Antibiotic Prophylaxis for Inpatient and Outpatient Surgery

Purpose: To provide a guideline for the safe and effective utilization of antimicrobials for surgical site infection prophylaxis. The appropriate use of antibiotic prophylaxis
prevents postoperative infections at the site of surgery, postoperative morbidity and mortality due to infectious complications, reduces the duration and cost of the
patient's health care needs, and minimizes the adverse consequences for the microbial flora of the patient or institution (i.e. antimicrobial resistance, Clostridium difficile)
Policy and Procedure for Pharmacy to Adjust Antibiotic Selection and Doses
 Upon receipt of an order for a medication that is eligible for dose adjustment per this P&T Committee approved protocol (see Table 1, 2, and 3), the pharmacist will
determine if the ordered drug is appropriate based on surgical procedure, history of MRSA, renal function, weight, and history of antibiotic allergies
 If the drug, dose, or number of doses need to be adjusted, pharmacy will make the necessary changes in the electronic medical record per protocol
Vancomycin: Vancomycin should not be routinely used for surgical prophylaxis. Overuse of vancomycin promotes the development of resistance
 Significant penicillin allergy (i.e. hives, angioedema, anaphylaxis)
 Prosthetic valve. In this procedure, vancomycin should be used in addition to cefazolin for prophylaxis.
 Given the limited value of post-op antibiotic dosing and risk for adverse effects, a standard post-op dose of 1 gram will be used when ordered by the physician.
 Orthopedic, Foot/Ankle, Open Heart, and Neuro/Spine procedures ONLY: patients who are having hardware placed AND MRSA screen positive or have history of
MRSA within the past 12 months and NO recent NEGATIVE MRSA screen should receive ONE dose of vancomycin PRE-OP in addition to standard prophylaxis
Gentamicin: Gentamicin should only be administered one time pre-operatively and does not require postoperative dosing in most procedures (May be redosed ONCE for
cardiac surgery patients and given for up to 3 days in trauma patients). Dosing is based on Actual body weight (ABW) unless the patient is obese, greater than 20% over Ideal
Body Weight (IBW), then an adjusted dosing weight (DW) will be used. Calculation: DW = IBW + 0.4 (ABW - IBW)
Oral Prophylaxis for Colon Procedures: It is recommended that all patients undergoing a colorectal procedure (if time permits), be provided oral antibiotics in addition to
standard IV prophylaxis prior to incision.
 Recommended agents: Neomycin 1 gram and Metronidazole 500mg PO scheduled 19, 18, and 9 hrs PRIOR to surgery (e.g. 1PM. 2PM and 11PM for an 8 AM surgery)
 Alternative agents: Neomycin and Erythromycin 1 gram PO scheduled 19, 18, and 9 hrs PRIOR to surgery (e.g. 1PM. 2PM and 11PM for an 8 AM surgery)
Timing: Most antibiotics for surgical prophylaxis should be initiated within 60 minutes of the first incision. Antibiotic prophylaxis with vancomycin and ciprofloxacin should be
initiated 60 - 120 minutes before the first incision is made
 For the prevention of surgical site infections, it is important to infuse most, if not ALL of the drug before cutting.
 When a tourniquet is used, recommended guidelines state the entire infusion should be completed prior to tourniquet inflation
 Vancomycin and Ciprofloxacin to be initiated in pre-op at the discretion of the room.
Redosing in Patients with Escessive Blood Loss: Most antibiotics should be redosed in patients who have lost over 1500 mL of blood. (See Table 2 for recommendations)
Common Procedures where Antibiotic prophylaxis is NOT Indicated:
 OB/GYN: Laparoscopy (diagnostic, operative or tubal sterilization), Laparotomy, Hysteroscopy (diagnostic, operative, endometrial ablation, essure), IUD insertion,
Endometrial biopsy, Urodynamics
 Biliary tract: Laparoscopic procedures that are considered elective and low-risk
 Orthopedic: Clean operations involving hand, knee, or foot AND not involving implantation of foreign materials
 Urologic: Cystography, urodynamic study, simple cystourethroscopy, or removal of external urinary catheter unless urine cultures are positive prior to the procedure
Duration and Postoperative Dosing: A single dose of a pre-op antibiotic is generally sufficient to prevent a post-surgical infection. Current guidelines do NOT recommend
post-op administration of antibiotics for most procedures, as there is no evidence that prophylactic antibiotic administration after incision closure decreases SSI risk, even in
the presence of a drain. Prolonged use of prophylactic antimicrobials is associated with the emergence of resistance and Clostridium difficile-associated diarrhea. Current
exceptions include implant-based breast reconstruction, joint arthroplasty, and cardiac procedures where optimal duration of antibiotic therapy remains unknown. If
continued prophylactic dosing is recommended in the post-operative period, dose according to the Table 3.
Last Reviewed by ASP Committee: October 2018 Last Approved by P&T Committee: October 2018

