Damietta Cardiology

& Gastroenterology Centre

Antimicrobial
Surgical Prophylaxis
▪ Approved June 2023

Clinical pharmacy department

Dr: Omnya Wagdy
Dr: Nadeen Darahem
Dr: Amira Magdy

DCGC general manager:

##
Dr Kamal Salama

2
 Contents

▪ INTRODUCTION ERROR! BOOKMARK NOT DEFINED.

▪ Objective 4

▪ Scope 5

▪ MRSA risk 6

▪ TIMING OF PROPHYLAXIS 7

▪ Antibiotic of choice 9

▪ ENDOCARDITIS RISK 13

▪ PRE-OPERATIVE DOSING AND REDOSING OF ANTIMICROBIAL 14

▪ PATIENT SPECIFIC FACTORS 15

▪ PREPARATION AND ADMINISTRATION 16

▪ POST-OPERATIVE DOSING AND RENAL MODIFICATIONS 17

▪ DISCLAIMER 19

▪ ABBREVIATIONS 20

▪ REFERENCES 21

2
 ▪ Introduction
Surgical site infection is an infection related to an operative procedure that occurs at or near
the surgical incision within 30 or within 90 days if prosthetic material is implanted at
surgery, depending on the type of procedure performed. SSIs are often localized to the
incision site but can also extend into deeper adjacent structures.

Clinical criteria for defining SSI include one or more of the following:
o A purulent exudate draining from a surgical site.
o A positive fluid culture obtained from a surgical site that was closed primarily.
o A surgical site that is reopened in the setting of at least one clinical sign of infection
(pain, swelling, erythema, warmth) and is culture positive or not cultured.

• Wound classification
A widely accepted wound classification system has been developed by the National
Academy of Sciences and the National Research Council based upon the degree of expected
microbial contamination during surgery. It stratifies wounds as clean, clean-contaminated,
contaminated, or dirty using the following definitions:
▪ Clean wounds are uninfected operative wounds in which no inflammation is
encountered and the wound is closed primarily. By definition, a viscus (respiratory,
alimentary, genital, or urinary tract) is not entered during a clean procedure.
▪ Clean-contaminated wounds are operative wounds in which a viscus is entered
under controlled conditions and without unusual contamination.
▪ Contaminated wounds are open, fresh accidental wounds, operations with major
breaks in sterile technique, or gross spillage from a viscus. Wounds in which acute,
non-purulent inflammation was encountered also were included in this category.
▪ Dirty wounds are old traumatic wounds with retained devitalized tissue, foreign
bodies, or faecal contamination or wounds that involve existing clinical infection or
perforated viscus.
Antimicrobial prophylaxis is justified for most clean-contaminated procedures. The use of
antimicrobial agents for dirty procedures or established infection is not classified as
prophylaxis; rather, it represents treatment for presumed infection.

3
 • Microbiology
The predominant organisms causing surgical site infections (SSIs) after clean procedures are
skin flora, including streptococcal species, Staphylococcus aureus, and coagulase-negative
staphylococci.
In clean-contaminated procedures, the predominant organisms include gram-negative rods
and enterococci in addition to skin flora.
Fungi (particularly Candida albicans) have been isolated from an increasing percentage of
SSIs.
This trend is probably due to the widespread use of prophylactic and empiric antibiotics,
increased severity of illness, and greater numbers of immunocompromised patients
undergoing surgical procedures.
Exogenous sources of infection include contamination of the surgical site by organisms from
the operating room environment or personnel. Anal, vaginal, or nasopharyngeal carriage of
group A streptococci by operating room personnel has been implicated as a cause of several
SSI outbreaks.

▪ Objective
Surgical antimicrobial prophylaxis is an accepted part of surgical practice in some
procedures to prevent infections at the surgical site and optimise postoperative recovery.
The use of antimicrobials for the prevention of infection must be weighed against any harm
associated with their use such as allergic and adverse drug reactions and potential
contribution to the development of antimicrobial resistance.
Ideally, antimicrobial prophylaxis should prevent SSI, prevent morbidity and mortality,
reduce duration and cost of health care, cause minimal adverse drug effects, and have
minimal adverse effects on the microbial flora of the patient.

