Table 2

Recommendations for Surgical Antimicrobial Prophylaxis

Type of ProcedureRecommended Agentsa,bAlternative Agents in Pts Withβ-Lactam AllergyStrength of Evidencec
Cardiac Coronary artery bypassCefazolin, cefuroximeClindamycin,d vancomycindA
Cardiac device insertion procedures (e.g., pacemaker implantation)Cefazolin, cefuroximeClindamycin, vancomycinA
Ventricular assist devicesCefazolin, cefuroximeClindamycin, vancomycinC
Thoracic Noncardiac procedures, including lobectomy, pneumonectomy, lung resection, and thoracotomyCefazolin, ampicillin-sulbactamClindamycin,d vancomycindA
Video-assisted thoracoscopic surgeryCefazolin, ampicillin-sulbactamClindamycin,d vancomycindC
Gastroduodenale Procedures involving entry into lumen of gastrointestinal tract (bariatric, pancreaticoduodenectomyf)CefazolinClindamycin or vancomycin + aminoglycosideg or aztreonam or fluoroquinolonehjA
Procedures without entry into gastrointestinal tract (antireflux, highly selective vagotomy) for high-risk patientsCefazolinClindamycin or vancomycin + aminoglycosideg or aztreonam or fluoroquinolonehjA
Biliary tract Open procedureCefazolin, cefoxitin, cefotetan, ceftriaxone,k ampicillin-sulbactamhClindamycin or vancomycin + aminoglycosideg or aztreonam or fluoroquinolonehjMetronidazole + aminoglycosideg or fluoroquinolonehjA
Laparoscopic procedure Elective, low-risklNoneNoneA
Elective, high-risklCefazolin, cefoxitin, cefotetan, ceftriaxone,k ampicillin-sulbactamhClindamycin or vancomycin + aminoglycosideg or aztreonam or fluoroquinolonehjMetronidazole + aminoglycosideg or fluoroquinolonehjA
Appendectomy for uncomplicated appendicitisCefoxitin, cefotetan, cefazolin + metronidazoleClindamycin + aminoglycosideg or aztreonam or fluoroquinolonehj Metronidazole + aminoglycosideg or fluoroquinolonehjA
Small intestine NonobstructedCefazolinClindamycin + aminoglycosideg or aztreonam or fluoroquinolonehjC
ObstructedCefazolin + metronidazole, cefoxitin, cefotetanMetronidazole + aminoglycosideg gor fluoroquinolonehjC
Hernia repair (hernioplasty and herniorrhaphy)CefazolinClindamycin, vancomycinA
ColorectalmCefazolin + metronidazole, cefoxitin, cefotetan, ampicillin-sulbactam,h ceftriaxone + metronidazole,n ertapenemClindamycin + aminoglycosideg or aztreonam or fluoroquinolonehj, metronidazole + aminoglycosideg or fluoroquinolonehjA
Head and neck CleanNoneNoneB
Clean with placement of prosthesis (excludes tympanostomy tubes)Cefazolin, cefuroximeClindamycindC
Clean-contaminated cancer surgeryCefazolin + metronidazole, cefuroxime + metronidazole, ampicillin-sulbactamClindamycindA
Other clean-contaminated procedures with the exception of tonsillectomy and functional endoscopic sinus proceduresCefazolin + metronidazole, cefuroxime + metronidazole, ampicillin-sulbactamClindamycindB
Neurosurgery Elective craniotomy and cerebrospinal fluid-shunting proceduresCefazolinClindamycin,d vancomycindA
Implantation of intrathecal pumpsCefazolinClindamycin,d vancomycindC
Cesarean deliveryCefazolinClindamycin + aminoglycosidegA
Hysterectomy (vaginal or abdominal)Cefazolin, cefotetan, cefoxitin, ampicillin-sulbactamhClindamycin or vancomycin + aminoglycosideg or aztreonam or fluoroquinolonehjMetronidazole + aminoglycosideg or fluoroquinolonehjA
