Should cefazolin (Ancef) and levofloxacin (Levaquin) be overlapped in a patient with liver cancer undergoing Transarterial Chemoembolization (TACE) with biliary risk factors?

No, Do Not Overlap Cefazolin and Levofloxacin for TACE Prophylaxis

You should use either cefazolin OR levofloxacin as monotherapy—not both together—because randomized controlled trial evidence demonstrates that levofloxacin is non-inferior to cefazolin, making dual therapy unnecessary and exposing the patient to redundant antibiotic coverage. 1

Evidence-Based Antibiotic Selection

The 2023 Korean Liver Cancer Association guidelines explicitly state that either first-generation cephalosporin (cefazolin) or fluoroquinolone (levofloxacin) can be used as prophylactic antibiotics for TACE, based on RCT evidence showing non-inferiority between these agents. 1

Monotherapy Options for Patients with Biliary Risk Factors:

Option 1: Cefazolin Monotherapy

• Cefazolin 2g IV as a single dose at the time of TACE 2, 3
• If continuing post-procedure, may transition to oral fluoroquinolone for 3-5 additional days (total duration ≤5-7 days) 2

Option 2: Levofloxacin Monotherapy

• Levofloxacin 500mg orally or IV once daily 2
• RCT evidence confirms non-inferiority to cefazolin 1
• Can be given as single dose or short course (≤5-7 days total) 2

Option 3: Moxifloxacin Monotherapy

• Moxifloxacin 400mg orally or IV once daily 2
• Retrospective study showed 100% prevention of liver abscess 1, 2

Why Overlapping Is Not Indicated

The target pathogens for post-TACE liver abscess include gram-negative bacilli (especially E. coli), Enterococcus faecalis, Staphylococcus aureus, and Staphylococcus epidermidis. 2, 3, 4 Both cefazolin and fluoroquinolones provide adequate coverage of these organisms as monotherapy. 1

• No additive benefit: The guidelines recommend "1st-generation cephalosporin OR fluoroquinolone"—not both simultaneously 1
• Increased antibiotic exposure: Using both agents unnecessarily increases resistance risk and adverse events without improving outcomes 2, 5
• Evidence supports equivalence: The RCT demonstrating non-inferiority between levofloxacin and cefazolin means either agent alone is sufficient 1

Duration of Prophylaxis

Prolonged antibiotic use beyond 2 weeks provides no additional benefit in preventing liver abscess compared to short-term use. 1 The total antibiotic duration should not exceed 5-7 days from the time of TACE. 2, 3

Common Pitfalls to Avoid

• Do not add metronidazole to standard TACE prophylaxis regimens—it targets anaerobes which are not the primary pathogens in post-TACE infections and adds unnecessary exposure 2, 5
• Do not use ampicillin-sulbactam due to high resistance rates among community-acquired E. coli 2
• Do not extend prophylaxis beyond 5-7 days—this provides no benefit and increases resistance risk 1, 2
• Assess for biliary risk factors (biliary obstruction, bilioenteric anastomosis, biliary stent) on pre-treatment imaging to determine if prophylaxis is indicated 1, 3, 6, 4

Clinical Algorithm

For patients WITH biliary risk factors:

1. Choose ONE antibiotic regimen (cefazolin OR levofloxacin OR moxifloxacin) 1, 2
2. Administer as single dose or short course (≤5-7 days total) 2
3. If starting with IV cefazolin, may transition to oral fluoroquinolone after 24-48 hours if clinically stable 2

For patients WITHOUT biliary risk factors:

• Prophylactic antibiotics are optional and may be omitted entirely 1
• One small RCT showed no difference in infection rates without prophylaxis in unselected patients 7
• However, a large propensity-matched cohort demonstrated that prophylactic antibiotics reduced liver abscess occurrence by two-thirds 1