4
 ▪ Scope
This Surgical Antimicrobial Prophylaxis protocol is addressed to the health care team in the
surgical department including:
Physicians and surgeons: Safe and appropriate prescribing according to surgical prophylaxis
guidelines and ensuring antimicrobials are ordered so that they are administered within
appropriate time frames.
Pharmacists: Timely and accountable supply of antimicrobials, appropriate and timely
advice to prescribers and nurses with regard to the selection, dose, route and duration
Nurses: Ensuring safe and timely administration, preparation of prescribed antimicrobials
and performing sensitivity tests.
Pharmacy stock: Provide the hospital with the required antibiotics for surgical prophylaxis.
This protocol applies to all patients performing any surgery at our centre.

5
 ▪ MRSA risk
Vancomycin prophylaxis should be considered for patients with known MRSA colonization
or at high risk for MRSA colonization.
Vancomycin is less effective than cefazolin for preventing SSIs caused by methicillin-
susceptible S. aureus (MSSA). Surgical prophylaxis with vancomycin alone has been
associated with higher rates of MSSA surgical site infections than cefazolin alone.
For this reason, vancomycin is used in combination with cefazolin at some institutions with
both MSSA and MRSA SSIs
o MRSA screening test
To prevent surgical site infections with MRSA, patients undergoing some elective surgical
procedures should be considered for pre-operative screening such as Cardio-thoracic
surgeries and major vascular surgeries.
Patients at high risk for MRSA colonization undergoing other procedures should also be
screened
(e.g., patients with recent hospitalization, nursing-home residents, haemodialysis
patients, recent or current antibiotic exposure, chronic underlying disease (e.g., cancer,
renal disease), injecting drug use, immune suppression, e.g., transplant patients, prior
colonisation with MRSA, presence of indwelling devices (i.e., long term vascular access,
indwelling urinary catheter, gastrostomy feeding tubes, wound drains), presence of
unhealed or chronic wounds.)
The aim of such screening would be to assess the need for decolonisation procedures
and/or suitable antibiotic prophylaxis.

MRSA screening methods Sites for sampling

Culture based techniques. Nose and perineum or groin, plus unhealed
wound or indwelling medical device
(including umbilical catheter in neonates)

PCR rapid testing Nose, plus unhealed wound or indwelling

medical device.

6
 o Decolonisation (In case of positive MRSA results)
Nasal decolonisation:
Apply 2% mupirocin ointment (match head size) to the inner surface of each nostril two or
three times a day for five days in the week before the procedure.
Skin decolonisation:
1. Bathe daily with an antiseptic wash or soap (2% chlorhexidine or 1% triclosan) for at
least five days up to the day of surgery. Special attention should be paid to known
carriage sites including axilla, groin, perineum and buttock area.
2. Wash hair using one of the antiseptics twice weekly.
3. Change and wash clothing, bedding, towels, etc., at the commencement of treatment
and at least twice more throughout the treatment.

▪ Timing of prophylaxis
• Pre-operative dosing
The optimal time for administration of preoperative doses is within 60 minutes before
surgical incision.
The administration of some agents, such as fluoroquinolones and vancomycin should begin
within 120 minutes before surgical incision as they require longer infusion durations.

• Extra dosing
Patients receiving therapeutic antimicrobials for an infection at surgical site (known or
suspected) or at a different site should also be given anti-microbial prophylaxis before
surgery. 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.
Doses should be scheduled to allow for re-dosing just prior to skin incision.

7
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.
In most circumstances, elective surgery should be postponed when the patient has an
infection at a remote site.
For patients with chronic renal failure, administration of perioperative doses of gentamicin
or vancomycin in addition to scheduled doses increases the risk of toxicity. Administration
of perioperative doses of penicillins (e.g., ampicillin-sulbactam) or cephalosporins (e.g.,
cefazolin) in addition to scheduled doses is generally considered safe, particularly if the
probable pathogens associated with the procedure are gram-negative.

• Intraoperative redosing
Why: needed to ensure adequate serum and tissue concentrations of the antimicrobial
when: if the duration of the procedure exceeds two half-lives of the drug or excessive blood
(e.g., more than 1500mL in adults) or following fluid resuscitation and extensive burns .
The redosing interval is measured from the time of administration of the preoperative dose,
not from the beginning of the procedure.
Redosing may not be warranted in patients with renal insufficiency or renal failure.

