Surgical Principles: Preoperative Antibiotics

General Antibiotic Prophylactic Approach

Wound Classification

Class I (Clean)

  • Prophylaxis: None Required for Most Procedures
  • Indications for Prophylaxis in Class I:
    • Breast Cancer
    • Cardiac Procedures
    • Carotid Endarterectomy (CEA)
    • Hemodialysis Access

Class II (Clean-Contaminated)

  • Prophylaxis: Single Preoperative Dose (< 60 Min Before)
  • Some Say None in Cholecystectomy

Class III/IV (Contaminated/Dirty)

  • Prophylaxis:
    • Preoperative Dose (< 60 Min Before)
    • Continue Postoperatively (Stop < 24 Hours After)

Gastrointestinal Surgery

Skin Flora (GP)

  • General Procedures:
    • Hernia Repair
  • Antibiotic Options:
    • Cefazolin (Ancef)

Upper Enteric Bacteria (GPC & GNB)

  • General Procedures:
    • Gastroduodenal Surgery
    • Small Intestine Surgery (Not Obstructed)
  • Antibiotic Options:
    • Cefazolin (Ancef)

Lower Enteric Bacteria (GPC, GNB & Anaerobes)

  • General Procedures:
    • Small Intestine Surgery (Obstructed)
    • Colorectal Surgery
    • Appendectomy
  • Antibiotic Options:
    • Cefoxitin (Mefoxin)
    • Cefotetan (Cefotan)
    • Cefazolin (Ancef) & Metronidazole (Flagyl)
    • Ceftriaxone (Rocephin) & Metronidazole (Flagyl)

Biliopancreatic Bacteria (Enteric GPC, GNB & Clostridia)

  • General Procedures:
    • Cholecystectomy
    • Biliary Tract Procedures
    • Pancreatic Procedures
  • Antibiotic Options:
    • Cefazolin (Ancef)
    • Cefotetan (Cefotan)
    • Cefoxitin (Mefoxin)
    • Ampicillin-Sulbactam (Unasyn)

Penicillin/Cephalosporin Allergy

  • Need One from Each Category
  • GPC & Anaerobe Coverage:
    • Clindamycin
    • Vancomycin
  • GNB Coverage:
    • Gentamicin
    • Ciprofloxacin
    • Levofloxacin
    • Aztreonam

Antibiotic Choices for Specialty Surgery

Vascular Surgery

  • Cefazolin (Ancef)
  • Vancomycin
  • Clindamycin

Breast Surgery

  • Indications:
    • Lumpectomy: None
    • Mastectomy
      • Prophylactic: None
      • Malignancy: Prophylaxis Recommended
    • Axillary Lymph Node Dissection: Prophylaxis Recommended
  • Antibiotic Choice:
    • Cefazolin (Ancef)
    • Vancomycin
    • Clindamycin

Thoracic Surgery

  • Cefazolin (Ancef)
  • Vancomycin
  • Clindamycin
  • Ampicillin-Sulbactam (Unasyn)

Cardiac Surgery

  • Cefazolin (Ancef)
  • Vancomycin
  • Clindamycin
  • Cefuroxime

Genitourinary Surgery

  • Cefazolin (Ancef)

Gynecologic Surgery

  • Hysterectomy or Pelvic Reconstruction
    • Cefazolin (Ancef)
    • Cefotetan (Cefotan)
    • Cefoxitin (Mefoxin)
  • Cesarean Section
    • Cefazolin (Ancef)
    • Add Azithromycin if Membranes are Ruptured

Neurosurgery

  • Cefazolin (Ancef)
  • Vancomycin
  • Clindamycin

Orthopedic Surgery

  • Cefazolin (Ancef)
  • Vancomycin
  • Clindamycin

Parenteral (IV) Dosing

Dosing & Redosing

  • Ampicillin-Sulbactam (Unasyn): 3 g (Redose at 2 Hours)
  • Azithromycin: 500 mg
  • Aztreonam: 2 g (Redose at 4 Hours)
  • Cefazolin (Ancef)
    • < 120 kg: 2 g (Redose at 4 Hours)
    • ≥ 120 kg: 3 g (Redose at 4 Hours)
  • Cefotetan (Cefotan): 2 g (Redose at 6 Hours)
  • Cefoxitin (Mefoxin): 2 g (Redose at 2 Hours)
  • Ceftriaxone (Rocephin): 2 g
  • Cefuroxime (Ceftin): 1.5 g (Redose at 4 Hours)
  • Ciprofloxacin: 400 mg
  • Clindamycin: 900 mg (Redose at 6 Hours)
  • Gentamicin: 5 mg/kg
  • Levofloxacin: 500 mg
  • Metronidazole (Flagyl): 500 mg
  • Vancomycin: 15 mg/kg – Max 2 g