What is the empirical antibiotic for surgical prophylaxis?

From the Guidelines

Cefazolin is the preferred empirical antibiotic for surgical prophylaxis in most procedures. The typical adult dose is 2g IV (3g for patients >120kg) administered within 60 minutes before surgical incision, as recommended by the Australian Therapeutic Guidelines 1. For prolonged procedures, redosing should occur every 4 hours during surgery. Prophylaxis should generally be discontinued within 24 hours after surgery.

Key Considerations

• For patients with beta-lactam allergies, alternatives include clindamycin (900mg IV) or vancomycin (15mg/kg IV) 1.
• Specific procedures may require additional coverage:
  • For colorectal surgery, add metronidazole (500mg IV) for anaerobic coverage, as suggested by the Australian Therapeutic Guidelines and the French Society of Anesthesia and Intensive Care Medicine 1.
  • For urologic procedures, consider adding gentamicin (5mg/kg IV), as recommended by the Canadian urological association 1.
  • For procedures involving MRSA-colonized patients, add vancomycin, as recommended by the American Society of Health-Systems Pharmacists, Infectious Diseases Society of America, Surgical Infection Society, Society for Healthcare Epidemiology of America 1.

Rationale

The goal of surgical prophylaxis is to achieve adequate tissue concentrations of antibiotics at the time of incision to prevent surgical site infections 1. Antibiotics are selected based on their activity against the most likely contaminating organisms for the specific surgical site. Limiting prophylaxis duration helps prevent antimicrobial resistance, C. difficile infections, and other adverse effects while maintaining efficacy 1.

From the FDA Drug Label

The prophylactic administration of Cefazolin for Injection, USP preoperatively, intraoperatively, and postoperatively may reduce the incidence of certain postoperative infections in patients undergoing surgical procedures which are classified as contaminated or potentially contaminated The preoperative administration of a single 1 gram dose of Ceftriaxone for Injection may reduce the incidence of postoperative infections in patients undergoing surgical procedures classified as contaminated or potentially contaminated

Empirical Antibiotic for Surgical Prophylaxis:

• Cefazolin (IV) is indicated for perioperative prophylaxis in surgical procedures that are classified as contaminated or potentially contaminated 2.
• Ceftriaxone (IV) is also indicated for surgical prophylaxis in patients undergoing surgical procedures classified as contaminated or potentially contaminated 3. Key Points:
• Both Cefazolin and Ceftriaxone can be used for empirical antibiotic prophylaxis in surgical procedures.
• The choice of antibiotic should be based on the type of surgery, patient risk factors, and local epidemiology and susceptibility patterns.

From the Research

Empirical Antibiotic for Surgical Prophylaxis

• The use of empirical antibiotics for surgical prophylaxis is a crucial aspect of preventing surgical site infections (SSIs) [(4,5,6)].
• Cefazolin is a first-line agent for prevention of SSIs after total joint arthroplasty, and its use is associated with decreased postoperative SSI without an increase in interoperative hypersensitivity reactions 5.
• Patients labeled allergic to beta-lactam antibiotics frequently receive clindamycin or vancomycin perioperatively due to the perceived risk of a hypersensitivity reaction after exposure to cefazolin [(5,6)].
• However, alternative antibiotics for surgical prophylaxis are associated with increased adverse events and surgical site infection compared to cefazolin 6.

Beta-Lactam Allergy and Cross-Reactivity

• Beta-lactams, which include penicillins, cephalosporins, carbapenems, and monobactams, are the most common antibiotic classes reported to cause allergic reactions to drugs 7.
• Cross-reactivity among beta-lactams is infrequent in subjects with an IgE-mediated allergy and anecdotal in those with a T-cell-mediated allergy 7.
• Identities or similarities of beta-lactam side-chain structures are mainly responsible for cross-reactivity among these antibiotics 7.

Surgical Antibiotic Prophylaxis Dosing

• Current guideline recommendations do not treat obesity specifically, although it can affect pharmacokinetics and pharmacodynamics 8.
• Except for metronidazole, cefoxitin, and gentamicin, there is currently no evidence suggesting the need for dosing adjustments in surgical antibiotic prophylaxis for adult patients with obesity 8.