Prophylactic Antimicrobial policy:

Ideally, an antimicrobial agent for surgical prophylaxis should (1) prevent SSI, (2) prevent SSI-
related morbidity and mortality, (3) reduce the duration and cost of health care (when the costs
associated with the management of SSI are considered, the cost-effectiveness of prophylaxis
becomes evident), (4) produce no adverse effects, and (5) have no adverse consequences for the
microbial flora of the patient or the hospital.53

To achieve these goals, an antimicrobial agent should be (1) active against the pathogens most
likely to contaminate the surgical site, (2) given in an appropriate dosage and at a time that
ensures adequate serum and tissue concentrations during the period of potential contamination,
(3) safe, and (4) administered for the shortest effective period to minimize adverse effects, the
development of resistance, and costs

These Recommendations are provided for adult (age 19 years or older) and pediatric (age 1–18
years) patients. These guidelines do not specifically address newborn (premature and full-term)
infants.
While the guidelines do not address all concerns for patients with renal or hepatic dysfunction,
antimicrobial prophylaxis often does not need to be modified for these patients when given as a
single preoperative dose before surgical incision.
The recommendations herein may not be appropriate for use in all clinical situations. Decisions
to follow these recommendations must be based on the judgment of the clinician and
consideration of individual patient circumstances and available resources.

Preoperative-dose timing:

Successful prophylaxis requires the delivery of the antimicrobial to the operative site before
contamination occurs. Thus, the antimicrobial agent should be administered at such a time to
provide serum and tissue concentrations exceeding the minimum inhibitory concentration (MIC)
for the probable organisms associated with the procedure, at the time of incision, and for the
duration of the procedure.
Overall, administration of the first dose of antimicrobial beginning within 60 minutes before
surgical incision is recommended.
Administration of vancomycin and fluoroquinolones should begin within 120 minutes before
surgical incision because of the prolonged infusion times required for these drugs. Because these
drugs have long half-lives, this early administration should not compromise serum levels of these
agents during most surgical procedures.

Selection and dosing:

To ensure that adequate serum and tissue concentrations of antimicrobial agents for prophylaxis
of SSIs are achieved, antimicrobial specific pharmacokinetic and pharmacodynamics properties
and patient factors must be considered when selecting a dose.
It seems advisable to administer prophylactic agents in a manner that will ensure adequate levels
of drug in serum and tissue for the interval during which the surgical site is open.

Weight-based dosing: The dosing of most antimicrobials in pediatric patients is based on body
weight, but the dosing of many antimicrobials in adults is not based on body weight, because it is
safe, effective, and convenient to use standardized doses for most of the adult patient population.
However, in obese patients, especially those who are morbidly obese, serum and tissue
concentrations of some drugs may differ from those in normal-weight patients because of
pharmacokinetic alterations that depend on the lipophilicity of the drug and other factors.
Obesity has been recognized as a risk factor for SSI; therefore, optimal dosing of antimicrobial
prophylaxis is needed in these patients.

Redosing.
Intraoperative redosing is needed to ensure adequate serum and tissue concentrations of the
antimicrobial if the duration of the procedure exceeds two half-lives of the antimicrobial or there
is excessive blood loss (i.e., >1500 mL)
The redosing interval should be measured from the time of administration of the preoperative
dose, not from the beginning of the procedure.
Redosing may also be warranted if there are factors that shorten the half-life of the antimicrobial
agent (e.g., extensive burns)
Redosing may not be warranted in patients in whom the half-life of the antimicrobial agent is
prolonged (e.g., patients with renal insufficiency or renal failure)

Duration.:
The duration of antimicrobial prophylaxis should be less than 24 hours for most procedures.
A cardiothoracic procedure for which prophylaxis duration of up to 48 hours has been accepted
without evidence to support the practice is an area that remains controversial.
Moreover, prolonged prophylaxis was associated with an increased risk of acquired antimicrobial
resistance compared with short-term prophylaxis
There are no data to support the continuation of antimicrobial prophylaxis until all indwelling
drains and intravascular catheters are removed

Drug administration

The preferred route of administration varies with the type of procedure, but for a majority of
procedures, i.v. administration is ideal because it produces rapid, reliable, and predictable serum
and tissue concentrations.

Patients with prosthetic implants.

For patients with existing prosthetic implants who undergo an invasive procedure, there is no
evidence that antimicrobial prophylaxis prevents infections of the implant. However, updated
guidelines from the American Heart Association (AHA) suggest that prophylaxis may be
justified in a limited subset of patients for the prevention of endocarditis.11

Drug of choice:
For most procedures, cefazolin is the drug of choice for prophylaxis because it is the most widely
studied antimicrobial agent, with proven efficacy. It has a desirable duration of action, spectrum
of activity against organisms commonly encountered in surgery, reasonable safety, and low cost.
Routine use of vancomycin prophylaxis is not recommended for any procedure.8 Vancomycin
may be included in the regimen of choice when a cluster of

MRSA cases (e.g., mediastinitis after cardiac procedures) or methicillinresistant coagulase-

negative staphylococci SSIs have been detected at an institution. Vancomycin prophylaxis
should be considered for patients with known MRSA colonization or at high risk for MRSA
colonization in the absence of surveillance data (e.g., patients with recent hospitalization,
nursing-home residents, hemodialysis patients).

In institutions with SSIs attributable to communityassociated MRSA, antimicrobial agents with

known in vitro activity against this pathogen may be considered as an alternative to vancomycin.
The use of vancomycin for MRSA prophylaxis does not supplant the need for routine surgical
prophylaxis appropriate for the type of procedure.
When vancomycin is used, it can almost always be used as a single dose due to its long half-life.

Patients receiving therapeutic antimicrobials for a remote infection before surgery should also be
given antimicrobial prophylaxis before surgery to ensure adequate serum and tissue levels of
antimicrobials with activity against likely pathogens for the duration of the operation.
If the agents used therapeutically are appropriate for surgical prophylaxis, administering an extra
dose within 60 minutes before surgical incision is sufficient. Otherwise, the antimicrobial
prophylaxis recommended for the planned procedure should be used.
For patients with indwelling tubes or drains, consideration may be given to using prophylactic
agents active against pathogens found in these devices before the procedure, even though
therapeutic treatment for pathogens in drains is not indicated at other times.
For patients with chronic renal failure receiving vancomycin, a preoperative dose of cefazolin
should be considered instead of an extra dose of vancomycin, particularly if the probable
pathogens associated with the procedure are gram-negative. In most circumstances, elective
surgery should be postponed when the patient has an infection at a remote site.
Allergy to b-lactam antimicrobials.
Allergy to b-lactam antimicrobials may be a consideration in the selection of surgical
prophylaxis. The b-lactam antimicrobials, including cephalosporins, are the mainstay of surgical
antimicrobial prophylaxis and are also the most commonly implicated drugs when allergic
reactions occur. Because the predominant organisms in SSIs after clean procedures are gram-
positive, the inclusion of vancomycin may be appropriate for a patient with a life-threatening
allergy to b-lactam antimicrobials.
Although true Type 1 (immunoglobulin E [IgE]-mediated) crossallergic reactions between
penicillins, cephalosporins, and carbapenems are uncommon, cephalosporins and carbapenems
should not be used for surgical prophylaxis in patients with documented or presumed
IgEmediated penicillin allergy.