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Guidelines for Prophylactic Antibiotics in Surgery

This paper is from a consensus conference to establish guidelines for the use of prophylactic antibiotics in surgery in Taiwan on March 8, 2003:
J Microbiol Immunol Infect 2004; 37: 71-4.

Appropriate use of antimicrobial agents for surgical prophylaxis has been shown to reduce the incidence of postoperative infection for a variety of surgical procedures. This is important because:

global emergence of antimicrobial resistance (due to the force of selection from over use of antibiotics)
transition to managed care requiring both cost containment and quality assurance

Standard guidelines recommend that prophylaxis is indicated only for clean-contaminated and specific clean surgical procedures where the benefits in preventing a rare infection exceed the risks and costs of prophylaxis. However, compliance with the guidelines is poor.

Antibiotic prophylaxis must be started in close proximity to the time of the surgical procedure in order to achieve effective tissue concentrations at the time of incision and throughout the operation. The major exception is cesarean section, in which the first dose of prophylaxis should be delayed until the umbilical cord is clamped to avoid placental transfer of the antibiotic to the fetus.

Selection of an antibiotic should consider spectrum of activity and cost-effectiveness. A single dose of antibiotic before the operation is sufficient prophylaxis for most surgical procedures. Theoretically, for longer procedures, re-administration of the drug is indicated at intervals of 1 or 2 times the half-life of the drug. No further benefit is conferred by the administration of additional doses after the patient has left the operating room.

