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Guidelines
Surgical Prophylaxis

Surgical Prophylaxis

General Principles

  • Antibiotics should be given within 60 minutes prior to the incision
    • Exception: Give vancomycin within 1-2 hours prior to the incision as it must be infused over at least 60 minutes
    • Rapid infusion may cause infusion reactions including chills, fever, tachycardia, hypotension, and flushing ("vancomycin flushing syndrome")
  • If a tourniquet is required, the antibiotics should be infused prior to applying the tourniquet
  • A single dose of an antibiotic that provides adequate tissue concentrations throughout the surgical procedure is sufficient.
  • Intra-operative antibiotics are warranted if:
    • Surgery is prolonged (see link below – recommended re-dosing interval) OR
    • Excessive blood loss OR
    • Factors that might shorten the antibiotic’s half-lives (e.g., extensive burns)
  • Re-administration may not be warranted if factors that might lengthen the antibiotic’s half-lives are present (e.g., patients with renal insufficiency or failure)
  • Only indicated in:
    • Cardiac surgery (48 hours)
    • Spinal surgery (48 hours)
    • Transplant surgery (48 hours)
    • Cochlear implantation (24 hours)
    • Selected other procedures as outlined below
  • If infection is found intra-operatively, use treatment antibiotic doses and duration
  • Prophylaxis should not be prolonged:
    • Even if drains or chest tubes remain in situ
    • Based on open wounds or indwelling catheters

Clinical Considerations

Patients who are on treatment courses of antibiotics at the time of surgery may not require additional prophylactic antibiotics if their treatment regimens already cover the potentially contaminating organisms. If doses are due while a patient is in surgery, ensure they are ordered and administered

In the setting of a confirmed beta-lactam allergy, vancomycin is preferred over clindamycin because 25% of Staphylococcus aureus are resistant to clindamycin

In the case of known colonization with MRSA, vancomycin should be used as surgical prophylaxis. 

Give vancomycin within 1-2 hours prior to the incision as it must be infused over at least 60 minutes
Rapid infusion may cause infusion reactions including chills, fever, tachycardia, hypotension, and flushing ("vancomycin flushing syndrome")

Additional Information

Reference: Bratzler DW et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013;70:195-283.

Revised by: S. Boodhan, K. Timberlake

Approved by: Antimicrobial Advisory Group, 2021; Drugs and Therapeutics Committee, 2021.

Last Updated: 04-20-2022