Treatment
Table 4. Antimicrobial Recommendations for Surgical
Prophylaxis Stratified by Type of Procedure (cont'd)
Type of Procedure
Recommended
Agentsa,b
Strength of Alternative in
Evidence β-Lactam Allergy
Urologic
Lower tract instrumentation
with risk factors for infectiont
Fluoroquinoloned-f
Trimethoprim–
sulfamethoxazole
A
Aminoglycosidec
+/clindamycin
Cefazolin
Clean without entry into
urinary tractu
Involving implanted
prosthesis
Cefazolin
A
Cefazolin
+/aminoglycoside
Cefazolin
+/aztreonam
A
Ampicillin-sulbactam
Clean with entry into urinary
tractu
Clean-contaminated
Cefazolin
Cefoxitin
Vancomycini
Clindamycin
+/aminoglycoside or
aztreonam
Vancomycini
+/aminoglycoside or
aztreonam
Fluoroquinoloned-f
A
Cefazolin
+
metronidazole
Clindamycini
Aminoglycosidec
+/clindamycin
Fluoroquinoloned-f
A
Aminoglycosidec
+
metronidazole or
clindamycin
Vascularv
Cefazolin
A
Clindamycini
Vancomycini
The antimicrobial agent should be started within 60 minutes prior to surgical incision (120
minutes for vancomycin or fluoroquinolones). While single-dose prophylaxis is usually sufficient,
the duration of prophylaxis for all procedures should be <24 hours. If an agent with a short half-life
is used (eg, cefazolin, cefoxitin), it should be readministered if the procedure duration exceeds the
recommended redosing interval (from the time of initiation of the preoperative dose [see Table
2]). Readministration may also be warranted if prolonged or excessive bleeding occurs, or if there
are other factors that may shorten the half-life of the prophylactic agent (eg, extensive burns).
Readministration may not be warranted in patients in whom the half-life of the agent may be
prolonged (eg, patients with renal insufficiency or failure).
b
For patients known to be colonized with methicillin-resistant S. aureus, it is reasonable to add a
single preoperative dose of vancomycin to the recommended agent(s).
c
Gentamicin or tobramycin.
d
Due to increasing resistance of E. coli to fluoroquinolones and ampicillin-sulbactam, local
population susceptibility profiles should be reviewed prior to use.
e
Ciprofloxacin or levofloxacin.
f
Fluoroquinolones are associated with an increased risk of tendonitis and tendon rupture in all ages.
However, this risk would be expected to be quite small with single-dose antibiotic prophylaxis.
Although the use of fluoroquinolones may be necessary for surgical antibiotic prophylaxis in some
children, they are not drugs of first choice in the pediatric population due to an increased incidence
of adverse events as compared with controls in some clinical trials.
g
Ceftriaxone use should be limited to patients requiring antimicrobial treatment for acute
cholecystitis or acute biliary tract infections which may not be determined prior to incision, not
patients undergoing cholecystectomy for noninfected biliary conditions, including biliary colic or
dyskinesia without infection.
12
a
