycin is based on bundled interventions.

25 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) VASCULAR Carotid endarterectomy • S. aureus Brachial artery repair • Coagulase negative Endovascular stenting staphylococcus (CoNS) Prophylaxis not routinely indicated Low risk High risk: • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op • placement of prosthetic dose material If MRSA colonization/past infection, or • repeat intervention within add: • vancomycin 15mg/kg IV x 1 pre- 7 days • vancomycin 15 mg/kg IV x 1 pre-op op dose • prolonged indwelling dose1 arterial sheath 1 Evidence for adding vancomycin is based on • procedure > 2 h duration bundled interventions. • presence of other infected implants • immunosuppression

26 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) VASCULAR Renal access procedures Optional: Optional: • native AV fistula • cefazolin 2g IV x 1 pre-op dose • vancomycin 15mg/kg IV x 1 pre- op dose or • clindamycin 600mg IV x 1 pre-op dose • artificial AV graft • cefazolin 2g IV x 1 pre-op dose • vancomycin 15mg/kg IV x 1 pre- If MRSA colonization/past infection, op dose add: or • vancomycin 15 mg/kg IV x 1 pre-op • clindamycin 600mg IV x 1 pre-op dose1 dose 1 Evidence for adding vancomycin is based on bundled interventions. Peritoneal dialysis • cefazolin 2g IV x 1 pre-op dose • vancomycin 15mg/kg IV x 1 pre- • catheter placement If MRSA colonization/past infection, op dose add: or • vancomycin 15 mg/kg IV x 1 pre-op • clindamycin 600mg IV x 1 pre-op dose1 dose 1 Evidence for adding vancomycin is based on bundled interventions.

27 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) VASCULAR Insertion of long term/ tunneled central venous catheters Prophylaxis not routinely indicated • Hickman • Broviac Insertion of implantable vascular access devices • Port-a-Cath

28 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) PLASTICS Clean procedures • S. aureus Low risk: • Streptococcus spp Prophylaxis not routinely indicated • dermatologic • facial bone fracture • tumor excision • simple rhinoplasty/ septoplasty • simple lacerations • flexor tendon injury • clean hand surgery High risk: • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op • placement of prosthetic dose material or • surgery involving bone • vancomycin 15mg/kg IV x 1 pre- • skin irradiation op dose • devitalized tissue • procedures below waist

29 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) PLASTICS Clean-contaminated • S. aureus • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op procedures • Streptococcus spp dose • involving contaminated • Enterobacteriaceae or skin/mucosa/intertriginous • P. aeruginosa • vancomycin 15mg/kg IV x 1 pre-op areas (oral cavity, upper dose respiratory tract, axilla, groin, perineum) • wedge excision lip/ear • flaps on nose/head/neck • grafts

30 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) PLASTICS Breast surgery • S. aureus Optional: Optional: Low risk: • Coagulase negative • cefazolin 2g IV x 1 pre-op dose • vancomycin 15mg/kg IV x 1 pre-op • simple clean procedures staphylococcus (CoNS) dose • lumpectomy/local excision • Streptococcus spp or • clindamycin 600mg IV x 1 pre-op dose High risk: • cefazolin 2g IV x 1 pre-op dose • vancomycin 15mg/kg IV x 1 pre-op • breast reduction dose • reconstruction If MRSA colonization/past infection, or mammoplasty add: • clindamycin 600mg IV x 1 pre-op • previous breast biopsy/ • vancomycin 15 mg/kg IV x 1 pre- dose surgery op dose1 • placement of prosthetic 1 Evidence for adding vancomycin is based material on bundled interventions. • morbid obesity (>100kg) • breast cancer procedures (axillary lymph node dissection, primary nonreconstructive surgery) • skin irradiation

