What is the recommended dose of cefuroxime (a second-generation cephalosporin) IV for surgical prophylaxis in an adult patient with normal renal function?

Cefuroxime IV Dose for Surgical Prophylaxis

The standard dose of cefuroxime for surgical prophylaxis is 1.5 g IV administered as a single dose within 30-60 minutes before surgical incision, with intraoperative re-dosing of 0.75 g every 2 hours if the procedure is prolonged. 1, 2

Standard Dosing Protocol

• Initial dose: 1.5 g IV slow infusion given 30-60 minutes before the surgical incision 1, 2
• This timing window is critical to ensure adequate serum and tissue concentrations during the period of potential contamination 2
• The infusion must be completed no later than the beginning of the intervention 2

Intraoperative Re-dosing

• Re-dose with 0.75 g IV when surgical duration exceeds 2 hours 1, 2
• Continue re-dosing 0.75 g every 2 hours throughout prolonged procedures 1, 2
• This re-dosing interval is shorter than first-generation cephalosporins (which require re-dosing at 4 hours) due to cefuroxime's pharmacokinetic profile 1

Procedure-Specific Variations

Cardiac Surgery

• Initial dose: 1.5 g IV plus 0.75 g added to cardiopulmonary bypass (CPB) priming solution 2
• Re-inject 0.75 g every 2 hours intraoperatively 2

Thoracic Surgery (Decortication)

• 2 g IV slow infusion as single dose 1
• Re-inject 1 g if duration exceeds 4 hours 1

Gastroduodenal and Biliary Tract Surgery

• 1.5 g IV slow infusion 1
• Re-inject 0.75 g if duration exceeds 2 hours 1

Hernia Repair with Prosthetic Mesh

• 1.5 g IV slow infusion 1
• Re-inject 0.75 g if duration exceeds 2 hours 1

Duration of Prophylaxis

• A single preoperative dose is adequate for most procedures 2
• Maximum duration should not exceed 24 hours postoperatively 2
• Postoperative doses beyond the operative period provide no additional benefit and increase antibiotic resistance risk 2
• The FDA label indicates that for preventive use, 750 mg may be given IV or IM every 8 hours when the procedure is prolonged, but guideline evidence supports limiting prophylaxis to the perioperative period only 3

Special Populations

• Morbidly obese patients (≥120 kg) may require higher doses to achieve adequate tissue concentrations 2
• For patients with renal impairment, dosing adjustments are required for therapeutic use, but prophylactic single-dose regimens typically do not require adjustment 3

Critical Timing Considerations

• Do not administer more than 120 minutes before incision - this is unnecessary and potentially dangerous 2
• Do not administer less than 30 minutes before incision - inadequate tissue levels may result 2
• The optimal window of 30-60 minutes ensures peak tissue concentrations coincide with the surgical incision 2

Common Pitfalls to Avoid

• Do not continue prophylaxis beyond 24 hours unless specifically indicated - this increases resistance without benefit 2
• Do not use inadequate dosing in obese patients - tissue penetration may be compromised 2
• Do not forget intraoperative re-dosing for procedures exceeding 2 hours - maintaining therapeutic levels throughout surgery is essential 1, 2
• Do not confuse prophylactic dosing with therapeutic dosing - the FDA label describes therapeutic regimens of 750 mg every 8 hours, which are not appropriate for prophylaxis 3

Alternative Agents

While cefuroxime is an acceptable second-generation cephalosporin for prophylaxis, cefazolin (2 g IV) remains the preferred first-line agent for most clean and clean-contaminated surgeries due to superior antistaphylococcal activity and lower risk of promoting antimicrobial resistance 4