HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA

PERI-OPERATIVE ANTIBIOTIC PROPHYLAXIS

***Please note that the Surgical and Anesthesiology Teams MUST discuss prophylaxis for procedures not listed below, as well as for patients currently receiving antibiotics for active infections.***

Pre-operative Antibiotic Dosing for Cardiac Surgery Patients

Weight (kg)	Cefazolin	Vancomycin	Gentamicin	Levofloxacin	Cefepime
< 80	2 g	1 g	4 mg/kg total body weight	500 mg	1 g
81-109	2 g	1.5 g	4 mg/kg total body weight	500 mg	1 g
> 110	2 g	2 g	4 mg/kg total body weight	500 mg	2 g

• For all antibiotics EXCEPT vancomycin, doses should be administered within 60 minutes prior to initial surgical incision. If vancomycin is required for prophylaxis, it should be administered within 2 hours prior to initial surgical incision.
• For cefazolin, redosing should occur if surgery lasts > 4 hours (2 half-lives).
• The following antibiotics should redosed upon discontinuation of cardiopulmonary bypass: vancomycin, cefazolin, cefepime, and levofloxacin.
• Note: gentamicin DOES NOT need to be redosed upon discontuation of bypass.
• Patients who do not undergo cardiopulmonary bypass do not need redosing of antibiotics unless duration of the procedure warrants.

Antibiotic Prophylaxis Recommendations by Procedure Post-operative Dosing

Cardiothoracic Surgery

Procedure	Antimicrobial Agent(s)	Alternative in β-lactam Allergic Patient1	Duration after Surgery
Median sternotomy2	cefazolin4 500 mg IV q8h plus vancomycin IV (see vancomycin nomogram)	vancomycin IV (see vancomycin nomogram) plus gentamicin IV (see gentamicin nomogram)	x 48 hours
Heart transplant, VAD placement	cefazolin4 500 mg IV q8h plus vancomycin IV (see vancomycin nomogram)	vancomycin IV (see vancomycin nomogram) plus levofloxacin4 500 mg IV q24h	x 48 hours
Lung transplant3(non-infected)	vancomycin (see vancomycin nomogram) plus cefepime4 1000 mg IV q12h	vancomycin IV (see vancomycin nomogram) plus levofloxacin4 500 mg IV q24h	x 48 hours

¹ Cefazolin (or cefepime in the case of lung transplantation) should be administered unless there is a history of immediate-type hypersensitivity (i.e. hives, shortness of breath, anaphylaxis) to penicillins or cephalosporins.

² Patients with or at high risk for post-operative renal insufficiency may receive vancomycin + levofloxacin post-operatively x 48 hours. Criteria include: pre-operatively SCr > 1.5 mg/dL, cardiogenic shock, CPB > 5 hours, high dose inotropes and vasopressors (epinephrine + milrinone, +/- norepinephrine, vasopressin, phenylephrine, IABP).

³ Lung transplant patients who are infected should receive antibiotics based on pre-operative gram stains and cultures in recipient and donor.

⁴ Dose adjustment is required for renal insufficiency. See the following link for recommendations: www.uphs.upenn.edu/bugdrug/antibiotic_manual/renal.htm

 

Pre-operative Antibiotic Dosing for Non-cardiac Surgery Patients

Weight (kg)	Cefazolin	Vancomycin	Gentamicin	Metronidazole	Levofloxacin	Cefepime	Clindamycin
< 80	1 g	1 g	3 mg/kg total body weight	500 mg	500 mg	1 g	600 mg
81-109	1 g	1.5 g	3 mg/kg total body weight	500 mg	500 mg	1 g	600 mg
> 110	2 g	2 g	3 mg/kg total body weight	500 mg	500 mg	2 g	600 mg

• For all antibiotics EXCEPT vancomycin, doses should be administered within 60 minutes prior to initial surgical incision. If vancomycin is required for prophylaxis, it should be administered within 2 hours prior to initial surgical incision.
• For cefazolin and clindamycin, redosing should occur if surgery lasts > 4 hours (2 half-lives).
• Maximum gentamicin dose is 500 mg.