• Post- operative dosing

there is no evidence that prophylactic antibiotic administration after incision closure
decreases SSI risk, even in the presence of a drains or chest tubes.
If needed, a single dose or continuation for less than 24 hours are provided.
Cardiothoracic procedures for which a prophylaxis duration of up to 48 hours has been
accepted.
Prophylaxis should be considered for patients having factors that indicate a high risk of
infectious complications (e.g., Emergency procedures, long procedure duration, old age of >
70 years old, immune suppression, presence of protheses, obesity, malnutrition and
infection at another site)

8
▪ Antibiotic of choice
Alternatives in
Surgical site Surgery name Agent(s) of choice case of B lactam
allergy
Clean:

• Thyroidectomy None None

• Lymph node excisions

Clean- contaminated: (Involves an Cefazolin + Clindamycin

incision through the oral or pharyngeal metronidazole,
mucosa) ampicillin–sulbactam
Head and
neck • Parotidectomy
• Submandibular gland excision
• Sialoadenectomy
• Sialo lithotomy

Coronary artery bypass graft or Valve Cefazolin Clindamycin,

replacement vancomycin
Cardiac device insertion procedures
(e.g., pacemaker implantation)

• Atrial Septal Defect (ASD) closure cefazolin + vancomycin Vancomycin +

• Patent Foramen Ovale (PFO) closure gentamicin
• Left Atrial Appendage (LAA) Closure
Cardiac • Valvuloplasty, septal occlusion for
high-risk patients only (e.g., femoral
catheter > 6hrs, prosthetic valves,
past history of endocarditis)
• Percutaneous Coronary Intervention None None
(PCI) (angioplasty/stent insertion)
• Ablation

Breast Breast procedures (Milk duct excision) Cefazolin Clindamycin

Or vancomycin

• PEG/ PEJ insertion (percutaneous Cefazolin Clindamycin or

endoscopic gastrostomy) vancomycin +
• Restrictive procedures gastrectomy / Gentamycin or
Bariatric surgical procedures Levofloxacin
GIT

9
 • Liver resection Cefazolin plus Gentamicin plus
• Pancreatic Whipple’s procedure, metronidazole metronidazole
pancreatic necrosectomy,
pancreatectomy

• Endoscopic ultrasound-guided fine- None None

needle aspiration of solid lesions
along the GI tract
• Diagnostic endoscopic ultrasound
GIT • Endoscopy
• Colonoscopy
• Sigmoidoscopy
• Sclerotherapy
• Esophageal stricture dilatation
• Removal of foreign body by
endoscope
• Excision of polyps
Cefazolin, ceftriaxone, Vancomycin
ampicillin-sulbactam +gentamicin or
Cholecystectomy open procedure
levofloxacin
(Surgery)
Metronidazole+
gentamicin or
levofloxacin
Cholecystectomy laparoscopic low risk* None None

Cholecystectomy laparoscopic high risk* Cefazolin, ceftriaxone, Vancomycin

ampicillin-sulbactam +gentamicin or
levofloxacin

Metronidazole+
gentamicin or
Biliary system levofloxacin

ERCP Cefazoline + Gentamicin

metronidazole +metronidazole
• Biliary obstruction without
cholangitis if complete drainage is
unlikely (e.g., in patients with
malignant hilar cholangio-carcinoma
or primary sclerosing cholangitis

• Involving transpapillary or
transmural drainage of pseudocysts

If the patient has communicating

pancreatic cysts or pseudocysts

10
 Non obstructed Cefazolin Clindamycin +
Gentamicin or
levofloxacin
Small Obstructed Cefazolin + Metronidazole +
intestine metronidazole Gentamicin or
levofloxacin

Cefazolin + Clindamycin +
metronidazole, Gentamicin or
ampicillin–sulbactam, levofloxacin
• Partial or total Colon resection ceftriaxone +
Colorectal
• Anal fistulotomy/ fistulectomy metronidazole, Metronidazole +
Gentamicin or
Levofloxacin

Hemorrhoidectomy None None

Genitourinary Orchiectomy (without entry into urinary Cefazolin Vancomycin

tract)

Splenectomy Cefazolin Vancomycin

Abdominal
Appendectomy Cefazolin Clindamycin+
(Laparoscopic or open surgery) +metronidazole Gentamicin or
levofloxacin
• Non complicated: acutely inflamed
appendix only Metronidazole+
gentamicin or
levofloxacin

• Varicose vein procedures

• Balloon angioplasty None None

• Brachial or carotid artery procedures

not involving insertion of prosthetic
Vascular material.

