NEW YORK-PRESBYTERIAN HOSPITAL ADULT RECOMMENDATIONS FOR SURGICAL PROPHYLAXIS These recommendations take into account the site of infection, most common organisms, hospital epidemiology and susceptibilities, expert opinion, and cost. The goals of these guidelines are to optimize antibiotic use and patient outcomes while limiting the emergence of resistant bacteria. These recommendations are modified from many sources including the Medical Letter 2006; Vol. 4 (Issue 52): 83-88 and Clin Infect Dis 2004; 38:1706-15. For endocarditis prophylaxis, consult the NYPH recommendations for the prevention of endocarditis based on the American Heart Association recommendations, Circulation 2007; 115. General Principles:• Choice of antimicrobial agent - Drug chosen should be active against the pathogens most commonly associated with wound infections following the specific procedure and against the pathogens endogenous to the region of the body being operated. - Selection of an appropriate agent for specific patients should take into account not only comparative efficacy but also adverse-effect profiles and patient drug allergies. - For most procedures, cefazolin 1 g or cefoxitin 2 g should be the agent of choice because of their relatively long duration of action, their effectiveness against the organisms most commonly encountered in surgery, and their relatively low cost. - Clindamycin or vancomycin should be used in penicillin-allergic patients. Clindamycin ...
mg/kg (usually 1
Usual IV Dose 2 grams 3 grams 600 mg 1.5 mg/kg 2 grams 500 mg 1 – 2 grams 400 mg 600 mg 160 mg (TMP)
grams gram)
q8 hrs q8 hrs
Redosing
(highly dependent on (highly dependent
frequency intra- q8 hrs q6 hrs No redose No redose
q4 hrs q4 hrs q4 hrs q8 hrs No redose q4 hrs renal function – no on renal function –
redose for patients no redose for
operatively
with ↑ SCr) patients with ↑ SCr)
IV push IV push
60 minute infusion
(3-5 min) (3-5 min)
30 minute 30 minute 30 minute 15-30 minute 30 minute 30 minute 2 hour 30 minute 60 minute
(doses > 1 gram
Administration OR OR
infusion infusion infusion infusion require 90 minute infusion infusion infusion infusion infusion
30 minute 30 minute
infusion)
infusion infusion
APPROVED BY THE ANTI-INFECTIVE SUBCOMMITTEE AND THE FORMULARY & THERAPEUTICS COMMITTEE
NYPH: LAST UPDATED 7/16/08
• Adult Gentamicin Dosing for Surgical Prophylaxis Based on Weight
(doses should be rounded to facilitate preparation, administration, and availability of gentamicin)
Weight (kg) Gentamicin Dose to Administer (1.5 mg/kg/dose)
30-40 60 mg
41-50 70
51-60 90
61-70 100
71-100 120
> 100 kg Use alternative if appropriate: aztreonam 2 g
PRIMARY ANTIBIOTIC PROPHYLAXIS DURATION OF
NATURE OF OPERATION PATHOGENS ALTERNATIVE
RECOMMENDED PROPHYLAXIS
Coronary artery bypass, other For up to 24
Staphylococcus aureus, S. epidermidis cefazolin 1-2 grams IV q8h
open-heart surgery vancomycin 1 gram IV q12h hours
cefazolin 1-2 grams IV q8h vancomycin 1 gram IV q12h For up to 24
Prosthetic valve Staphylococcus aureus, S. epidermidis
± gentamicin 1.5 mg/kg IV x 1 ± gentamicin 1.5 mg/kg IV x 1 hours
1a
1a clindamycin 600 mg IV q8h For up to 48
Pacemaker, defibrillator Staphylococcus aureus, S. epidermidis cefazolin 1-2 grams IV q8h
or vancomycin 1 g IV q12h hours (maximum)
placement
1a May be switched post-op to oral cephalexin 500 mg PO q6h or cefadroxil 1 g PO q12h or clindamycin (for PCN-allergic patients) 450 mg
PO q8h for a total duration not to exceed 48 hours.
