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 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 for a new TAVR and a dirty procedure is cefazolin (IV). The dose is 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery, with additional doses of 500 mg to 1 gram IV or IM during surgery and every 6 to 8 hours for 24 hours postoperatively. In cases where the occurrence of infection may be particularly devastating, such as open-heart surgery, the prophylactic administration of cefazolin may be continued for 3 to 5 days following the completion of surgery 1.
- Key points:
- Dose: 1 gram IV or IM
- Administration: 1/2 hour to 1 hour prior to surgery
- Additional doses: 500 mg to 1 gram IV or IM during surgery and every 6 to 8 hours for 24 hours postoperatively
- Duration: 3 to 5 days in devastating cases 1
From the Research
For a patient undergoing a transcatheter aortic valve replacement (TAVR) procedure that becomes contaminated, I recommend administering a single pre-procedural dose of cefazolin 2g IV (or vancomycin 15mg/kg IV if the patient has a beta-lactam allergy) within 60 minutes before the procedure. This recommendation is based on the need to prevent infective endocarditis, a serious complication of TAVR procedures, as highlighted in studies such as 2. The choice of cefazolin is due to its effectiveness against common skin flora like Staphylococcus species, which are often implicated in surgical site infections. If the procedure becomes contaminated during the intervention, extend antibiotic coverage with cefazolin 1g IV every 8 hours for 48-72 hours to address potential contamination. For heavily contaminated procedures, consider adding metronidazole 500mg IV every 8 hours to cover anaerobic organisms. Post-procedure, monitor closely for signs of infection including fever, elevated white blood cell count, or increasing inflammatory markers. It's also important to note that the combination of vancomycin with certain other antibiotics, such as piperacillin/tazobactam, may increase the risk of acute kidney injury, as seen in studies like 3 and 4. However, for TAVR procedures, the primary concern is preventing infection, and the recommended antibiotic regimen should be chosen based on this goal, with careful consideration of potential risks and benefits, as discussed in 5. In terms of specific antibiotic choices, cefazolin is preferred over vancomycin when possible, due to its narrower spectrum of activity and lower risk of nephrotoxicity. Overall, the key to effective antibiotic prophylaxis in TAVR procedures is to provide adequate coverage against potential pathogens while minimizing the risk of adverse effects.