Antibiotic Prophylaxis Recommendations by Procedure

Electrophysiology

Procedure	Antimicrobial Agent(s)	Alternative in β-lactam Allergic Patient	Duration after Surgery
AICD and pacemaker placement	cefazolin 500 mg IV q8h	vancomycin IV (see vancomycin nomogram)	x 24 hours

Vascular

Procedure	Antimicrobial Agent(s)	Alternative in β-lactam Allergic Patient	Duration after Surgery
All procedures	cefazolin 500 mg IV q8h	vancomycin IV (see vancomycin nomogram)	x 24 hours

Orthopaedics

Procedure	Antimicrobial Agent(s)	Alternative in β-lactam Allergic Patient	Duration after Surgery
Insertion of prosthetic joints, open operations	cefazolin 500 mg IV q8h	vancomycin (see vancomycin nomogram)	x 24 hours
Other	Post-operative antibiotics are not recommended for this procedure		none

Head and Neck

Procedure	Antimicrobial Agent(s)	Alternative in β-lactam Allergic Patient	Duration after Surgery
Operations involving the mucous membranes and deep tissues	cefazolin 1 g IV q8h + metronidazole 500 mg IV q12h	clindamycin 600 mg IV q8h + gentamicin (see gentamicin nomogram)	x 24 hours

Thoracic Surgery

Procedure	Antimicrobial Agent(s)	Alternative in β-lactam Allergic Patient	Duration after Surgery
General thoracic: pulmonary and esophageal	Post-operative antibiotics are not recommended for this procedure		none

Neurosurgery

Procedure	Antimicrobial Agent(s)	Alternative in β-lactam Allergic Patient	Duration after Surgery
All procedures	Post-operative antibiotics are not recommended for this procedure		none

General Surgery

Procedure	Antimicrobial Agent(s)	Alternative in β-lactam Allergic Patient	Duration after Surgery
Gastroduodenal: procedures involving entry into lumen of gastrointestinal tract	Post-operative antibiotics are not recommended for this procedure		none
Cholecystectomy (open or laparoscopic)	Post-operative antibiotics are not recommended for this procedure		none
Biliary tract surgeries: all open and laparoscopic procedures, chronically intubated biliary tract	Post-operative antibiotics are not recommended for this procedure		none
Bariatric surgery	Post-operative antibiotics are not recommended for this procedure		none
Hernia repair without MESH	Post-operative antibiotics are not recommended for this procedure		none
Hernia repair with MESH	cefazolin 500 mg IV q8h	vancomycin (see vancomycin nomogram)	x 24 hours
Gastrostomy or jejunostomy (open or endoscopic) tube placement	Post-operative antibiotics are not recommended for this procedure		none
Appendectomy: simple appendicitis (antibiotics are empiric or definitive for complicated appendicitis)	Post-operative antibiotics are not recommended for this procedure		none
Abdominal trauma	Post-operative antibiotics are not recommended for this procedure		none
Colorectal: operations that open the colon and/or rectum	Post-operative antibiotics are not recommended for this procedure		none
Breast augmentation5	cefazolin6 500 mg IV q8h	vancomycin7 (see vancomycin nomogram)	x 24 hours
Mastectomy with tissue expanders5	cefazolin6 (500 mg IV q8h)	vancomycin7 (see vancomycin nomogram)	x 24 hours
Tunneled central venous catheter placement (Hickman, Port-a-cath, Medcomp)	Post-operative antibiotics are not recommended for this procedure		none
Liver transplant	ampicillin/sulbactam 1.5 g IV q6h	levofloxacin 500 mg IV q24h +/- metronidazole 500 mg IV q12h	x 24 hours

Gynecologic Surgery

Procedure	Antimicrobial Agent(s)	Alternative in β-lactam Allergic Patient	Duration after Surgery
Cesarean section	Post-operative antibiotics are not recommended for this procedure		none
Hysterectomy	Post-operative antibiotics are not recommended for this procedure		none

Urologic Surgery⁵

Procedure	Antimicrobial Agent(s)	Alternative in β-lactam Allergic Patient	Duration after Surgery
Transrectal prostate biopsy	Post-operative antibiotics are not recommended for this procedure		none
Radical prostatectomy	cefazolin 500 mg IV q8h	trimethoprim/sulfamethoxazole160 mg/800 mg IV/PO q12h or levofloxacin 500 mg IV/PO q24h	x 24 hours
Transurethral resection of prostate (TURP): pre-procedure urine infected8	treatment based on culture results		x 7 days
Transurethral resection of prostate (TURP): pre-procedure urine NOT infected9	Post-operative antibiotics are not recommended for this procedure		none
Cystoscopy	Post-operative antibiotics are not recommended for this procedure		none

⁵ Institution specific, not based on guidelines used for other recommendations in this table.

⁶ Followed by cephalexin 500 mg PO q6h.

⁷ Followed by clindamycin 300 mg PO q6h.

⁸ Antibiotics should be tailored to culture and sensitivity results if available.

⁹ No data to support prophylaxis.