cefoxitin 2 grams IV or
2a
Enteric gram-negative bacilli, gram-positive
cefazolin 1-2 grams IV
Esophageal, gastroduodenal clindamycin 600 mg IV + 1 Pre-op Dose
cocci 2a
gentamicin 1.5 mg/kg IV
cefazolin 2-3 grams IV ± metronidazole
Bariatric surgery Staphylococcus aureus, Streptococcus sp., clindamycin 900 mg IV 1 Pre-op Dose
500 mg IV
cefoxitin 2 grams IV or
2b
Enteric gram-negative bacilli, enterococci,
cefazolin 1-2 grams IV
Biliary tract clindamycin 600 mg IV + 1 Pre-op Dose
clostridia 2b
gentamicin 1.5 mg/kg IV
Oral:
neomycin + erythromycin base (after
appropriate diet and catharsis); 1 gram of
each at 1pm, 2pm and 11pm the day
before an 8am operation (Adjust timing for
Enteric gram-negative bacilli, anaerobes, clindamycin 600 mg IV +
a later operative start) or
Colorectal 1 Pre-op Dose
enterococci gentamicin 1.5 mg/kg IV
IV:
cefazolin 1-2 grams IV + metronidazole
500 mg IV or
cefoxitin 2 grams IV
Enteric gram-negative bacilli, anaerobes, clindamycin 600 mg IV +
Appendectomy, non-perforated cefoxitin 2 grams IV 1 Pre-op Dose
enterococci gentamicin 1.5 mg/kg IV
2a High risk only (morbid obesity, esophageal obstruction, decreased gastric acidity or gastrointestinal motility)
2b High risk only (Age>70 yrs, biliary stent, non-functioning gall bladder, obstructive jaundice or common duct stones)
APPROVED BY THE ANTI-INFECTIVE SUBCOMMITTEE AND THE FORMULARY & THERAPEUTICS COMMITTEE
NYPH: LAST UPDATED 7/16/08
2. GASTRO-INTESTINAL
1. CARDIAC
PRIMARY ANTIBIOTIC PROPHYLAXIS DURATION OF
NATURE OF OPERATION PATHOGENS ALTERNATIVE
RECOMMENDED PROPHYLAXIS
ampicillin 2 grams IV
3a
+ gentamicin 1.5 mg/kg IV
vancomycin 1 gram IV
1 Pre-op Dose
Enteric gram-negative bacilli, enterococci or
3a
+ gentamicin 1.5 mg/kg IV
3a
cefazolin 1-2 grams IV
3a High risk (urine culture positive or unavailable, pre-operative catheter, transrectal prostatic biopsy, placement of prosthetic material);
transurethral resection of prostate
cefoxitin 2 grams IV or
Vaginal or abdominal Enteric gram-negative bacilli, anaerobes,
cefazolin 1-2 grams IV clindamycin 600 mg IV + 1 Pre-op Dose
hysterectomy Group B strep, enterococci
gentamicin 1.5 mg/kg IV
Enteric gram-negative bacilli, anaerobes, cefazolin 1 gram IV cefoxitin 2 grams IV
1 Pre-op Dose
Cesarean section
Group B strep, enterococci (after cord clamping) (after cord clamping)
Anaerobes, enteric gram negative bacilli, S. clindamycin 600-900 mg IV +
Incisions through oral or cefazolin 1-2 grams IV
1 Pre-op Dose
aureus gentamicin 1.5 mg/kg IV
pharyngeal mucosa
Craniotomy S. aureus, S. epidermidis cefazolin 1-2 grams IV vancomycin 1 gram IV 1 Pre-op Dose
APPROVED BY THE ANTI-INFECTIVE SUBCOMMITTEE AND THE FORMULARY & THERAPEUTICS COMMITTEE
NYPH: LAST UPDATED 7/16/08
4. GYNECOLOGIC
3.
