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Surgical Prophylaxis

Surgical Prophylaxis


Specific antibiotics can be given for certain surgical procedures to reduce the incidence of infection.

This is not meant to replace standard preoperative/operative procedures to reduce infections (i.e. – proper scrubbing, maintenance of sterility, minimal disruption of tissues, hemostasis, etc).

It is recommended to use antibiotic prophylaxis for certain procedures which are clean contaminated (exposure of mucosal surfaces) as well as implantation of medical device to minimize infection rate.

Clinical Considerations

  • It is important to have the blood/tissues have peak/effective antibiotic levels at the time of the incision
  • The optimal timing of the antibiotic administration is within 60 minutes of the incision
  • Since Vancomycin requires a more prolonged administration, it should be started at 2 hours before the incision
  • Weight based dosing should be used to calculate the dosing; patient with weights greater than 120 kg, should be given a higher dose of Cefazolin prior to surgery
  • Prophylaxis should not extend past 24 hours even with indwelling drains
  • Single preoperative dose can be given in most cases providing the adequate levels are maintained during surgery
  • Reduction may reduce the risk of developing post-operative C. difficile

In situations where the blood/levels may not be maintained during surgery, a re-dosing of the antibiotic should be considered:

  • Prolonged surgery where the operative time is greater than 2 half-lives of the antibiotic
  • Excessive intra-operative blood loss with fluid replacement diluting the antibiotic levels
  • In non-penicillin allergic patient, anti-staphylococcal beta-lactams are the preferred agents against methicillin sensitive Staphylococcus aureus (MSSA)
  • There can be a higher failure rate when using Vancomycin alone

Vancomycin should be considered only if there is an increased risk for methicillin resistant Staphylococcus aureus (MRSA):

  • Patient is known to be colonized with MRSA carrier or has increased risk for such as repeat orthopedic/cardiac procedures
  • Based on institutional MRSA rates
  • There should be consideration to add Vancomycin to Cefazolin to maintain optimal coverage for both MSSA and MRSA

Patient undergoing cardiac and orthopedic surgery with documented nasal colonization with MSSA or MRSA should be considered for decolonization:

  • Preoperative intranasal mupirocin
  • Preoperative chlorhexidine showering