General Principles
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The goal of antimicrobial surgical prophylaxis is to achieve serum and tissue antibiotic concentrations that exceed the minimum inhibitory concentrations (MICs) of the majority of organisms likely to be encountered, at the time of the incision and for the duration of the procedure.
Preoperative doses should be given within 60 minutes before incision. For exceptions and administration details, see Pre-Op Antibiotic Administration .
Intraoperative repeat dosing is recommended if prolonged surgical procedure (> 2 half-lives of the antimicrobial), or major blood loss (> 1.5L). See Intraoperative Antibiotic Administration for redosing interval.
Patients receiving therapeutic antimicrobials for an infection before surgery should also be given antimicrobial prophylaxis pre-op to ensure adequate serum and tissue levels of antimicrobials with activity against likely pathogens at the time of incision. If the agents used for treatment are appropriate for surgical prophylaxis, administering an extra dose within 60 minutes prior to surgical incision is sufficient.
Dosing: Recommended adult doses for patients with normal weight and renal function. Refer to Pre-Op Antibiotic Administration for more information.
β-lactam allergy – use ALTERNATIVE REGIMENS if allergy to cefazolin, or severe non-IgE-mediated reaction to any β-lactam (specifically, interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, severe cutaneous reactions [e.g. Stevens-Johnson syndrome, toxic epidermal necrolysis, drug rash with eosinophilia & systemic symptoms]). In the absence of these findings, cefazolin can be used as surgical prophylaxis. See ß-lactam allergy assessment algorithm .
Postoperative doses for prophylaxis are not routinely indicated. If the surgery is contaminated, it should be indicated that the postoperative antibiotic orders are for treatment.
Drains: The practice of continuing antimicrobials started as prophylaxis until all drains/catheters (intravascular or urinary) are removed is not recommended due to lack of evidence, risk of development of antimicrobial resistance or superinfection, and drug toxicity.
MRSA: For patients with known methicillin resistant S. aureus (MRSA) colonization or past infection, consider adding vancomycin to the surgical prophylaxis regimen, particularly when prosthetic material/devices are implanted. Vancomycin alone is less effective than cefazolin for preventing surgical site infections due to methicillin susceptible S. aureus (MSSA).
Patients colonized with antibiotic-resistant organisms (other than MRSA), or immunosuppressed: Consider consultation with Infectious Diseases to tailor antimicrobial surgical prophylaxis.