Reviewed by Jamie Kisgen, PharmD, BCPS(AQ-ID), Megan Seddon, PharmD, Eric Chernin, RPh, Julie Larkin, MD Last Updated 10/2018
 Antibiotic Prophylaxis for Inpatient and Outpatient Surgery
Table 1: Appropriate Antibiotic Selection and Recommended Alternatives for Common Surgical Procedures

History of MRSA & Preferred Alternative Acceptable Intra-operative Post-operative

Procedure Recommended Orders
NO negative screen for Beta-lactam Allergy Alternative Redosing for Long Cases antibiotics
Cardiothoracic MAJOR Cefazolin Cefazolin + Clindamycin +/- Maximum of
Vancomycin + Gentamicin Cefazolin in 4 hours
(Non-Valve) Protocol Peridex 0.1% PREOP Vancomycin (once) Gentamicin 48 hours
Cardiothoracic MAJOR
Cefazolin + Vancomycin Cefazolin + Clindamycin + Maximum of
Valve Protocol Vancomycin + Gentamicin Cefazolin in 4 hours
Peridex 0.1% 15ml PREOP Vancomycin Gentamicin 48 hours
- TAVR (Transcath Valve)
Cardiothoracic MINOR Cefazolin Cefazolin +
Vancomycin Clindamycin Not Applicable N/A
AICD/Pacer Protocol Peridex 0.1% 15ml PREOP Vancomycin (once)
Cardiothoracic MINOR Cefazolin
N/A Vancomycin Clindamycin Not Applicable N/A
Lung Protocol Peridex 0.1% 15ml PREOP
ENT (Otolaryngology) Cefazolin in 4 hours Maximum of
Cefazolin N/A Clindamycin N/A
ADULT Protocol Clindamycin in 6 hours 24 hours
ENT (Otolaryngology) – Cefazolin in 4 hours Maximum of
Cefazolin 25 mg/kg IV N/A Clindamycin N/A
PEDIATRIC Protocol Clindamycin in 6 hours 24 hours
Cefazolin + Cefazolin in 4 hours Maximum of
Foot/Ankle Protocol Cefazolin Vancomycin Clindamycin
Vancomycin (once) Clindamycin in 6 hours 24 hours
Foot/Ankle PEDIATRIC Cefazolin + Cefazolin in 4 hours Maximum of
Cefazolin 25 mg/kg IV Clindamycin N/A
Protocol Vancomycin (once) Clindamycin in 6 hours 24 hours
Cefazolin in 4 hours Maximum of
General Surgery (Non-GI) Cefazolin N/A Vancomycin Clindamycin
Clindamycin in 6 hours 24 hours
Aztreonam in 4 hours
Clindamycin + Maximum of
GI Bariatric Protocol Cefazolin 3 grams N/A Clindamycin + Aztreonam Cefazolin in 4 hours
Aztreonam 24 hours
Clindamycin in 6 hours
GI Colorectal Protocol Aztreonam in 4 hours
Clindamycin + Maximum of
- Fiorica GYN procedures Cefazolin + Metronidazole N/A Clindamycin + Aztreonam Cefazolin in 4 hours
Aztreonam 24 hours
- Appendectomy Clindamycin in 6 hours
GI Upper Protocol Aztreonam in 4 hours
Clindamycin + Maximum of
- PEG Placement Cefazolin N/A Clindamycin + Aztreonam Cefazolin in 4 hours
Aztreonam 24 hours
- General/GI Surgery Clindamycin in 6 hours
Neurosurgery and Spine Cefazolin + Cefazolin in 4 hours Maximum of
Cefazolin Vancomycin Clindamycin
Protocol Vancomycin (once) Clindamycin in 6 hours 24 hours
OB/GYN Standard Protocol
Clindamycin + Cefazolin in 4 hours Maximum of
- Hysterectomy/Myomectomy Cefazolin N/A Clindamycin + Gentamicin
Aztreonam Clindamycin in 6 hours 24 hours
- Cesarean Section
OB Intrapartum Clindamycin +
Clindamycin + Gentamicin Cefazolin in 4 hours Maximum of
- Unscheduled/ STAT Cesarean Cefazolin + Azithromycin N/A Aztreonam +
+ Azithromycin Clindamycin in 6 hours 24 hours
Section Azithromycin

