Operation
Recommended drugs
Dose
All major vascular
surgery requiring
grafts or a groin
incision
cefazolin
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg IV
All carotid
procedures
cefazolin
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg IV
Mediport insertion cefazolin
Hickman insertion
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg IV
Vascular surgery:
Venous closure
(Varicose veins)
cefazolin
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg IV
cefazolin
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg IV
Neurosurgery:
Craniotomy and
open procedures
on the spine,
including
laminectomy
Orthopedics (excluding podiatry):
Osteotomy, total
joint replacement,
open reduction,
internal fixation
of fractures, open
procedures on
spine including
laminectomy,
arthroscopy of
joint, repair or
reconstruction of
any joint, removal
of external
fixator hardware
Cefazolin
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg IV
Revision of total
joint replacement
cefazolin
1-2 gm IV
AFTER THE JOINT SPACE IS CULTURED
or clindamycin
600-900 mg IV
for allergic patients
Podiatry:
Bunionectomy,
I&D of foot,
Cefazolin
or clindamycin
1-2 gm IV
600-900 mg IV
Lapidus procedure
open reduction,
internal fixation,
excision of bone,
tarsal tunnel
release
for allergic patients
Plastic surgery:
Abdominoplasty,
breast implant,
breast
reconstruction,
face lift,
excision of
hydradentitis,
liposuction,
mammoplasty
Cefazolin
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg IV
Ophthalmology:
Per surgeon
Topical antibiotic
General surgery:
Herniorrhaphy
when mesh is
utilized
cefazolin
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg IV
Breast surgery
which involves
needle
localization
cefazolin
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg IV
Splenectomy
cefazolin
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg IV
Biliary and
gastroduodenal
cefazolin
or clindamycin
and gentamicin
for allergic patients
1-2 gm IV
600-900 mg IV
1.7 mg/kg IV*
Gastric bypass
cefazolin
or clindamycin
and gentamicin
for allergic patients
2 gm IV
600-900 mg IV
1.7 mg/kg IV*
Colorectal
Oral prophyaxis:
neomycin and erythromycin base 1 gm of
during
day PO
2, and
each
pre-op
at 1,
11 pm
Parenteral prophylaxis:
2
Appendectomy
Ampicillin-sulbactam
3 gm IV
or metronidazole
and ciprofloxacin
for allergic patients
500 mg IV
400 mg IV
ampicillin-sulbactam
or clindamycin
and gentamicin
for allergic patients
1-2 gm IV
600-900 mg IV
1.7 mg/kg IV*
Oral surgery:
Per surgeon
Urology:
Bladder suspension cefazolin
(Slings, TVTs)
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg
Radical
Prostatectomy
cefazolin
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg
Lithotripsy
ciprofloxacin
or ampicillin-sulbactam
for allergic patients
400 mg IV
1-2 gm IV
Otolaryngoscopy:
Per surgeon
Thoracic surgery:
Thoracotomy,
cefazolin
Pleurodesis,
or clindamycin
Esophagogastrectomy for allergic patients
Lung resection,
1-2 gm IV
600-900 mg IV
Cardiology:
Pacemaker
cefazolin
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg IV
Gynecology:
Hysterectomy,
vaginal and
abdominal
cefazolin or
clindamycin with
gentamicin
for allergic pts.
1 gm IV
600-900 mg
1.7 mg/kg*
3
Bladder suspension cefazolin
(Slings, TVTs)
or clindamycin
for allergic patients
1-2 gm IV
600-900 mg
D&C’s following
Missed abortions
or terminations.
doxycycline
for allergic patients
consult gynecologist
100 mg IV
cefazolin
or clindamycin
and gentamicin
for allergic pts
1-2 gm IV
600-900 mg
1.7 mg/kg*
Obstetrics:
Cesarean section
NB: Use of the Group B Strep. Protocol during labor is not sufficient for
maternal wound prophylaxis
* Maximum dose = 200 mg
4
NEWTON-WELLESLEY HOSPITAL
NEWTON, MASSACHUSETTS
EFFECTIVE DATE:
01/09
POLICY TYPE: ADMIN
CLINICAL
DEPARTMENTAL
X-IC
PROPHYLACTIC ANTIBIOTICS IN ELECTIVE SURGERY, ADMINISTRATION OF
PURPOSE: The purpose of this policy is to define guidelines for the
selection and timely administration of prophylactic antibiotics to all
patients undergoing elective surgery.
SCOPE: This policy applies to anesthesiologists, surgeons, and
obstetricians caring for patients undergoing elective surgery and
requiring administration of prophylactic antibiotics.