31 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) PLASTICS Autologous breast • S. aureus • cefazolin 2g IV x 1 pre-op dose • vancomycin 15mg/kg IV x 1 pre-op reconstruction • Coagulase negative dose • deep inferior epigastric staphylococcus (CoNS) If MRSA colonization/past infection, or perforators (DIEP) flap • Streptococcus spp add: • clindamycin 600mg IV x 1 pre-op • transverse rectus-abdominus • vancomycin 15 mg/kg IV x 1 pre- dose myocutaneous (TRAM) flap op dose1 1 Evidence for adding vancomycin is based on bundled interventions. Reconstructive surgery Tissue flaps • S. aureus • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op Panniculectomy • Streptococcus spp dose or • vancomycin 15mg/kg IV x 1 pre- op dose Reconstructive limb surgery • S. aureus • cefazolin 2g IV x 1 pre-op • clindamycin 600mg IV x 1 pre-op Traumatic/crush hand injuries • Streptococcus spp dose dose • Enterobacteriaceae or • Anaerobes If MRSA colonization/past infection • vancomycin 15mg/kg IV pre-op x and use of prosthetic material, add: 1 pre-op dose • vancomycin 15 mg/kg IV x 1 pre- op dose1 If heavily soiled/contaminated, 1 Evidence for adding vancomycin is based consider adding: on bundled interventions. • gentamicin 5mg/kg IV x 1 pre-op dose to above regimens

32 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any SURGERY COMMON PATHOGENS β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) PLASTICS Carpal tunnel • S. aureus • Streptococcus spp Low risk Prophylaxis not routinely indicated

High risk: • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op • morbid obesity (> dose 100kg) or • immunocompromised • vancomycin 15mg/kg IV x 1 pre- op dose

33 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) ORTHOPEDIC Diagnostic or operative Prophylaxis not routinely indicated arthroscopy Fractures with internal • S. aureus • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op fixation (nails, plates, • Coagulase negative If MRSA colonization/past infection, dose screws, wires) staphylococcus (CoNS) add: or • Streptococcus spp • vancomycin 15 mg/kg IV x 1 pre-op • vancomycin 15mg/kg IV x 1 pre-op • Enterobacteriaceae dose1 dose 1 Evidence for adding vancomycin is based on bundled interventions. Joint replacement • S. aureus - Preoperative assessment of nasal culture for S. aureus carriage should be Joint revision surgery • Coagulase negative considered. - hip staphylococcus (CoNS) • If nasal S. aureus (MSSA or MRSA) carrier, suggest intranasal mupirocin - knee 2% bid for 4 days prior to surgery ± chlorhexidine 4% body wash the day - elbow prior to surgery. - ankle NB: No evidence of benefit if not nasal S. aureus carrier. - shoulder - Vancomycin alone should be restricted to true cefazolin allergy or severe non- Note: withholding prophylactic IgE mediated reaction as it is associated with a higher frequency of antibiotic prior to revision postoperative infections (including Gram positive infections). arthroplasty is not - For patients with known MRSA colonization or infection, add vancomycin to recommended unless there is surgical prophylaxis regimen. (NB: Evidence for adding vancomycin is based a high suspicion of infection on bundled interventions.) and pre-op cultures are - Insufficient evidence to recommend use of antibiotic-impregnated bone cement negative or not obtained in primary arthroplasties.

• cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op Rotator cuff repair If MRSA colonization/past infection, dose - surgical/arthroscopic

34 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

add: or • vancomycin 15 mg/kg IV x 1 pre-op • vancomycin 15mg/kg IV x 1 pre-op dose1 dose 1 Evidence for adding vancomycin is based on bundled interventions.