• Percutaneous thrombectomy

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 • AVF / AVG (Arteriovenous fistula/
Arteriovenous graft) with insertion
Cefazolin Clindamycin,
of prosthetic material (e.g., Dacron
vancomycin
graft) High risk of MRSA
infection: add
• Carotid artery procedures involving
vancomycin
prosthetic material.

• EVAR (Endovascular Aortic Aneurysm

repair)

Vascular reconstructive surgery Involving Cefazolin Vancomycin +

upper or lower limbs (including Gentamicin
Vascular graft/patch/stent insertion, groin
incision)

Limb amputation Cefazolin Vancomycin +

Gentamicin
PLUS, for amputation of
an ischaemic limb: add PLUS, for amputation
metronidazole. of an ischaemic limb:
add metronidazole
Reoperation: Add
vancomycin

General Hernia Repair Procedures (Hernioplasty Cefazolin Clindamycin,

and Herniorrhaphy) vancomycin

(*) Factors that indicate a high risk of infectious complications in laparoscopic cholecystectomy include
emergency procedures, diabetes, long procedure duration, intraoperative gallbladder rupture, age of >70
years, conversion from laparoscopic to open cholecystectomy, American Society of Anaesthesiologists
classification of 3 or greater, episode of colic within 30 days before the procedure, reintervention in less than
one month for non-infectious complication, acute cholecystitis, bile spillage, jaundice, pregnancy, non-
functioning gallbladder, immunosuppression, and insertion of prosthetic device. Because a number of these
risk factors are not possible to determine before surgical intervention, it may be reasonable to give a single
dose of antimicrobial prophylaxis to all patients undergoing laparoscopic cholecystectomy.

12
 ▪ Endocarditis risk
Antibiotic prophylaxis to prevent endocarditis is only recommended for patients with
cardiac conditions associated with the highest risk of adverse outcomes from
endocarditis and only for certain procedures.
Cardiac conditions for which antibiotic prophylaxis to prevent endocarditis is
recommended:
• Prosthetic heart valve, prosthetic material used for cardiac valve repair
• Previous infective endocarditis
• Rheumatic heart disease in all populations
• Congenital heart disease, only if it involves:
o Unrepaired cyanotic defects, including palliative shunts and conduits
o Repaired defects with residual defects at or adjacent to the site of a prosthetic
patch or device (which inhibit endothelialisation)

Procedure Recommended antibiotic Penicillin allergy

• Any invasive procedure to treat an Amoxicillin 2g IV Vancomycin
established infection (e.g., drainage (Child: 50mg/kg up to 2g)
of abscess)

• Percutaneous endoscopic
gastrostomy, PEJ

• Any gastrointestinal procedure in

the presence of infection or
colonisation unless already treating
enterococci

• Sclerotherapy for oesophageal

varices

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Pre-operative dosing and redosing of antimicrobial agents
Antimicrobial Adult dose Paediatric dose Redosing (hr)
Prophylactic antibiotics
Cefazolin 2 gm 30 mg/kg 4
(Weigh based)
If > 120 kg, 3 gm

Vancomycin (#) < 80 kg, 1 gm 15 mg/kg 8

(Weigh based)
80 - 99 kg, 1.25 gm
Requires prolonged
infusion time, can be given 100 -120 kg, 1.5 gm
60-120 minutes prior to
>120 kg = 2 grams
incision
Ceftriaxone 2 gm 50–75 mg/kg _

Levofloxacin 500 mg 10 mg/kg _

Metronidazole 500 IV 15 mg/kg Neonates 12

weighing < 1200 gm
should receive a single
7.5 mg/kg dose

1 gm PO in colorectal surgery 15 mg/kg 6-10

Ampicillin -sulbactam 3 gm 50 mg/kg of the 2

ampicillin component

Gentamicin* 5 mg/kg 2.5 mg/kg

(Weight based)
Clindamycin 900 mg 10 mg/kg 6

Therapeutic antibiotics
Cefepime 2g 50 mg/kg 6

Meropenem 500 mg 20 mg/kg 3

Piperacillin- Tazobactam 3.375 grams 100/12.5 mg/kg 2

*Gentamicin for surgical antibiotic prophylaxis should be limited to a single dose given preoperatively. Dosing is
based on the patient’s actual body weight. If the patient’s actual weight is more than 20% above ideal body weight
(IBW), the dosing weight (DW) can be determined as follows: DW = IBW + 0.4(actual weight – IBW).

