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Antimicrobial Surgical Prophylaxis Guidelines Updated
The Medical Letter Treatment Guidelines released updated antimicrobial surgical prophylaxis guidelines in June 2009.1 The previous version was released in December 2006. Key differences between these 2 documents will be highlighted in this overview, and a summary of recommended antimicrobials and doses for surgical prophylaxis will be presented in Table 1.
In the updated guidelines, a small section on screening for methicillin-resistant Staphylococcus aureus (MRSA) has been added.1 Currently, pre-operative identification of patients colonized with MRSA and subsequent decolonization with intranasal mupirocin remains controversial. The updated guidelines point out that The Society of Thoracic Surgeons recommend decolonization with mupirocin prior to cardiac surgery for all patients without a documented negative test for MRSA. The efficacy of chlorhexidine for decontamination is also unclear.
Cefuroxime is no longer a recommended antimicrobial for cardiac surgery, with cefazolin and vancomycin listed as the preferred agents.1 Cefotetan has now been added as an alternative agent for colorectal, non-perforated appendectomy, and vaginal, abdominal, or laproscopic hysterectomy. Both cefoxitin and cefotetan are more active than cefazolin against bowel anaerobes, including Bacteroides fragilis. For genitourinary procedures, the recommendations are now divided into 3 sections: cystoscopy alone, cystoscopy with manipulation or upper tract instrumentation (shockwave lithotripsy, ureteroscopy), and open or laparoscopic surgery including percutaneous renal surgery, procedures with entry into the urinary tract, and those involving implantation of a prosthesis. In the previous version, only ciprofloxacin was recommend; however, the new recommendations add the use of trimethoprim-sulfamethoxazole for cystoscopy alone and cystoscopy with manipulation or upper tract instrumentation, and recommend cefazolin for open or laparoscopic surgery. If manipulation of the bowel is involved prophylaxis is given according to colorectal guidelines.
Doxycycline is the only antibiotic recommended for abortion procedures, with 100 mg given orally 1 hour before the abortion and 200 mg given orally one-half hour after.1 The recommendations for head and neck surgery have also changed with the new prophylactic regimen being clindamycin 600 to 900 mg intravenously (IV) or cefazolin 1 to 2 g IV + metronidazole 0.5 g IV.
Table 1. Antimicrobial prophylaxis for Surgery.1
Procedure |
Recommended Agent(s) and Dosage Before Surgery* |
Cardiac |
cefazolin 1 to 2 g IV; some experts recommend an additional dose when patients are removed from bypass during open-heart surgery
OR
vancomycin 1 g IV when MRSA is a concern or for patients allergic to penicillin or cephalosporins; for operations in which gram-negative bacilli are common pathogens, consider adding another drug such as an aminoglycoside
|
Gastrointestinal |
Esophageal gastroduodenal |
High risk only (defined as morbid obesity, esophageal obstruction, decreased gastric acidity or gastrointestinal motility):
cefazolin 1 to 2 g IV
|
Biliary tract |
High risk only (defined as age >70 years, acute cholecystitis, non-functioning gallbladder, obstructive jaundice or common duct stones)
cefazolin 1 to 2 g IV
|
Colorectal
|
Oral:
neomycin 1 g + erythromycin base 1 g at 1 PM, 2PM, and 11 PM the day before an 8 AM operation
OR
neomycin 2 g + metronidazole 2 g at 7 PM and 11 PM the day before an 8 AM operation
Parenteral:
cefoxitin or cefotetan both dosed at 1 to 2 g IV
OR
cefazolin 1 to 2 g IV + metronidazole 0.5 g IV
OR
ampicillin/sulbactam 3 g IV
|
Appendectomy, non-perforated |
cefoxitin or cefotetan both dosed at 1 to 2 g IV
OR
cefazolin 1 to 2 g IV + metronidazole 0.5 g IV
OR
ampicillin/sulbactam 3 g IV
If perforation has occurred, antibiotics are often continued for 5 to 7 days.
|
Genitourinary |
Cystoscopy alone
|
High risk only (defined as urine culture positive or unavailable, preoperative catheter, transrectal prostatic biopsy, placement of prosthetic material):
ciprofloxacin 500 mg orally or 400 mg IV
OR
trimethoprim/sulfamethoxazole 1 double-strength tablet
|
Cystoscopy with manipulation or upper tract instrumentation |
Same regimens as cystoscopy alone, but given to all patients regardless of risk status. |
Open or laproscopic surgery |
cefazolin 1 to 2 g IV |
Gynecologic and Obstetric |
Vaginal, abdominal, or laproscopic hysterectomy
|
cefoxitin or cefotetan or cefazolin, all dosed at 1 to 2 g IV
OR
ampicillin/sulbactam 3 g IV
|
Cesarean section |
cefazolin 1 to 2 g IV |
Abortion
|
doxycycline 300 mg orally, given as 100 mg 1 hour before the procedure and 200 mg one half hour after |
Head and Neck Surgery |
Incisions through oral or pharyngeal mucosa |
clindamycin 600 to 900 mg IV
OR
cefazolin 1 to 2 g IV + metronidazole 0.5 g IV
|
Neurosurgery |
cefazolin 1 to 2 g IV
OR
vancomycin 1 g IV when MRSA is a concern or for patients allergic to penicillin or cephalosporins; for operations in which gram-negative bacilli are common pathogens, consider adding another drug such as an aminoglycoside
|
Ophthalmic |
gentamicin, tobramycin, ciprofloxacin, gatifloxacin, levofloxacin, moxifloxacin, ofloxacin, or neomycin-gramicidin-polymyxin B; all dosed as multiple drops topically over 2 to 24 hours
cefazolin 100 mg subconjunctivally (some clinicians also give this injection)
|
Orthopedic |
cefazolin 1 to 2 g IV or cefuroxime 1.5 g IV
OR
vancomycin 1 g IV when MRSA is a concern or for patients allergic to penicillin or cephalosporins; for operations in which gram-negative bacilli are common pathogens, consider adding another drug such as an aminoglycoside
|
Thoracic (non-cardiac) |
cefazolin 1 to 2 g IV or cefuroxime 1.5 g IV
OR
vancomycin 1 g IV when MRSA is a concern or for patients allergic to penicillin or cephalosporins; for operations in which gram-negative bacilli are common pathogens, consider adding another drug such as an aminoglycoside
|
Vascular |
Arterial surgery involving a prosthesis, the abdominal aorta, or a groin incision
|
cefazolin 1 to 2 g IV
OR
vancomycin 1 g IV when MRSA is a concern or for patients allergic to penicillin or cephalosporins; for operations in which gram-negative bacilli are common pathogens, consider adding another drug such as an aminoglycoside
|
Lower extremity amputation for ischemia |
*For patients allergic to penicillins and cephalosporins, clindamycin with either gentamicin, ciprofloxacin, levofloxacin, or aztreonam is a reasonable alternative.
IV = intravenous; MRSA = methicillin-resistant Staphylococcus aureus
Reference
- The Medical Letter. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett. 2009;7(82):1-6.
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