Reviewed by Jamie Kisgen, PharmD, BCPS(AQ-ID), Megan Seddon, PharmD, Eric Chernin, RPh, Julie Larkin, MD Last Updated 10/2018
 Antibiotic Prophylaxis for Inpatient and Outpatient Surgery
Table 1: Appropriate Antibiotic Selection and Recommended Alternatives for Surgical Procedures

Preferred Alternative
History of MRSA & Acceptable Intra-operative Re- Post-operative
Procedure Recommended Orders for
NO negative screen Alternative dosing for Long Cases antibiotics
Beta-lactam Allergy
Oral/Maxillofacial Cefazolin in 4 hours Maximum of
Cefazolin N/A Clindamycin N/A
ADULT Protocol Clindamycin in 6 hours 24 hours
Oral/Maxillofacial Cefazolin in 4 hours Maximum of
Cefazolin 25mg/kg IV N/A Clindamycin N/A
PEDIATRIC Protocol Clindamycin in 6 hours 24 hours
Cefazolin + Cefazolin in 4 hours Maximum of
Orthopedic ADULT Protocol Cefazolin Vancomycin Clindamycin
Vancomycin (once) Clindamycin in 6 hours 24 hours
Orthopedic PEDIATRIC Cefazolin in 4 hours Maximum of
Cefazolin 25 mg/kg IV Clindamycin 10mg/kg Clindamycin N/A
Protocol Clindamycin in 6 hours 24 hours
Cefazolin in 4 hours Maximum of
Pain Management Cefazolin N/A Vancomycin Clindamycin
Clindamycin in 6 hours 24 hours
Plastic Surgery ADULT Cefazolin in 4 hours Maximum of
Cefazolin N/A Vancomycin Clindamycin
Protocol Clindamycin in 6 hours 24 hours
Plastic Surgery PEDIATRIC Cefazolin in 4 hours Maximum of
Cefazolin 25 mg/kg IV N/A Clindamycin 10mg/kg N/A
Protocol Clindamycin in 6 hours 24 hours