35 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) ORTHOPEDIC Fractures, complex (open) • S. aureus • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op • Coagulase negative dose staphylococcus (CoNS) If MRSA colonization/past infection, or • Enterobacteriaceae add: • vancomycin 15mg/kg IV x 1 pre-op • vancomycin 15 mg/kg IV x 1 pre-op dose dose1 1 Evidence for adding vancomycin is based on If heavily soiled/contaminated (Grade bundled interventions. III), add: • gentamicin 5mg/kg IV x 1 pre-op dose Amputation of lower limb • S. aureus • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV + gentamicin • Coagulase negative 1.5mg/kg IV x 1 pre-op dose staphylococcus (CoNS) If ischemic limb, add: • Enterobacteriaceae • metronidazole 500mg IV x 1 pre-op • Clostridium spp dose Fasciotomy • S. aureus • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op • Streptococcus spp dose or • vancomycin 15mg/kg IV x 1 pre-op dose

36 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) SPINAL SURGERY - Preoperative assessment of nasal culture for S. aureus carriage should be considered. • If nasal S. aureus (MSSA or MRSA) carrier, suggest intranasal mupirocin 2% bid for 4 days prior to surgery ± chlorhexidine 4% body wash the day prior to surgery. NB: No evidence of benefit if not nasal S. aureus carrier. - Vancomycin alone should be restricted to true cefazolin allergy as it is associated with a higher frequency of postoperative infections (including Gram positive infections). - For patients with known MRSA colonization or past infection, add vancomycin to surgical prophylaxis regimen. (NB: Evidence for adding vancomycin is based on bundled interventions.) Laminectomy • S. aureus • cefazolin 2g IV x 1 pre-op dose • vancomycin 15mg/kg IV x 1 pre-op Microdiscectomy • Coagulase negative If MRSA colonization/past infection, dose staphylococcus (CoNS) add: • vancomycin 15 mg/kg IV x 1 pre-op dose1 1 Evidence for adding vancomycin is based on bundled interventions. Spinal fusion • S. aureus • cefazolin 2g IV x 1 pre-op dose • vancomycin 15mg/kg IV x 1 pre-op Insertion of foreign material • Coagulase negative dose staphylococcus (CoNS) If MRSA colonization/past infection, add: • vancomycin 15 mg/kg IV x 1 pre-op dose1 1 Evidence for adding vancomycin is based on bundled interventions.

37 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) NEUROSURGERY Craniotomy • S. aureus • cefazolin 2g IV x 1 pre-op dose • vancomycin 15mg/kg IV x 1 pre-op Stereotactic brain • Coagulase negative dose biopsy/procedure staphylococcus (CoNS) Cerebrospinal fluid • S. aureus • cefazolin 2g IV x 1 pre-op dose • vancomycin 15mg/kg IV x 1 pre-op shunting operations • Coagulase negative dose NB: Antimicrobial- staphylococcus (CoNS) impregnated devices are not recommended. External ventricular drain • S. aureus • cefazolin 2g IV x 1 dose pre- • vancomycin 15mg/kg IV x 1 dose (EVD) • Coagulase negative insertion pre-insertion Intracranial pressure (ICP) staphylococcus (CoNS) monitor NB: Evidence for antibiotic prophylaxis inconclusive. Antimicrobial-coated EVD catheters not recommended. Contaminated procedures • compound skull fractures • open scalp lacerations Institute treatment rather than prophylaxis • CSF fistulae

38 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) HEAD AND NECK SURGERY Clean procedures: no • S. aureus incision through oral/nasal/ • Streptococcus spp Prophylaxis not routinely indicated pharyngeal mucosa, no • Oral anaerobes insertion of prosthetic material: • thyroidectomy • submandibular gland excision • lymph node excision • tympanoplasty/ear surgery • mastoidectomy • septoplasty Low risk procedures: • Tonsillectomy • Adenoidectomy High risk procedures: • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op • Insertion of prosthetic dose material