(#) IV Vancomycin doses should be based on actual body weight

14
 ▪ Patient-specific factors
Antibiotic choice or dose may need to be modified according to patient factors (e.g.,
immune suppression, presence of prostheses, allergies, age, obesity, renal function and
colonisation with multi-drug resistant bacteria) and antimicrobial specific pharmacokinetic
and pharmacodynamics properties.
• Paediatrics
the principles of antimicrobial prophylaxis and exposure at surgical sites in adults should
apply to children with certain modifications to doses.

• Obese patients
Most antibiotics used for surgical prophylaxis require no dosage adjustments in obese
patients, except for Cefazolin, Gentamicin and Vancomycin as they require certain
modifications to their doses based on the patient’s weight.

• Renal patients
Patients with renal impairment can be given the same pre-operative antibiotic doses as
normal patients. Adjustments are done to the frequency and the dose of the post-operative
antibiotic according to the patient’s creatinine clearance.

▪ Beta lactam allergy

Patients should be carefully questioned about their history of antimicrobial allergies to
determine whether a true allergy exists before selection of agents for prophylaxis.
➢ Severe penicillin allergy
Includes Ig-E mediated reactions (anaphylaxis, urticaria, bronchospasm, angioedema,
hypotension, hives) and exfoliative dermatitis (Stevens-Johnson syndrome, toxic epidermal
necrolysis). These patients should not receive a beta-lactam for surgical prophylaxis.
➢ Cephalosporins allergy
Any allergy to Cephalosporins (including itching/rash) will contraindicate the use of them.
:‫طريقة عمل اختبار الحساسية‬

‫ رشطة‬90 ‫االنسولي من المادة المحلولة أو الفيال وتكمل الرسنجة ب‬

‫ن‬ ‫ رشطات باستخدام شنجة‬10 ‫• يتم أخذ‬
(Intradermal not ‫ رشط فقط ن يف اليد داخل طبقات الجلد وليس تحت الجلد‬10 ‫ماء مقطر ويحقن مقدار‬
subcutaneous).
‫ دقيقة‬30 -15 ‫• يحدد حول منطقة الحقن بقلم ويتك المريض من‬
‫ن‬ ‫ن‬
‫• إذا حدث احمرار أو تورم أو حكة يف مكان الحقن ي‬
‫يعن وجود حساسية للمادة المحقونة‬
15
‫‪▪ Preparation and Administration‬‬
‫‪• Adults:‬‬
‫طريقة الحل واإلعطاء‬ ‫المضاد الحيوي‬
‫ن يف حالة جرعة ‪ 500‬مجم يؤخذ ‪ 20‬مل من فيال ‪ 750‬مجم ويعاد حله ن يف ‪ 80‬سم جلوكوز ‪ %5‬أو محلول ملح ‪%0.9‬‬
‫ليفوفلوكساسي‬
‫عل مدار ‪ 60‬دقيقة‬
‫عط ي‬
‫وي ي‬
‫ويعط خالل ‪ 30‬دقيقة‬
‫ي‬ ‫يحل ن يف ‪ 100‬سم محلول ملح او جلوكوز ‪%5‬‬ ‫ر‬
‫سيفتياكسون‬
‫يعط عل مدار ‪ 30‬دقيقة‬ ‫فالجيل‬
‫ويعط خالل ‪ 30‬دقيقة‬
‫ي‬ ‫يحل ن يف ‪ 100‬سم محلول ملح او جلوكوز ‪%5‬‬ ‫سيفازولي‬
‫ويعط عل مدار ‪ 30‬دقيقة تدريجيا‬
‫ي‬ ‫يحل ن يف ‪ 100‬سم محلول ملح‬ ‫يونيكتام‬
‫عل مدار ‪ 30‬دقيقة لكل فيال ‪ 500‬مجم‬ ‫ئ‬
‫البط ي‬ ‫يعط بالتنقيط الوريدي‬
‫ي‬
‫كت ‪500‬مجم فيال يحل ن يف ‪ 10‬مل ماء معقم للحقن ثم يعاد حله يف ‪100‬سم جلوكوز ‪%5‬او محلول ملح‪%0.9‬‬
‫ن‬ ‫تر ن‬ ‫فانكوميسي‬
‫ن‬ ‫ن‬
‫كت ‪ 1000‬مجم فيال يحل يف ‪ 20‬مل ماء معقم للحقن ثم يعاد حله يف ‪200‬سم جلوكوز ‪%5‬او محلول ملح‪%0.9‬‬ ‫تر ن‬
‫عل مدار ‪ 60- 20‬دقيقة‬ ‫ن‬
‫عط ي‬
‫يخفف يف ‪ 50‬مل ملح ‪ %0.9‬أو جلوكوز ‪ %5‬وي ي‬ ‫كلينداميسي‬
‫عل مدار ساعة‬
‫ويعط ي‬
‫ي‬ ‫يخفف ن يف ‪ 100‬مل ملح ‪ %0.9‬أو جلوكوز ‪%5‬‬ ‫جينتاميسي‬