POLICY & PROCEDURE STATEMENT: Newton-Wellesley Hospital supports optimum
patient care by defining guidelines for the timely administration of
prophylactic antibiotics.
DEFINITIONS:
Prophylactic antibiotic - an antibiotic administered in the absence of
infection, for the purpose of preventing bacterial infection.
Protocol - a predetermined set of antibiotic choices, doses, and
administration times for patients having elective surgery selected on the
basis of published studies or a strong theoretical rationale.
PROCESS:
I.
II.
Patients having the operations identified in Attachment I should
routinely receive the recommended prophylactic antibiotics in the
absence of a specific order to the contrary.
The only exception to the recommended timing of antibiotic
administration is for:
A.
Revision of joint prostheses, for which antibiotics are
administered after a culture has been obtained;
III.
Surgeons who do not want the antibiotic guidelines followed must
write an order and inform the anesthesia team that no antibiotic
prophylaxis is to be given or that an alternative is to be
substituted for the protocol drug.
IV.
The Medical Letter on Drugs and Therapeutics and the Surgical
Infection Prevention Guideline were used as the primary references
for Attachment I. However, there may be some differences between
the Guidelines and the Appendix that are based on recommendations by
the Infectious Disease Service.
V.
Because of concern about development of vancomycin resistance in the
hospital, and, because of difficulties with administration of
vancomycin by rapid intravenous infusion, the Infection Control
Committee has recommended and the Executive Committee of the Medical
5
Staff has approved an alternative antibiotic for most patients who
are allergic to penicillins and cephalosporins. Clindamycin will be
administered rather than vancomycin. Prophylaxis with vancomycin
should be considered for patients who are receiving orthopedic
prostheses and are known to be colonized by methicillin-resistant
Staph. Aureus. Preoperative consultation with the Infectious
Diseases service is encouraged for such patients.
VI.
If the patient requires endocarditis prophylaxis an endocarditis
prophylaxis protocol will be followed and surgical prophylaxis will
be overridden. Please see Attachment II for Endocarditis
Prophylaxis.
VII.
Please see Attachment III, Selection of Antibiotics for a discussion
of the management of penicillin allergic patients.
VIII. Calculation of dose by weight:
A.
When 1-2 gm is the recommended dose, 1 gram will be given if the
patient weighs 50-80 kg and 2 grams will be given if the patient
weighs more than 80 kg.
B.
When 600 - 900 mg is the recommended dose, 600 mg will be given
if the patient weighs 50-80 kg and 900 mg will be given if the
patient weighs more than 80 kg
C.
Recommended antimicrobials for pediatric patients are the same
as for adults. Pediatric dosages should be adjusted on a weight
basis and guidelines can be found in Appendix IV.
IX.
Unless stated otherwise, prophylactic antibiotics should be
administered within 1 hour prior to incision.
POLICY REVISIONS:
I.
II.
These policies and appendices will be reviewed by the Infection
Control Committee and the Department of Anesthesiology at least once
every three years.
Interim changes to the policy, such as addition, deletion, or
modification of items contained in Attachment I, must be proposed by
the Chairs or Chiefs of the relevant services and approved by the
Infection Control Committee and the Department of Anesthesiology.
REFERENCES:
Current Joint Commission Standards
The Medical Letter on Drugs and Therapeutics, 2002
Hospital Infection Control Practices Advisory Committee. Recommendations
for preventing the spread of vancomycin resistance. Infect Control Hosp
Epidemiol 1995; 16(2):105-13.
Hospital Infection Control Practices Advisory Committee. Guideline for
Prevention of Surgical Site Infections. Infect Control Hosp Epidemiol
1999; 20(4):247-78.
American Academy of Pediatrics, The Red Book, 2002
Rx Epocrates
6
Surgical Infection Prevention Guideline:
ORIGINATOR:
Director of Infection Control and Epidemiology
ORIGINATION DATE:
SPONSOR:
2006
01/08/96
Direction of Infection Control
COLLABORATORS:
Chairman, Department of Anesthesia
Chairman, Department of Surgery
Chairman, Department of Obstetrics-Gynecology
Chief of Infectious Diseases
Infection Control Committee
REVIEWED:
2/17/04
REVISED:
03/01/96
03/15/96
04/10/96
12/10/96
09/11/97
10/31/97
11/24/97
05/04/98
05/20/98
06/29/98
08/28/98
10/20/98
04/01/99
CROSS-REFERENCES:
05/28/99
09/16/99
10/19/99
05/03/00
11/05/01
02/22/05
04/07/06
12/12/06
10/28/08
01/09
N/A
APPROVED BY:
Patient Services Executive Committee
05/10/06, 12/10/08
Executive Committee of the Medical Staff
05/16/06; 12/17/08
Infection Control Committee
10/28/08
CANCELLATION:
EFFECTIVE:
N/A
08/03/06
KEY SEARCH WORDS: Infection control, prophylactic, antibiotic, IC,
administration of prophylactic, elective surgery
ATTACHMENTS:
Attachment I:
Attachment II:
Attachment III:
Attachment IV:
List of Recommended Drugs
Endocarditis Prophylaxis
Selection of Antibiotics for Surgical Prophylaxis in
penicillin – Allergic Patients
Pediatric doses for recommended antibiotics
7
Endocarditis Prophylaxis
For dental procedures, procedures that involve the manipulation of
gingival tissue, periapical region of teeth or perforation of the oral
mucosa or procedures that involve incision or biopsy of the respiratory
tract:
Endocarditis prophylaxis is now recommended only for the following cardiac
conditions:
1.