OphthalmicTopical neomycin-polymyxin B-gramicidin or fourth-generation topical fluoroquinolones (gatifloxacin or moxifloxacin) given as 1 drop every 5–15 min for 5 dosesoAddition of cefazolin 100 mg by subconjunctival injection or intracameral cefazolin 1–2.5 mg or cefuroxime 1 mg at the end of procedure is optionalNoneB
Orthopedic Clean operations involving hand, knee, or foot and not involving implantation of foreign materialsNoneNoneC
Spinal procedures with and without instrumentationCefazolinClindamycin,d vancomycindA
Hip fracture repairCefazolinClindamycin,d vancomycindA
Implantation of internal fixation devices(e.g., nails, screws, plates, wires)CefazolinClindamycin,d vancomycindC
Total joint replacementCefazolinClindamycin,d vancomycindA
Urologic Lower tract instrumentation with risk factors for infection (includes transrectal prostate biopsy)Fluoroquinolone,hj trimethoprim-sulfamethoxazole, cefazolinAminoglycosideg with or without clindamycinA
Clean without entry into urinary tractCefazolin (the addition of a single dose of an aminoglycoside may be recommended for placement of prosthetic material [e.g., penile prosthesis])Clindamycin,d vancomycindA
Involving implanted prosthesisCefazolin ± aminoglycoside, cefazolin ± aztreonam, ampicillin-sulbactamClindamycin ± aminoglycoside or aztreonam, vancomycin ± aminoglycoside or aztreonamA
Clean with entry into urinary tractCefazolin (the addition of a single dose of an aminoglycoside may be recommended for placement of prosthetic material [e.g., penile prosthesis])Fluoroquinolone,hj aminoglycosideg with or without clindamycinA
Clean-contaminatedCefazolin + metronidazole, cefoxitinFluoroquinolone,hj aminoglycosideg + metronidazole or clindamycinA
VascularpCefazolinClindamycin,d vancomycindA
Heart, lung, heart-lung transplantationq Heart transplantationrCefazolinClindamycin,d vancomycindA (based on cardiac procedures)
Lung and heart-lung transplantationr,sCefazolinClindamycin,d vancomycindA (based on cardiac procedures)
Liver transplantationq,tPiperacillin-tazobactam, cefotaxime + ampicillinClindamycin or vancomycin + aminoglycosideg or aztreonam or fluoroquinolonehjB
Pancreas and pancreas-kidney transplantationrCefazolin, fluconazole (for patients at high risk of fungal infection [e.g., those with enteric drainage of the pancreas])Clindamycin or vancomycin + aminoglycosideg or aztreonam or fluoroquinolonehjA
CefazolinClindamycin or vancomycin + aminoglycosideg or aztreonam or fluoroquinolonehjA
Plastic surgery
Clean with risk factors or clean-contaminatedCefazolin, ampicillin-sulbactamClindamycin,d vancomycindC
  • a The antimicrobial agent should be started within 60 minutes before surgical incision (120 minutes for vancomycin or fluoroquinolones). While single-dose prophylaxis is usually sufficient, the duration of prophylaxis for all procedures should be less than 24 hours. If an agent with a short half-life is used (e.g., cefazolin, cefoxitin), it should be readministered if the procedure duration exceeds the recommended redosing interval (from the time of initiation of the preoperative dose [see Table 1]). Readministration may also be warranted if prolonged or excessive bleeding occurs or if there are other factors that may shorten the half-life of the prophylactic agent (e.g., extensive burns). Readministration may not be warranted in patients in whom the half-life of the agent may be prolonged (e.g., patients with renal insufficiency or failure).

