What is the recommended antibiotic prophylaxis for cardiac surgery?

From the Guidelines

Antibiotic prophylaxis should be considered for patients undergoing implantation of a prosthetic valve, any type of prosthetic graft, or pacemakers, as recommended by the 2015 ESC guidelines 1. The goal of antibiotic prophylaxis in cardiac surgery is to prevent surgical site infections, which can significantly impact morbidity, mortality, and quality of life.

• The standard regimen typically includes cefazolin (Ancef) 2g IV within 60 minutes before surgical incision, with redosing every 4 hours during prolonged procedures and a final dose 24 hours after surgery.
• For patients with beta-lactam allergies, vancomycin 15mg/kg IV (maximum 2g) is the preferred alternative, started 60-120 minutes before incision.
• Patients with MRSA colonization should receive both cefazolin and vancomycin.
• The choice of antibiotic prophylaxis should be based on the most recent and highest quality evidence, which in this case is the 2015 ESC guidelines 1.
• It is essential to note that the guidelines recommend considering perioperative antibiotic prophylaxis for specific cardiac surgeries, but the specific regimen and duration may vary depending on the institution and the patient's individual risk factors.
• Proper timing of administration is critical for achieving adequate tissue concentrations during the procedure, and prophylaxis should be discontinued after 24-48 hours to minimize antibiotic resistance development, Clostridioides difficile infections, and other adverse effects.
• The antibiotics used for prophylaxis target the most common pathogens in cardiac surgery infections, including Staphylococcus aureus, coagulase-negative staphylocci, and gram-negative organisms.

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. 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 recommended antibiotic prophylaxis for cardiac surgery is 1 gram of cefazolin administered IV or IM 1/2 hour to 1 hour prior to the start of surgery. In cardiac surgery, the prophylactic administration of cefazolin may be continued for 3 to 5 days following the completion of surgery 2.

From the Research

Recommended Antibiotic Prophylaxis for Cardiac Surgery

The recommended antibiotic prophylaxis for cardiac surgery includes:

• Cephalosporins, such as cefazolin, as the first-line antibiotic prophylaxis to prevent surgical site infection (SSI) 3, 4, 5
• Vancomycin, often in combination with other antibiotics, as an alternative or second-line prophylaxis 3, 4, 5, 6

Key Considerations

Key considerations for antibiotic prophylaxis in cardiac surgery include:

• The timing of administration, with evidence suggesting that administration within 30-60 minutes before the incision is optimal 4
• The duration of prophylaxis, with some studies suggesting that longer-term prophylaxis (≥24 hours) may be more effective in preventing sternal SSIs 7
• The choice of antibiotic, with cefazolin and vancomycin being commonly used options 3, 4, 5, 6

Specific Antibiotic Regimens

Specific antibiotic regimens that have been studied include:

• Cefazolin 30 mg/kg infused over 10 minutes, repeated every 4 hours 6
• Vancomycin 15 mg/kg infused over 1 hour, repeated every 12 hours 6
• Combination regimens, such as vancomycin and gentamicin 3 or vancomycin and cefuroxime 4