UNC Health Care Guideline University of North Carolina Hospitals Pharmacy & Therapeutics Committee
PEDIATRIC ANTIBIOTIC PROPHYLAXIS FOR SURGICAL PROCEDURES
Intra-operative re- NEONATAL PEDIATRIC DOSING dosing interval for prolonged procedures SECTION GUIDE or major blood loss First 4 weeks of life or PMA* 44 (>20 mL/kg) weeks Normal Maximum Compromised Intra-operative Antibiotic IV Dose Renal Renal Function Neonatal IV Dose Dose re-dosing interval Function (CrCl <30 mL/min) 50 mg/kg 12 hrs Ampicillin 50 mg/kg 2000 mg 4 hours 8 hours (100 mg/kg for (8 hrs if >3 kg & >7 meningitis) days old) Ampicillin/ 50 mg/kg 3.1 grams 12 hrs Sulbactam (dose per (3 grams of 4 hours 8 hours 50 mg/kg (8 hrs if >3 kg & >7 (premixed 1g A / ampicillin) ampicillin) days old) 0.5g S) 12 hrs < 80 kg: 1 gram Cefazolin 25 mg/kg 4 hours 12 hours 25 mg/kg (8 hrs if >3 kg & >7 > 80 kg: 2 grams days old)
Ceftriaxone 25 mg/kg 2000 mg 16 hours 16 hours N/A N/A
Cefuroxime 50 mg/kg 1500 mg 4 hours 12 hours 50 mg/kg 12 hrs
12 hrs Clindamycin 10 mg/kg 600 mg 8 hours 8 hours 7.5 mg/kg (8 hrs if >3 kg & >7 days old) Ertapenem 15 mg/kg 1000 mg 12 hours no re-dose N/A N/A 2.5 mg/kg 24 hrs Gentamicin** 2 mg/kg No max 6 hours 12 hours (or defer to current (or defer to Neofax) regimen) Levofloxacin 10 mg/kg 750 mg 16 hours no re-dose N/A N/A
Initial: 15 mg/kg 24 hrs Metronidazole 10 mg/kg 500 mg 8 hours no re-dose Maintenance: 7.5 (12 hrs if >3 kg & >7 mg/kg days old) 25 mg/kg 12 hrs Oxacillin 50 mg/kg 2000 mg 6 hours no re-dose (or defer to current (8 hrs if >3 kg & >7 regimen) days old) 12 hrs 50,000 Penicillin G 1.2 million units 4 hours no re-dose 25,000 units/kg (8 hrs if >3 kg & >7 units/kg days old)
Piperacillin/ 50 mg/kg 3.375 grams 12 hrs Tazobactam (dose per (3 grams of 6 hours 8 hours 50 mg/kg (8 hrs if >3 kg & >7 (premixed 1 g P / piperacillin) piperacillin) days old) 0.125 g T)
12 hrs Vancomycin 15 mg/kg 2000 mg 12 hours no re-dose 10 mg/kg (8 hrs if >3 kg & >7 days old) *PMA (Postmenstrual Age) = Gestational Age + postnatal age (Example: Born at 28 weeks and 21 days old = 31 weeks PMA) **Tobramycin dosing is equivalent to gentamicin; may be substituted during drug shortages
Updated 6.23.2011
UNC Health Care Guideline University of North Carolina Hospitals Pharmacy & Therapeutics Committee
Re-dosing Schedule for Operation Recommended Antibiotic Prophylaxis Prolonged Surgery** (Hours) Preferred: Ampicillin OR Cefazolin 4 / 4 Dental, Oral, Respiratory Tract or Alternatives: Clindamycin 20 mg/kg IV/PO (Max Dose 600 mg) 8 Esophageal Procedures OR Ceftriaxone 16
Preferred: Cefuroxime OR Cefazolin 4 / 4 Cardiothoracic Alternatives: Clindamycin +/- Gentamicin 8 / 6 OR Vancomycin +/- Gentamicin 12 / 6 Gastroduodenal, Esophageal Preferred: Cefazolin 4 (High Risk Only: open procedures, Alternatives: Clindamycin + Gentamicin 8 / 6 biliary tract) Preferred: Ertapenem OR Cefazolin + Metronidazole 12 / 4 / 8 Colorectal Alternatives: Clindamycin + Gentamicin 8 / 6
Appendectomy Preferred: Ampicillin/Sulbactam 4 (Non-perforated, non-infected) Alternatives: Cefazolin +/- Metronidazole 4 / 8
Appendectomy Perferred: Pipercillin/Tazobactam 6 (Suspected perforation or suspected or Alternatives: Metronidazole + Gentamicin + Ampicillin 8 / 6 / 4 documented infection)
Orthopedic Implantation of Joint Preferred: Cefazolin 4 Devices Alternatives: Clindamycin OR Vancomycin 8 / 12
Preferred: Cefazolin 4 Genitourinary Alternatives: Gentamicin + Metronidazole (or Clindamicin) OR 6 / 8 / 8 (High-Risk Patients Only) Ampicillin/Sulbactam 4
Preferred: Cefazolin 30 - 40 mg/kg (Max Dose 2 grams) +/- 4 Head and Neck Metronidazole OR Oxacillin 8 / 4 (Hardware Placement or Alternatives: Clindamycin 15 mg/kg (Max Dose 600 mg) +/- 8 Clean/Contaminated) Gentamicin 6
Neurosurgery Preferred: Cefazolin OR Oxacillin 4 / 4 (Elective Craniotomy or CSF shunting) Alternatives: Vancomycin 12
Transplantation Preferred: Cefazolin OR Cefuroxime 4 / 4 (Heart, Lung or Heart & Lung) Alternatives: Vancomycin +/- Gentamicin 12 / 6
Transplantation Preferred: Ampicillin/Sulbactam 4 (Liver) Alternatives: Clindamycin + Gentamicin 8 / 6
Transplantation Preferred: Cefazolin 4 (Kidney or Kidney & Pancreas) Alternatives: Clindamycin 8
Timing of first dose: Antibiotics should be initiated no earlier than 60 minute prior to incision (with the exception of vancomycin doses > Endocarditis prophylaxis: Only for dental procedures and 2 grams); if the patient is on chronic antibiotic therapy then no first patients at high risk: doses are needed. **Antibiotic re-dosing: Re-dosing should occur if the operation is 1. Prosthetic cardiac valve or prosthetic material used for still in process 2 half-lives after the first dose was administered or if cardiac valve repair; the patient experiences major blood loss. If a patient is on chronic antibiotic therapy then send any scheduled doses to the OR with 2. Previous infective endocarditis; patient. 3. Unrepaired cyanotic congenital heart disease (CHD), Patients with penicillin/cephalosporin allergies: Verify it is a true including palliative shunts and conduits; completely repaired allergy (e.g. urticaria, pruritus, angioedema, bronchospasm, congenital heart defect with prosthetic material or device, hypotension or arrhythmia) or serious adverse drug reaction (drug- during the first six months after the procedure; repaired CHD induced hypersensitivity, drug fever or toxic epidermal necrolysis). with residual defects at the site of a prosthetic patch or Cephalosporins may be an appropriate option due to limited cross- prosthetic device (which inhibit endothelialization); cardiac reactivity with the penicillin class. In case of true allergy, vancomycin transplantation recipients who develop cardiac valvulopathy. or clindamycin may be appropriate alternatives.
Updated 6.23.2011