  • b For patients known to be colonized with methcillin-resistant Staphylococcus aureus, it is reasonable to add a single preoperative dose of vancomycin to the recommended agent(s).

  • c Strength of evidence that supports the use or nonuse of prophylaxis is classified as A (levels l–lll), B (levels IV–VI), or C (level VII). Level I evidence is from large, well-conducted, randomized controlled clinical trials. Level II evidence is from small, well-conducted, randomized controlled clinical trials. Level III evidence is from well-conducted cohort studies. Level IV evidence is from well-conducted case-control studies. Level V evidence is from uncontrolled studies that were not well conducted. Level VI evidence is conflicting evidence that tends to favor the recommendation. Level VII evidence is expert opinion.

  • d For procedures in which pathogens other than staphylococci and streptococci are likely, an additional agent with activity against those pathogens could be considered. For example, if there are surveillance data showing that gram-negative organisms are a cause of surgical-site infections (SSIs) for the procedure, practitioners may consider combining clindamycin or vancomycin with another agent (cefazolin if the patient is not β-lactam allergic; aztreonam, gentamicin, or single-dose fluoroquinolone if the patient is β-lactam allergic).

  • e Prophylaxis should be considered for patients at highest risk for postoperative gastroduodenal infections, such as those with increased gastric pH (e.g., those receiving histamine H2-receptor antagonists or proton-pump inhibitors), gastroduodenal perforation, decreased gastric motility, gastric outlet obstruction, gastric bleeding, morbid obesity, or cancer. Antimicrobial prophylaxis may not be needed when the lumen of the intestinal tract is not entered.

  • f Consider additional antimicrobial coverage with infected biliary tract. Seethe biliary tract procedures section of this article.

  • g Gentamicin or tobramycin.

  • h Due to increasing resistance of Escherichia coli to fluoroquinolones and ampicillin-sulbactam, local population susceptibility profiles should be reviewed prior to use.

  • i Ciprofloxacin or levofloxacin.

  • j Fluoroquinolones are associated with an increased risk of tendonitis and tendon rupture in all ages. However, this risk would be expected to be quite small with single-dose antibiotic prophylaxis. Although the use of fluoroquinolones may be necessary for surgical antibiotic prophylaxis in some children, they are not drugs of first choice in the pediatric population due to an increased incidence of adverse events as compared with controls in some clinical trials.

  • k Ceftriaxone use should be limited to patients requiring antimicrobial treatment for acute cholecystitis or acute biliary tract infections which may not be determined prior to incision, not patients undergoing cholecystectomy for noninfected biliary conditions, including biliary colic or dyskinesia without infection.

  • l Factors that indicate a high risk of infectious complications in laparoscopic cholecystectomy include emergency procedures, diabetes, long procedure duration, intraoperative gallbladder rupture, age of >70 years, conversion from laparoscopic to open cholecystectomy, American Society of Anesthesiologists classification of 3 or greater, episode of colic within 30 days before the procedure, reintervention in less than one month for noninfectious complication, acute cholecystitis, bile spillage, jaundice, pregnancy, nonfunctioning gallbladder, immunosuppression, and insertion of prosthetic device. Because a number of these risk factors are not possible to determine before surgical intervention, it may be reasonable to give a single dose of antimicrobial prophylaxis to all patients undergoing laparoscopic cholecystectomy.

  • m For most patients, a mechanical bowel preparation combined with oral neomycin sulfate plus oral erythromycin base or with oral neomycin sulfate plus oral metronidazole should be given in addition to i.v. prophylaxis.

  • n Where there is increasing resistance to first- and second-generation cephalosporins among gram-negative isolates from SSIs, a single dose of ceftriaxone plus metronidazole may be preferred over the routine use of carbapenems.

  • o The necessity of continuing topical antimicrobials postoperatively has not been established.

  • p Prophylaxis is not routinely indicated for brachiocephalic procedures. Although there are no data in support, patients undergoing brachiocephalic procedures involving vascular prostheses or patch implantation (e.g., carotid endarterectomy) may benefit from prophylaxis.

  • q These guidelines reflect recommendations for perioperative antibiotic prophylaxis to prevent SSIs and do not provide recommendations for prevention of opportunistic infections in immunosuppressed transplantation patients (e.g., for antifungal or antiviral medications).

  • r Patients who have left-ventricular assist devices as a bridge and who are chronically infected might also benefit from coverage of the infecting microorganism.

  • s The prophylactic regimen may need to be modified to provide coverage against any potential pathogens, including gram-negative (e.g., Pseudomonas aeruginosa) or fungal organisms, isolated from the donor lung or the recipient before transplantation. Patients undergoing lung transplantation with negative pretransplantation cultures should receive antimicrobial prophylaxis as appropriate for other types of cardiothoracic surgeries. Patients undergoing lung transplantation for cystic fibrosis should receive 7–14 days of treatment with antimicrobials selected according to pretransplantation culture and susceptibility results. This treatment may include additional antibacterial or antifungal agents.

  • t The prophylactic regimen may need to be modified to provide coverage against any potential pathogens, including vancomycin-resistant enterococci, isolated from the recipient before transplantation.