‫‪• Paediatrics:‬‬
‫طريقة الحل واإلعطاء‬ ‫المضاد الحيوي‬
‫تسحب الكمية المطلوبة من الفيال حسب الجرعة المحسوبة مسبقا طبقا للوزن و تخفف ن يف محلول ملح او جلوكوز‪%5‬‬
‫ئ‬ ‫ليفوفلوكساسي بحيث يكون الت ن‬
‫النهائ للمحلول ‪ 5‬مجم‪/‬مل و ي‬
‫يعط ع يل مدار ‪60‬دقيقة‬ ‫ي‬ ‫كت‬

‫يحل ‪1‬جم فيال ن يف ‪ 10‬مل محلول ملح او جلوكوز‪ %5‬ثم تسحب الكمية المطلوبة طبقا لوزن الطفل ويعاد تخفيفها ن يف‬ ‫ر‬
‫سيفتياكسون‬
‫حدين الوالدة و‪ 30‬دقيقة لألطفال‬
‫ي‬ ‫ويعط عل مدار ‪ 60‬دقيقة ل‬
‫ي‬ ‫‪100‬سم محلول ملح او جلوكوز‪%5‬‬

‫تسحب الكمية المطلوبة حسب وزن الطفل ويعط عل مدار ‪ 30‬دقيقة‬ ‫فالجيل‬
‫يحل ‪1‬جم فيال ن يف ‪ 5‬مل محلول ملح او جلوكوز‪ %5‬ثم تسحب الكمية المطلوبة من الفيال حسب الجرعة المحسوبة‬
‫ئ‬ ‫ن‬ ‫ن‬
‫هائ للمحلول ‪20‬مجم‪/‬مل وي ي‬
‫عط‬ ‫مسبقا طبقا للوزن ويعاد تخفيفها يف محلول ملح او جلوكوز‪ %5‬بحيث يكون التكت الن ي‬ ‫سيفازولي‬
‫عل مدار ‪30‬دقيقة‬

‫يحل ‪1.5‬جم فيال ن يف ‪ 3‬سم محلول ملح ثم تسحب الكمية المطلوبة من الفيال حسب الجرعة المحسوبة مسبقا طبقا‬
‫ن‬
‫يسيلي) ويعط‬ ‫ئ‬
‫النهائ للمحلول ‪ 30‬مجم‪/‬مل (‪20‬مجم‪/‬مل امب‬ ‫للوزن ويعاد تخفيفها نف محلول ملح بحيث يكون الت ن‬
‫كت‬ ‫يونيكتام‬
‫ي‬ ‫ي‬
‫عل مدار ‪ 30‬دقيقة‬
‫ن‬ ‫ئ‬
‫عل مدار ‪ 60‬دقيقة ويحل الفيال يف ‪ 10‬مل محلول ملح او جلوكوز‪ %5‬ثم تسحب الكمية‬ ‫لبط ي‬ ‫يعط بالتنقيط الوريدي ا‬
‫ي‬
‫ن‬
‫المطلوبة من الفيال حسب الجرعة المحسوبة مسبقا طبقا للوزن ويعاد تخفيفها يف محلول ملح او جلوكوز‪ %5‬بحيث‬ ‫فانكوميسي‬
‫النهائ للمحلول ‪5‬مجم‪/‬مل‬ ‫ئ‬ ‫يكون الت ن‬
‫كت‬
‫ن‬ ‫ي‬
‫تسحب الكمية المطلوبة من الفيال حسب الجرعة المحسوبة مسبقا طبقا للوزن و تخفف يف كمية مناسبة من محلول‬
‫ئ‬ ‫كلينداميسي‬
‫ال ‪ 60‬دقيقة‬
‫عل مدار ‪ 30‬ي‬ ‫النهائ للمحلول ‪ 15‬مجم‪/‬مل ويع ي‬
‫ط ي‬ ‫ي‬ ‫ملح او جلوكوز‪ %5‬بحيث يكون التك نت‬