Site/procedure	Likely pathogen(s)	Recommended antibiotic(s)	Alternative	Duration
Recommendations for Use of Prophylactic Antibiotics in Surgery (for adults only)
Large skin (clean)	Staphylococcus aureus CoNS Streptococci	Nil or Cefazolin 1 gm IV at IA	Clindamycin 600 mg IV at IA	1 dose
Oto-naso-larynx Procedures
Head and neck (clean)	S. aureus CoNS	Cefazolin 1-2 gm IV at IA	Clindamycin 600 mg IV at IA	<1 day
Head and neck (clean-contaminated)	S. aureus CoNS Streptococci Enteric GNB	Cefazolin 1-2 gm IV at IA	Clindamycin 600 mg + gentamicin 2mg/kg IV at IA	<1 day
Ear (clean-contaminated)	S. aureus Streptococci	Cefazolin 1-2 gm IV at IA	Clindamycin 600 mg IV at IA	<1 day
Nose and sinus (clean-contaminated)	S. aureus Enteric GNB Anaerobes	Cefazolin 1-2 gm IV at IA	Clindamycin 600 mg IV at IA	<1 day
Tonsil (clean-contaminated)	S. aureus Enteric GNB Anaerobes	Cefazolin 1-2 gm IV at IA	Clindamycin 600 mg + gentamicin 2 mg/kg IV at IA	<1 day
Cardiovascular
Coronary artery graft bypassing (clean)	S. aureus CoNS	Cefazolin 1-2 gm IV at IA then 1 gm q8h	Vancomycin 1 gm IV on call to OR	<1 day
Prosthetic valve (clean)	S. aureus CoNS	Cefazolin 1-2 gm IV at IA then 1 gm q8h	Vancomycin 1 gm IV on call to OR	<1 day
Large vessel in abdomen or lower limb (clean)	S. aureus CoNS	Cefazolin 1-2 gm IV at IA then 1 gm q8h	Vancomycin 1 gm IV on call to OR	<1 day
Thoracic
Lung (clean-contaminated), pulmonary resection (lobectomy and pneumonectomy)	S. aureus CoNS Streptococci	Cefazolin 1-2 gm IV at IA then 1 gm q8h	Vancomycin 1 gm IV on call to OR or Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA or 2GC 1-2 gm	<2 days
Esophagus (clean-contaminated)	S. aureus CoNS Enteric GNB	Cefazolin 1-2 gm IV at IA then 1 gm q8h	Vancomycin 1 gm IV on call to OR or Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA or 2GC 1-2 gm IV at IA	<2 days
Orthopedics
Total hip arthroplasty (clean)	S. aureus CoNS	Cefazolin 1-2 gm IV at IA then 1 gm q8h	Vancomycin 1 gm IV on call to OR	<2 days
Total knee arthroplasty (clean)	S. aureus CoNS	Cefazolin 1-2 gm IV at IA then 1 gm q8h	Vancomycin 1 gm IV on call to OR	<2 days
Internal fixation for close reduction (clean)	S. aureus CoNS	Cefazolin 1-2 gm IV at IA then 1 gm q8h	Vancomycin 1 gm IV on call to OR	<1 day
Spine (clean)	S. aureus CoNS	Cefazolin 1-2 gm IV at IA then 1 gm q8h	Vancomycin 1 gm IV on call to OR	<2 days
Other selective, non-prosthesis bone procedures (clean)	S. aureus CoNS	Cefazolin 1-2 gm IV at IA then 1 gm q8h	Vancomycin 1 gm IV on call to OR	<1 day
Neurosurgery
Craniotomy (clean)	S. aureus CoNS	Cefazolin 1-2 gm IV	Oxacillin 2 gm IV at IA Vancomycin 1 gm IV on call to OR	<1 day
Ventriculo-peritoneal shunting (clean)	S. aureus CoNS	Cefazolin 1-2 gm IV	Oxacillin 2 gm IV at IA Vancomycin 1 gm IV on call to OR	<2 days
Colorectal
Colorectum (clean-contaminated)	Enteric GNB Anerobes	Oral: Neomycin 1 gm qid + metronidazole 1 gm qid the day before operation or Tinidazole 1 gm the night before operation + Cefoxitin 1-2 gm IV at IA or Cefmetazole 1-2 gm IV at IA or Cefazolin 1 gm IV at IA ± gentamicin 2 mg/kg ± metronidazole 500 mg IV at IA	Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA or Amoxicillin/clavulanate 750 mg IV at IA or Ampicillin/sulbactam 1.5 gm IV at IA	<1 day
General Surgery
Non-complicated appendectomy ( infected)	Enteric GNB Anerobes	Cefoxitin 1-2 gm IV at IA or Cefmetazole 1-2 gm IV at IA or Cefazolin 1 gm + gentamicin 2 mg/kg + metronidazole 500 mg IV at IA	Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA or Amoxicillin/clavulanate 750 mg IV at IA or Ampicillin/sulbactam 1.5 gm IV at IA	<1 day
Open biliary (clean-contaminated)	Enteric GNB	Cefazolin 1 gm IV at IA	Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA or 2GC 1-2 gm IV at IA	<1 day
Open cholecystectomy (clean-contaminated)	Enteric GNB	Cefazolin 1 gm IV at IA	Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA or 2GC 1-2 gm IV at IA	<1 day
Laparoscopic cholecystectomy (clean-contaminated)	Enteric GNB	Cefazolin 1 gm IV at IA	Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA or 2GC 1-2 gm IV at IA	<1 day
Gastroduodenal (clean-contaminated)	Gram-positive cocci Enteric GNB	Cefazolin 1-2 gm IV at IA	Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA	<1 day
Intestinal (clean-contaminated)	Gram-positive cocci Enteric GNB	Cefazolin 1-2 gm IV at IA	Clindamycin 600 mg IV + gentamicin 2 mg/kg IV at IA	<1 day
Laparoscopic or non-laparoscopic herniorrhaphy with mesh (clean)	S. aureus CoNS	Cefazolin 1 gm IV at IA	Clindamycin 600 mg IV at IA	1 dose
Laparoscopic or non-laparoscopic herniorrhaphy without mesh (clean)	S. aureus CoNS	Nil or Cefazolin 1 gm IV at IA	Clindamycin 600 mg IV at IA	1 dose
Breast (clean)	S. aureus CoNS	Nil or Cefazolin 1-2 gm IV at IA	Clindamycin 600 mg IV at IA	1 dose
Thyroid (clean)	S. aureus CoNS	Nil or Cefazolin 1-2 gm IV at IA	Clindamycin 600 mg IV at IA	1 dose
Urology
Transrectal prostate biopsy (clean-contaminated)	Enteric GNB	Cefazolin 1 gm IV at IA	Gentamicin 2 mg/kg IV on call to OR or Ciprofloxacin 500 mg oral or 400 mg IV on call to OR	1 dose
Transurethral prostate biopsy (clean-contaminated)	Enteric GNB	Cefazolin 1 gm IV at IA	Gentamicin 2 mg/kg IV on call to OR or Ciprofloxacin 500 mg oral or 400 mg IV on call to OR	<1 day
Transurethral bladder tumor resection (clean-contaminated)	Enteric GNB	Cefazolin 1 gm IV at IA	Gentamicin 2 mg/kg IV on call to OR	<1 day
Gynecology & Obstetrics
Hysterectomy, abdominal or vaginal (clean-contaminated)	Enteric GNB Group B streptococcus Anerobes	Cefazolin 1 gm IV at IA or Cefoxitin 1 gm IV at IA or Cefmetazole 1 gm IV at IA	Clindamycin 600 mg IV at IA + gentamicin 2 mg/kg IV at IA or Amoxicillin/clavulanate 750 mg IV at IA or Ampicillin/sulbactam 1.5 gm IV at IA	<1 day
Cesarean section (clean-contaminated)	Enteric GNB Group B streptococcus Anerobes	Cefazolin 1-2 gm IV immediately after cord clamping	Clindamycin 600 mg IV at IA + gentamicin 2 mg/kg IV at IA	<1 day

Abbreviations

CoNS = coagulase-negative staphylococci; GNB = Gram-negative bacilli; IA = induction of anesthesia; IV = intravenous; 2GC = second-generation cephalosporins; OR = operating room.
Indications for vancomycin: 1) penicillin allergy; 2) high rate of MRSA in the hospital.
For non-complicated appendicitis, the first dose of antibiotic should be given when diagnosis has been made and a second dose can be given at induction of anesthesia.

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Article Information
Title:	Guidelines for Prophylactic Antibiotics in Surgery
Subtitle:	Guidelines for Prophylactic Antibiotics in Surgery
Author:
Article URL:	http://www.qi.org.tw/Quality/ind/amb.aspx
Created:	2011-05-02 13:49
Updated:	2011-05-02 13:35
Keywords:	Guidelines for Prophylactic Antibiotics in Surgery
Description:	Guidelines for Prophylactic Antibiotics in Surgery