Radiology ADULT Protocol Cefazolin N/A Vancomycin Clindamycin N/A N/A

Radiology PEDIATRIC
Cefazolin 25 mg/kg IV N/A Clindamycin 10mg/kg N/A N/A N/A
Protocol
Urology Cysto Protocol Cefazolin OR Ciprofloxacin BL Allergy: Ciprofloxacin Maximum of
N/A Aztreonam Cefazolin in 4 hours
(including TURP) OR Gentamicin FQ Allergy: Cefazolin 24 hours
Urology Open/Robotic Clindamycin + Cefazolin in 4 hours Maximum of
Cefazolin N/A Clindamycin + Gentamicin
Protocol (skin coverage) Aztreonam Clindamycin in 6 hours 24 hours
Urology Penile Prosthesis Clindamycin + Maximum of
Vancomycin + Gentamicin N/A Vancomycin + Gentamicin N/A
Protocol Gentamicin 24 hours
Maximum of
Vascular ADULT Protocol Cefazolin N/A Vancomycin Clindamycin Cefazolin in 4 hours
24 hours
Vascular PEDIATRIC Cefazolin in 4 hours Maximum of
Cefazolin 25 mg/kg IV N/A Clindamycin 10mg/kg N/A
Protocol Clindamycin in 6 hours 24 hours
References:
1. Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195-283
2. Ban KA, et al. ACS and SIS: Surgical Site Infection Guidelines, 2016 Update. Journal of the American College of Surgeons 2017;224(1):59-74
3. Berrios-Torres SI, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection 2017. JAMA Surg. 2017;152(8):784-791.
4. Use of Prophylactic Antibiotics in Labor and Delivery. ACOG Practice Bulletin No. 120. Obstet Gynecol 2011;117(6):1472-1483
5. Best Practice Policy Statement On Urologic Surgery Antimicrobial Prophylaxis. American Urologic Association. Updated 1/2014

Reviewed by Jamie Kisgen, PharmD, BCPS(AQ-ID), Megan Seddon, PharmD, Eric Chernin, RPh, Julie Larkin, MD Last Updated 10/2018
 Antibiotic Prophylaxis for Inpatient and Outpatient Surgery
Table 2: Appropriate Dosing and Timing of Antibiotics
Pediatric Time of INITIATION prior Re-dosing in delayed Skin Intra-op Redose for Blood
Drug Usual Adult Dose Infusion Time
Dose to cut for adequate levels procedures/on active therapy Coverage Redosing Loss > 1.5 Liters
Commonly Used Prophylactic Antibiotics
Azithromycin 500 mg IV N/A Usual: 60 min Optimal: 30 min N/A NO N/A N/A
Usual: 30 min Optimal: 30 min < 4 hours: no redose required
Aztreonam 2 grams IV 30 mg/kg NO 4 hours 1 grams
Minimum 5 min Minimum : 10 min ≥ 4 hours: 2 grams
< 90 min: no redose required
2 grams IV (≤ 120 kg) Usual:5 or 30 min Optimal: 10-30 min
Cefazolin 25 mg/kg 90 min - 3 hours: 1 gram YES 4 hours 2 grams
3 grams IV (>120 kg) Minimum 5 min Minimum: 10 min
> 3 hours: 2 grams
< 90 min: no redose required
Usual: 30 min Optimal: 30 min
Cefuroxime 1.5 grams IV 25 mg/kg 90 min - 3 hours: 750 mg YES 4 hours 1.5 grams
Minimum 5 min Minimum : 10 min
> 3 hours: 1.5 grams
< 4 hours: no redose required
Usual: 60 min Optimal: 60 min
Ciprofloxacin 400 mg IV N/A 4 - 8 hours: 200mg NO N/A N/A
Minimum 60 min Minimum : 30 min
> 8 hours: 400mg
< 2 hours: no redose required
600 mg IV (< 60kg) Usual: 30 min Optimal: 30 min
Clindamycin 10 mg/kg 2 - 4 hours: 300 mg YES 6 hours 300 mg
900 mg IV (≥ 60 kg) Minimum 30 min Minimum : 15 min
> 4 hours: 600 mg
120 mg (< 60 kg) < 2 hours: no redose required
Usual: 30 min Optimal: 30 min
Gentamicin 160 mg (60-80 kg) 2.5 mg/kg 2 - 4 hours: 80 mg NO N/A 80 mg
Minimum 15 min Minimum : 15 min
240 mg (> 80 kg) > 4 hours: Full dose
< 2 hours: no redose required
Gentamicin 100 mg (≤ 80 kg) Usual: 30 min Optimal: 30 min
N/A 2 - 4 hours: 80 mg NO N/A 80 mg
(C-Section only) 120 mg (> 80 kg) Minimum 15 min Minimum : 15 min
> 4 hours: Full dose
Usual: 60 min Optimal: 30 min < 6 hours: no redose required
Metronidazole 500 mg IV 15 mg/kg NO 6 hours 500 mg
Minimum 30 min Minimum : 15 min ≥ 6 hours: 500 mg
1 grams IV (≤ 80 kg) Prophylaxis Only
1 g = 90 min Optimal: 90 min
Vancomycin 1.5 grams IV (> 80kg) 15 mg/kg < 4 hours: no redose required YES N/A 500 mg
1.5 g = 120 min Minimum : 45 min
(Post-op dose: 1 gram) ≥ 4 hours: 500 mg
Therapeutic Antibiotics
Ampicillin-
Should NOT be used routinely for GI or GU procedures due to high rates of resistance with Escherichia coli (>40% resistance at SMH)
Sulbactam
< 3 hours: no redose required
Optimal: 30 min
Cefepime 2 grams IV 50 mg/kg Usual: 30 min 3 - 6 hours: 1 gram YES 6 hours 1 gram
Minimum: 15 min
> 6 - 12 hours: 2 grams
Optimal: 30 min < 8 hours: no redose required
Ceftriaxone 2 grams IV 50 mg/kg Usual: 30 min YES N/A 1 gram
Minimum: 15 min ≥ 8 hours: 1 gram
Optimal: 30 min < 12 hours: no redose required
Ertapenem 1 gram IV 15 mg/kg Usual: 30 min YES N/A N/A
Minimum: 15 min ≥ 12 hours: 1 gram
Optimal: 30 min < 3 hours: no redose required
Meropenem 500 mg IV 20 mg/kg Usual: 30 min YES 3 hours 500 mg
Minimum : 15 min ≥ 3 hours: 500 mg
Piperacillin/Tazo 100/12.5 Optimal: 30 min < 3 hours: no redose required
3.375 grams IV Usual: 30 min YES 2 hours 3.375 grams
(Zosyn) mg/kg Minimum : 15 min ≥ 3 hours: 3.375 grams
Vancomycin Patients on therapeutic vancomycin should be redosed based on the EMAR schedule 500 mg