‫يخفف الفيال ن يف ‪ 100‬مل ملح ‪ %0.9‬أو جلوكوز ‪ %5‬ثم تسحب الكمية المطلوبة من الفيال حسب الجرعة المحسوبة‬
‫جينتاميسي‬
‫ال ‪ 60‬دقيقة‬
‫عل مدار ‪ 30‬ي‬
‫ويعط ي‬
‫ي‬ ‫مسبقا طبقا للوزن‬

‫‪16‬‬
 ▪ Post-operative dosing and renal modifications
• Adults
Antibiotic Usual adult post- CrCl 30 – 60 CrCl 10- 29 CrCl less than
op dose ml/min ml/min 10 ml/min

Cefazolin Non 2 gm q8hr x 2 doses 1 gm x 1 dose 12 No Post-op Dose

cardiac hours required
after the last
operative dose
cardiac 2 gm q8hr x 5 doses 1 gm q12h x 3 doses 1 gram x 1 dose
24 hours
after last
operative dose
Clindamycin 900 mg q8 hr x 2 doses No adjustment
required unless
patient ALSO has
hepatic failure
then dose should
be 300 mg IV q8h
x 2 doses

Gentamicin No Post-op Dose required as it covers 24 hr

Metronidazole 500 mg q8 hr x 2 doses No adjustment

required unless
patient ALSO has
hepatic failure,
then dose should
be 500 mg q12h
x 1 dose

Vancomycin Non- 1 gram x 1 dose 12 No Post-op Dose required

cardiac hours after the last
operative dose

Cardiac 1 gm q12h x 3 1 gm x 1 dose 24 hours after the last No Post-op Dose

doses operative dose required

Ampicillin-Sulbactam 3 gm q6hr x 3 3 gm q8hr x 2 1 gm x 1 dose 12 No Post-op Dose

doses doses hours after the last required
operative dose

Ceftriaxone No Post-op Dose required as it covers 24 hr

Levofloxacin No Post-op Dose required as it covers 24 hr

17
▪ Paediatrics
Antibiotic Dose Interval Renal impairment modifications

Cefazolin 30 mg/kg (max 2000 mg) q8hr x 2 doses CrCl 15-29mL/min: 50 mg/kg x 1
dose 12 hours after the last
operative dose

CrCl < 15mL/min: No Post-op

Dose required

Clindamycin 10 mg/kg (max 900 mg) q8hr x 2 doses No adjustments needed

Gentamicin * 2.5 mg/kg q8hr x 2 doses CrCl 30-49mL/min: 2.5 mg/kg x 1

dose 12 hours after the last
operative dose

CrCl less than 29 ml/min: No

Post-op Dose required

Metronidazole 15 mg/kg (max 500 mg) q8hr x 2 doses No adjustments needed

Vancomycin 15 mg/kg (max 1500 mg) q8hr x 2 doses CrCl 30-49mL/min: 15 mg/kg x 1
dose 12 hours after the last
operative dose

CrCl less than 29mL/min: No

Post-op Dose required

Ampicillin- 50 mg/kg (max 2000 mg) q6hr x 3 doses CrCl 10-29mL/min: 30 mg/kg x 1
Sulbactam of ampicillin component dose 12 hours after the last
operative dose

CrCl < 10mL/min: No Post-op

Dose required

Ceftriaxone 50 mg/kg (max 2000 mg) No Post-op Dose required as it covers 24 hr

Levofloxacin 10 mg/kg (max 500 mg) q12h (if 6 months to < 5 CrCl less than 30 ml/min: No
years old) post-op dose required

No post-op dose
required (if > 5 years old)

(*) Gentamicin Dosing is based on the patient’s actual body weight. If the patient’s actual weight is more
than 20% above ideal body weight (IBW), the dosing weight (DW) can be determined as follows: DW = IBW +
0.4(actual weight – IBW).

