What are the current guidelines for surgical and perioperative antibiotic prophylaxis?

From the Guidelines

Current surgical antibiotic prophylaxis guidelines recommend administering antibiotics within 60 minutes before surgical incision, with the most recent and highest quality study suggesting administration within 120 min prior to the incision for certain antibiotics, such as vancomycin and fluoroquinolones 1.

Key Recommendations

• Antibiotic prophylaxis should be administered for operative procedures that have a high rate of postoperative surgical site infection, or when foreign materials are implanted 1.
• A single dose is generally sufficient, with additional doses administered intraoperatively for procedures > 2–4 h or with associated significant blood loss (> 1.5 L) 1.
• There is no evidence to support the use of postoperative antibiotic prophylaxis 1.

Choice of Antibiotic

• Cefazolin is the recommended first-line prophylaxis for most clean procedures 1.
• Patients with beta-lactam allergies should receive clindamycin or vancomycin 1.
• For procedures involving the gastrointestinal tract, cefazolin plus metronidazole or cefoxitin alone is appropriate 1.

Timing and Redosing

• Antibiotic prophylaxis should be administered within 120 min prior to the incision, with administration of the first dose beginning within 30–60 min before the surgical incision recommended for most antibiotics 1.
• Redosing is necessary during longer procedures, with the frequency depending on the antibiotic used 1.

Institution-Specific Guidelines

• Each institution is encouraged to develop guidelines for the proper surgical prophylaxis, taking into account local epidemiology and resistance patterns 1.

From the FDA Drug Label

To prevent postoperative infection in contaminated or potentially contaminated surgery, recommended doses are: 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery. For lengthy operative procedures (e.g., 2 hours or more), 500 mg to 1 gram IV or IM during surgery (administration modified depending on the duration of the operative procedure). 500 mg to 1 gram IV or IM every 6 to 8 hours for 24 hours postoperatively It is important that (1) the preoperative dose be given just (1/2 to 1 hour) prior to the start of surgery so that adequate antibiotic levels are present in the serum and tissues at the time of initial surgical incision; and (2) cefazolin for injection be administered, if necessary, at appropriate intervals during surgery to provide sufficient levels of the antibiotic at the anticipated moments of greatest exposure to infective organisms. In surgery where the occurrence of infection may be particularly devastating (e.g., open-heart surgery and prosthetic arthroplasty), the prophylactic administration of cefazolin for injection may be continued for 3 to 5 days following the completion of surgery.

The current guidelines for surgical and perioperative antibiotic prophylaxis using Cefazolin are:

• Preoperative dose: 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery
• Intraoperative dose: 500 mg to 1 gram IV or IM during surgery for lengthy operative procedures
• Postoperative dose: 500 mg to 1 gram IV or IM every 6 to 8 hours for 24 hours postoperatively
• Extended prophylaxis: may be continued for 3 to 5 days following the completion of surgery in certain cases, such as open-heart surgery and prosthetic arthroplasty 2

From the Research

Current Guidelines for Surgical and Perioperative Antibiotic Prophylaxis

The current guidelines for surgical and perioperative antibiotic prophylaxis are as follows:

• Prophylaxis is uniformly recommended for all clean-contaminated, contaminated, and dirty procedures 3.
• It is considered optional for most clean procedures, although it may be indicated for certain patients and clean procedures that fulfill specific risk criteria 3.
• The first dose of antibiotic should be given before the procedure, preferably within 30 minutes before incision 3, or within 60 minutes prior to incision as recommended by the Center for Disease Control and Prevention (CDC) guidelines 4.
• Readministration at one to two half-lives of the antibiotic is recommended for the duration of the procedure 3.
• Postoperative administration is not recommended in general 3, and continuing antibiotic prophylaxis into the postoperative period can lead to increased toxicity, bacterial superinfections, and antibiotic resistance 5.

Antibiotic Selection

• Antibiotic selection is influenced by the organism most commonly causing wound infection in the specific procedure and by the relative costs of available agents 3.
• Cefazolin provides adequate coverage for most types of procedures 3, 6, although it may not be suitable for colorectal procedures or obstetric/gynecologic surgery that requires anti-anaerobic coverage 6.
• Glycopeptides might have a role for major prosthetic surgery in units with a high prevalence of methicillin-resistant Staphylococcus aureus 6.

Special Considerations

• Patient already receiving antibiotics or carrying resistant germs, clinicians' misunderstanding about timing and duration of antibiotic prophylaxis, or patient history of penicillin allergy can threaten the proper application and effectiveness of surgical antibiotic prophylaxis 7.
• Individual risk factors for surgical site infections (SSI) must be assessed before any surgical procedure, including body-mass index and immunosuppression 5.
• Perioperative antibiotic prophylaxis is clearly indicated for operations that carry a high risk of SSI, such as colorectal surgery, and for those that involve the implantation of alloplastic material, such as hip endoprostheses 5.