Prosthetic cardiac valve
2.
Previous history of infective endocarditis
3.
Some forms of congenital heart disease (unrepaired cyanotic CHD,
completely repaired CHD with prosthetic material or device for 6
months, repaired CHD with residual defects at site or adjacent to
site of prosthetic patch or device)
4.
Cardiac transplantation recipients who develop cardiac valvulopathy.
Genitourinary or gastrointestinal procedures:
Endocarditis prophylaxis is no longer routinely recommended.
For procedures on infected skin or musculoskeletal structures:
Endocarditis prophylaxis is recommended for patients listed above
Table 1. Antibiotic Regimens for Infective Endocarditis Prophylaxis
Situation
Agent
Adults
Children
2 g
50 mg/kg
2 g
50 mg/kg
600 mg
20 mg/kg
500 mg
15 mg/kg
Ampicillin
2 g Im or IV
50 mg/kg IM or IV
Cefazolin; or
1 g IM or IV
25 mg/kg IM or IV
600 mg IM or IV
20 mg/kg IM or IV
Oral
Amoxicillin
Penicillin or
ampicillin
allergic- oral
route
Cephalexin*#;
Unable to take
oral
Penicillin or
ampicillin
allergic and
unable to take
oral medication
*
Regimen: Single dose 30 to 60 minutes
before dental procedure
or
Clindamycin; or
Azithromycin or
clarithromycin.
Clindamycin
Or other first –or second- generation oral cephalosporin in equivalent
adult or pediatric dosage.
8
#
Cephalosporins should not be used in an individual with history of
anaphylaxis, angioedema, or urticaria with penicillins or ampicillin.
References:
1. Wilson, W. et al. Prevention of Infective Endocarditis – Guidelines
from the American Heart Association. Circulation (online
publication); April 19, 2007 found at
http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095
9
SELECTION OF ANTIBIOTICS FOR SURGICAL PROPHYLAXIS IN PENICILLIN – ALLERGIC
PATIENTS
1.
If the patient has had adverse reactions to cephalosporins(1) in the
past, administer alternative prophylaxis (2).
2.
If neither the patient nor the medical record reports a history of
allergy to penicillins, administer standard cephalosporin
prophylaxis. (3)
3.
If the patient or the medical record reports an allergy to
penicillins, the nature of the reaction must be investigated:
If the reaction to penicillin was a maculopapular rash or was of
a non-allergic nature (4), ask if the patient has tolerated
cephalosporins (1) in the past without adverse effects:
If the patient has tolerated cephalosporins in the past, or
cannot recall receiving cephalosporins in the past, administer
standard cephalosporin prophylaxis.
If the nature of the reaction to penicillins suggests anaphylaxis
or immediate-type (IgE-mediated) hypersensitivity - DO NOT
ADMINISTER CEPHALOSPORINS OR PENICILLINS. Administer alternative
prophylaxis (2).
Footnotes:
(1)
e.g., Keflex, Ceclor, Kefzol, Mefoxin, Ceftin (cephalexin, cefaclor,
cefazolin, cefoxitin, cefuroxime).
(2)
Usually clindamycin
(3)
Usually, cefazolin for general, gynecological, vascular, and
orthopedic surgery; ampicillin-sulbactam (Unasyn) for colon surgery.
(See the Protocol Table above.)
(4)
e.g., nausea, vomiting, headache, non-specific symptom
10
Pediatric doses for recommended antibiotics
Agent
Dose
Cefazolin
Cefuroxime
Clindamycin
Erythromycin base
Gentamicin
Neomycin
Vancomycin
20 mg/kg
35 mg/kg
10 mg/kg
20 mg/kg
2.5 mg/kg
25 mg/kg (3 doses 1 day before surgery)
20 mg/kg (max. 1000 mg)
11