6.
5. HEAD AND
AND OBS
TETRIC
GENIT
O
U
RINARY
NEUROSURGERY
NECK PRIMARY ANTIBIOTIC PROPHYLAXIS DURATION OF
NATURE OF OPERATION PATHOGENS ALTERNATIVE
RECOMMENDED PROPHYLAXIS
gentamicin, tobramycin, moxifloxacin,
S. epidermidis, S. aureus, streptococci,
gatifloxacin or neomycin-gramicidin-
For up to 24
enteric gram-negative bacilli, Pseudomonas
polymixin B; multiple drops topically over
hours
aeruginosa
2 to 24 hours
Total joint replacement,
For up to 24
cefazolin 1-2 grams IV q8h clindamycin 600 mg IV q8h or
S.aureus, S. epidermidis
internal fixation of fractures hours
vancomycin 1 gram IV q12h
cefazolin 1-2 grams IV vancomycin 1 gram IV
S. aureus, S. epidermidis, streptococci,
1 Pre-op Dose
enteric gram-negative bacilli
APPROVED BY THE ANTI-INFECTIVE SUBCOMMITTEE AND THE FORMULARY & THERAPEUTICS COMMITTEE
NYPH: LAST UPDATED 7/16/08
9. THORACIC
8.
7. OPHTHALMIC
(NON-CARDIAC)
O
RTH
O
PEDI
C
PRIMARY ANTIBIOTIC PROPHYLAXIS DURATION OF
NATURE OF OPERATION PATHOGENS ALTERNATIVE
RECOMMENDED PROPHYLAXIS
cefazolin 1-2 grams IV
vancomycin 1 gram IV 1 Pre-op Dose
Heart
aztreonam 1 g IV q8h
10a ampicillin/sulbactam (Unasyn ®) 3 grams
Lung For up to 5 days
IV q6h + vancomycin 1 g IV q12h
cefazolin 1-2 grams IV vancomycin 1 gram IV 1 Pre-op Dose
Kidney
aztreonam 1 g IV q8h
ampicillin/sulbactam (Unasyn ®) 3 grams
+ metronidazole 500 mg IV For up to 24
Liver IV q6h
q12h hours
+ vancomycin 1 g IV q12h
rifampin 600 mg PO or IV x 1
rifampin 600 mg PO or IV x 1
+ fluconazole 400 mg PO or
+ fluconazole 400 mg PO or IV x 1 For up to 48
LVAD IV x 1
+ TMP/SMX 160 mg (TMP) IV q8h for up hours
(CUMC) + vancomycin 1 g IV q12h for
to 48 hrs
up to 48 hrs
clindamycin 600 mg IV q8h
ampicillin/sulbactam (Unasyn ®) 3 grams
+ aztreonam 1 g IV q8h for up
IV q6h for up to 24 hours For up to 24 - 48
to 24 hours
Pancreas or kidney/pancreas hours
+ fluconazole 400 mg IV q24h for up to 48
+ fluconazole 400 mg IV q24h
hours
for up to 48 hours
10a Antibiotics listed are for routine (“non-septic”) lung transplants. Modification of antibiotic regimens is necessary in cases where culture
and susceptibility data from the donor and/or recipient are available.
Arterial surgery involving a
S. aureus, S. epidermidis, enteric gram-
cefazolin 1-2 grams IV
1 Pre-op Dose
prosthesis, the abdominal vancomycin 1 gram IV
negative bacilli
aorta, or a groin incision
Lower extremity amputation for
S. aureus, S. epidermidis, enteric gram-
1 Pre-op Dose
cefazolin 1-2 grams IV vancomycin 1 gram IV
ischemia
negative bacilli, clostridia
APPROVED BY THE ANTI-INFECTIVE SUBCOMMITTEE AND THE FORMULARY & THERAPEUTICS COMMITTEE
NYPH: LAST UPDATED 7/16/08
11. VASCULAR
10. TRANSPL
ANTS