39 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS if (See General Principles and Table 1 allergy to ceFAZolin, or severe and Table 2) non-IgE-mediated reaction to any β-lactam (interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. SJS, TEN, DRESS]) HEAD AND NECK SURGERY Clean contaminated • S. aureus procedures with incision • Streptococcus spp through oral/nasal/ • Oral anaerobes pharyngeal mucosa • Enterobacteriacea e Low risk • cefazolin 2g IV x 1 pre-op dose • clindamycin 600mg IV x 1 pre-op dose High risk: • cefazolin 2g IV + metronidazole • levofloxacin 500mg IV + • Head and neck cancer: 500mg IV x 1 pre-op dose metronidazole 500mg IV x 1 pre- o Radical/bilateral neck +/- op dose dissection • cefazolin 2g IV q8h + metronidazole +/- o Reconstructive 500mg IV q12h x 24h post-op • levofloxacin 500mg IV once post- surgery with op + metronidazole 500mg IV myocutaneoous flaps q12h x 24h post-op or microvascular free flaps Note: Limited evidence for this • Mandibular surgery if regimen; recommendation based on tobacco/alcohol/illicit drug poor outcomes with clindamycin use prophylaxis. Excision of Zenker’s • cefazolin 2g IV + metronidazole • clindamycin 600mg IV + diverticulum 500mg IV x 1 pre-op dose gentamicin 5mg/kg IV x 1 pre-op dose

40 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

REGIMEN(S) OF CHOICE SURGERY COMMON PATHOGENS (See General Principles) OPHTHALMOLOGY NB: Pre-op disinfection with povidone-iodine 5% solution recommended. Chlorhexidine 0.05% is alternative for iodine-allergic patients. Higher chlorhexidine concentrations are associated with corneal toxicity. Avoid leakage of either povidone-iodine or chlorhexidine into the anterior chamber. Cataract extraction • S. aureus Eye drops every 5-15 minutes for 5 Corneal transplant • Coagulase doses within 1 hour prior to start of Retinal detachment negative procedure*: Vitrectomy staphylococcus • moxifloxacin or Dacryocystorhinostomy (CoNS) • polymyxin B - gramicidin Eyelid Surgery • Streptococcus spp +/- Enucleation • Enterobacteriacea At end of procedure: e Intracameral injection**: • Pseudomonas spp • cefazolin 1-2.5mg or • cefuroxime 1mg or Subconjunctival injection: • cefazolin 100mg or • cefuroxime 50mg

* Necessity of continuing topical antimicrobials postoperatively has not been established. **Intracameral antibiotics may be more effective than subconjunctival antibiotics.

41 December 2018

AHS RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN ADULT PATIENTS

Selected references: 1. Ahmadzia HK, Patel EM, Joshi D, et al. Obstetric surgical site infections: 2 grams compared with 3 grams of cefazolin in morbidly obese women. Obstet Gynecol 2015:126:708-15. 2. Forse R, Karam B, Maclean D, Christou N. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery 1989;106:750-7. 3. Ho VP, Nicolau DP, Dakin GF, et al. Cefazolin dosing for surgical prophylaxis in morbidly obese patients. Surg Infect 2012;13:33-7. 4. Maggio L, Nicolau DP, DaCosta M, et al. Cefazolin prophylaxis in obese women undergoing cesarean delivery: a randomized controlled trial. Obstet Gynecol 2015;125:1205-10. 5. Peppard WJ, Eberle DG, Kugler NW, et al. Association between pre-operative cefazolin dose and surgical site infection in obese patients. Surg Infect 2017;18:485-90. 6. Swank ML, Wing DA, Nicolau DP, et al. Increased 3-gram cefazolin dosing for cesarean delivery prophylaxis in obese women. Am J Obstet Gynecol 2015;213:415.e1-8. 7. van Kralingen S, Taks M, Diepstraten J, et al. Pharmacokinetics and protein binding of cefazolin in morbidly obese patients. Eur J Clin Pharmacol 2011;67:985–92. 8. Calic D, et al. Evaluation of cefazolin antimicrobial prophylaxis during cardiopulmonary surgery with cardiopulmonary bypass. J Antimicrob Chemother 2017 Dec 8. Epub 2017.

42 December 2018