Reviewed by Jamie Kisgen, PharmD, BCPS(AQ-ID), Megan Seddon, PharmD, Eric Chernin, RPh, Julie Larkin, MD Last Updated 10/2018
 Antibiotic Prophylaxis for Inpatient and Outpatient Surgery
Table 3: Antimicrobial Prophylaxis Renal Dosing Post-Op Protocol
Usual Post-op Type of
Drug CrCl > 60 mL/min CrCl 30 – 60 ml/min CrCl 10 – 29 ml/min CrCl < 10 or HD
Adult Dose Procedure
1 gram x 1 dose 12 No Post-op Dose
Aztreonam 2 grams All 2 grams q8h x 2 doses
hours after the last dose Required
Non-cardiac or 1 gram x 1 dose 12 No Post-op Dose
1 gram q8h x 2 doses
1 gram Cardiac Minor hours after the last dose Required
Cefazolin Cardiac 1 gram q8h x 5 doses 1 gram x 1 dose 24
1 gram q12h x 3 doses hours after last
2 grams Bariatric 2 grams q8h x 2 doses 1 gram q8h x 2 doses operative dose
Non-cardiac 1.5 grams x 1 dose 12 hours after the last dose No Post-op Dose Required
Cefuroxime 1.5 grams IV 1.5 grams q12h x 3 1.5 grams q12h 1.5 grams x 1 dose 24 hours after last operative
Cardiac
doses x 3 doses dose
Urology 400 mg q12h – duration per urology 400 mg q24h – duration per urology
Ciprofloxacin 400 mg IV 400 mg x 1 dose 12 hours after the last operative
Non-Urology No Post-op Dose Required
dose
600 mg IV (< 60kg) 600 - 900 mg q8h x 2 No adjustment required unless CrCl < 10 AND patient has hepatic failure,
Clindamycin All
900 mg IV (≥ 60 kg) doses then dose should be adjusted to 300 mg IV q8h x 2 doses