18
Disclaimer statement
The recommendations given in this guide are meant to serve as treatment guidelines. They
should NOT supplant clinical judgment or Infectious Diseases consultation when indicated.
The recommendations were developed for all surgeries performed in Damietta cardiology and
gastroenterology centre and thus may not be appropriate for other settings.
We have attempted to verify that all information is correct, but because of ongoing research,
practice may change.

19
 ▪ Abbreviations

Abbreviations Definition
IDSA Infectious diseases society of America
SIS Surgical infection society
SHEA Society of health care epidemiology f America
ASHP American society of health system pharmacist
MRSA Methicillin resistant staphylococcus aureus
MSSA Methicillin sensitive staphylococcus aureus
ERCP Endoscopic retrograde cholangiopancreatography
SSI Surgical site infection
IBW Ideal body weight
CrCl Creatinine clearance
IV Intravenous
Q Every
Gm Gram
Mg Milligram
Hr Hour
Min Minute
Max Maximum
GIT Gastrointestinal tract
PCI Percutaneous coronary intervention
EVAR Endovascular aneurysm repair
LAA Left atrial appendage
PDA Patent duct arteriosus
PFO Patent Foramen Ovale

AVF Arteriovenous fistula

AFG Arteriovenous graft

PEG Percutaneous endoscopic gastrostomy

PEJ Percutaneous endoscopic jejunostomy

20
 ▪ References
1. ASHP
https://www.ashp.org/surgical-guidelines
2. Government of south Australia
Surgical+Prophylaxis+Antimicrobial+guideline+3.0+FINAL+March+2022.pdf (sahealth.sa.gov.au)
3. Uptodate
https://www.uptodate.com/contents/antimicrobial-prophylaxis-for-prevention-of-surgical-site-infection-
in-adults
4. Stanford
https://med.stanford.edu/content/dam/sm/bugsanddrugs/documents/clinicalpathways/SHC-Surgical-
Prophylaxis-ABX-Guideline.pdf
5. Lexicomp
https://online.lexi.com/lco/action/login
6. PubMed
https://www.ncbi.nlm.nih.gov/books/NBK549864/Science direct
7. IDSA
https://www.idsociety.org/practice-guideline/antimicrobial-prophylaxis-in-surgery/
8. SHEA
https://shea-online.org/guidance/antimicrobial-prophylaxis-in-surgery/
9. SIS
https://www.sisna.org/guidelines
10. Science direct
https://www.sciencedirect.com/science/article/pii/S1743919114001848
11. ASCRS
https://journals.lww.com/dcrjournal/Abstract/2014/03000/Prophylactic_Antibiotics_for_Hemorrhoidect
omy__Are.14.aspx
12. John Hopkin
https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540532/all/Surgical_prophy
laxis
13. Nebraska Medicine
https://www.unmc.edu/intmed/_documents/id/asp/surgical-antimicrobial-surgical-prophylaxis.pdf
21
 14. Sarasota Memorial health care system
https://www.smh.com/Portals/0/Antibiotic%20Surgical%20Prophylaxis%20Protocol%20SMH%20April%2
02021.pdf
15. MD Anderson centre surgical antibiotic prophylaxis algorithm
https://www.mdanderson.org/content/dam/mdanderson/documents/for-
physicians/algorithms/clinical-management/clin-management-surgical-antibiotic-prophylaxis-adult-web-
algorithm.pdf
16. Advocate’s Children hospital
https://www.advocatechildrenshospital.com/assets/documents/pediatric-clinical-pathways/aah-
pediatric-neonatal-surgical-prophylaxis-guidelines-(9.2022).pdf
17. Children Minnesota hospital
https://www.childrensmn.org/References/CDS/comprehensive-surgical-prophylaxis-guideline.pdf
18. Society of interventional radiology
https://www.cirse.org/wp-content/uploads/2018/07/SOP_SIR_2010_Practice-Guideline-for-Adult-
Antibiotic-Prophylaxis-during-Vascular-and-Interventional-Radiology-Procedures.pdf
19. The American Society of Colon and Rectal Surgeons
https://fascrs.org/ascrs/media/files/downloads/Clinical%20Practice%20Guidelines/the-american-
society-of-colon-practical-guideline-sinus-pilonidalis.pdf

22