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

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

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.