Non-cardiac No Post-op Dose Required

120 mg (< 60 kg)
Gentamicin 160 mg (60-80 kg) CrCl ≥ 40 ml/min: CrCl < 40 ml/min: No Post-op Dose Required
240 mg (> 80 kg) Cardiac Weight based dose x 1 dose 12h from last
operative dose
No adjustment required unless CrCl < 10 AND patient has hepatic failure,
Metronidazole 500 mg IV All 500 mg q8h x 2 doses
then dose should be adjusted to 500 mg IV 12h x 1 dose
1 gram x 1 dose 12 hours
Non-cardiac or
after the last operative No Post-op Dose Required
Cardiac Minor No Post-op Dose
Vancomycin 1 gram dose
Required
1 gram x 1 dose 24 hours after
Cardiac 1 gram q12h x 3 doses
the last operative dose

Reviewed by Jamie Kisgen, PharmD, BCPS(AQ-ID), Megan Seddon, PharmD, Eric Chernin, RPh, Julie Larkin, MD Last Updated 10/2018
 Antibiotic Prophylaxis for Inpatient and Outpatient Surgery
Table 4: Y-site Compatibility

Y-site Compatibility Chart for Common Antibiotics

Lactated Ringers

Dexamethasone
Metronidazole

Normal Saline
Azithromycin

Ciprofloxacin

Vancomycin
Clindamycin

Tazobactam
Piperacillin/
Ceftriaxone

Gentamicin
Aztreonam

Ertapenem
Cefepime
Cefazolin

D5W
Azithromycin (Zithromax) C C C C C C C C C
Aztreonam (Azactam) C C C C C C C I C I C C C C
Cefazolin (Ancef) C C C C C C I C C C C
Cefepime (Maxipime) C C I C C C C C C C
Ceftriaxone (Rocephin) C C I C C I C C I C
Ciprofloxacin (Cipro) C I C C I C C C C I
Clindamycin (Cleocin) C C I C C C C C C C C
Ertapenem (Invanz) C C C C C C I C C
Gentamicin C C C C C C C C C C C I
Metronidazole (Flagyl) C I C C C C C C C C C C C C C
Piperacillin/Tazo (Zosyn) C C I C C C C C C
Vancomycin C I I C I C C C C C C C C C C

C Compatible I Incompatible Not tested

Reviewed by Jamie Kisgen, PharmD, BCPS(AQ-ID), Megan Seddon, PharmD, Eric Chernin, RPh, Julie Larkin, MD Last Updated 10/2018
 Antibiotic Prophylaxis for Inpatient and Outpatient Surgery
Allergies:
 Any allergy to Cephalosporins (including itching/rash) will contraindicate the use of Cephalosporins for surgical prophylaxis unless reported as GI/upset stomach
 If the patient experienced ITCHING/ RASH ONLY with a penicillin, it is okay to give a cephalosporin (LOW RISK OF CROSS REACTION)
 If the patient experienced a penicillin allergy that includes any of the following, it will contraindicate the use of a cephalosporin (RISK OUTWEGHS BENEFIT):
 A penicillin allergy reported but the reaction is “unknown” and the patient and/or caregiver is unable to recall with prompting
 Respiratory difficulty (ex. trouble breathing, SOB, chest tightness)
 Angioedema (swelling of tongue, lip, etc)
 Hypotension / Anaphylaxis/ Hives
Note: If patient reports a reaction of hives, please have patient or patient surrogate identify their reaction using the examples depicted below. If the patient identifies
their “hives” as rash, clarify this with physician, as the patient may be able to receive a cephalosporin.

Differences in

Rash
1 4

VS.

2 Hives 5

3 6

Reviewed by Jamie Kisgen, PharmD, BCPS(AQ-ID), Megan Seddon, PharmD, Eric Chernin, RPh, Julie Larkin, MD Last Updated 10/2018