Central Administration of Pharmaceutical Affairs

Ministry of Health
(CAPA-MOHP)

Antibiotic Use for Surgical

Prophylaxis
Protocol

‫الاصدار السابع‬

‫اصدار اللجنة العليا لجودة الرعاية الصيدلية‬

‫واالستخدام الرشيد للدواء‬

EGYPT – MOHP – CAPA Issued Date:July 2023

 PREFACE
The Egyptian technical operational manuals and guides are published under the authority of the Central
Administration for Pharmaceutical Affairs (CAPA), Ministry of Health and Population (MOHP) within the
framework of the strategic plan to raise the quality of the practice of pharmaceutical care and the rational
use of medications, including antimicrobials, for patient benefit.
CAPA, the entrusted authority for organizing, supervising, and following up with the workflow in
collaboration with MOHP sectors, directorates in the pharmaceutical sector, and hospitals of the MOHP
issue series of pharmaceutical papers that focus on Medication Management and pharmacy practice
standards, including which describes the workflow of pharmacy service and explanation of the necessary
documentation involved to raise the quality of pharmaceutical care services provided to the patient and
professional competence of pharmacists at health care settings . New and Important issues shall be
published soon regarding operational manuals and job descriptions referring to pharmaceutical care
regulations and pharmacist job descriptions which are able to steer excellent management practice in
conductive environments toward fulfillment of customers' needs.

This Issue No.7, Antibiotic Use For Surgical Prophylaxis Protocol includes a guidance for the appropriate
use of antibiotics in surgical prophylaxis addressing general principles for prescribing, procedure, and
national guidelines for adults and pediatrics. For the aim of improving patients’ outcomes and minimizing
the unnecessary use of antibiotics in surgical prophylaxis, and thus subsequent resistance.

Acknowledgment

Editor-in-Chief

Dr. Ahd Ahmed Albrolisy AMS team member, CAPA, MOHP

Dr. Lamiaa Mohamed ElSawy
Dr. Lobna Mohamed Zaki
Dr. Rania Hamza Abou Zaid
Dr. Youmna Mohamed Hedaya
Dr. Doaa Abd El Fattah
Dr. Shaimaa Fouad Emam
AMS team member, CAPA, MOHP
AMS team member, CAPA, MOHP
AMS team member, CAPA, MOHP
AMS team member, CAPA, MOHP
Head of Rational Drug Use Department, CAPA, MOHP
CPGA Manager, CAPA MOHP

Dr. Ghada Ali Younis

Head of Central Administration of Pharmaceutical Affairs, CAPA, MOHP

Head of Pharmaceutical Care/Rational Drug Use Higher Committee, MOHP

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
Editorial Board
Prof. Dr. Amany El-Sharif
Dr. Amany El-Zeiny
Dr. Aliaa Gamal El Dein
Dr. Heba Anees
Dr. Hager ElKazaz
Dr. Hadeer Gamal
Dr. Hoda Asal
Dr. Hadir Rostom
Dr. Islam Anan
Dr. Mai Bassiouni
Dr. Nermeen Mohamed
Mohi Eldien
Prof. Dr. Nirmeen Ahmed
Sabry
Dr. Noha ElBoghdady
Prof. Dr. Osama Badary
Dr. Sherif Kamal
Dr. Wael Omran
Dr. Yara Khalaf
CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
Dean of Faculty of Pharmacy, Al-Azhar University
Assistant Director of Hospitals, National Cancer Institute, Cairo
University.
Microbiology Lecturer, Medical Research Institute, Alexandria
University
Deputy Manager of Clinical Nutrition Unit NCI
Clinical Pharmacy Consultant, National PPS team CAPA
Representative of Medicinal practices and for the Supreme Council of
University Hospitals
General Manager of Quality and Organizational Excellence at GAHAR
President of Egypt chapter/International society of pharmacovigilance
Professor of Health Economics, Medicine and Epidemiology
Director of Infection Control Department, Directorate of Health Affairs
, Alexandria
Head of Clinical Pharmacy department at Sharq El Madina Hospital,
Alexandria
Professor of Clinical Pharmacy, Cairo University
Medication Management Consultant
Clinical Pharmacy Lecturer at British University in Egypt
Professor of Clinical Pharmacy at British University in Egypt
Consultant to the Chairman of the Board of the Egypt Healthcare
Authority
Director Medication Management and Pharmacy Affairs
Supervisor of supply affairs at General Authority of Health Care
Antimicrobial Stewardship Consultant WHO, Egypt country office
 ANTIBIOTIC USE FOR SURGICAL PROPHYLAXIS

Items of content

1. Introduction
2. Objectives
3. Pre-operative considerations
4. General principles of surgical prophylaxis
5. Surgical wound classification
6. Preoperative dose timing
7. Duration of antibiotics
8. Allergy to Beta-lactam antimicrobials
9. Patients receiving therapeutic antimicrobial for active Infection before Surgery
10. Responsible team
11. Procedures
12. Antibiotic use for surgical prophylaxis guideline in adults
13. Antibiotic use for Surgical prophylaxis guideline in pediatrics
14. References

Introduction

Surgical antibiotic prophylaxis is defined as the use of antibiotics to prevent infections at the surgical site. This term
is used to describe antimicrobial therapy prescribed to clear infection by an organism or to clear an organism
colonized but not causing infection.

The use of preoperative antimicrobials has become an essential component of the standard of care for certain
surgical procedures and can result in a reduced risk of post-operative infection when appropriately prescribed.
However, the benefit of antimicrobial prophylaxis must be weighed against the risks of toxic and allergic reactions,
emergence of resistant bacteria, drug interactions, super-infection, and cost.

This Surgical Antimicrobial Prophylaxis Prescribing Protocol has been developed to assist clinicians with
recommendations on appropriate antimicrobial selection, dosing, timing and duration for a range of surgical
procedures.

Objectives

• To prevent surgical site infections

• To ensure rational prescription of surgical antibiotic prophylaxis in adults and pediatrics
• To improve patients’ outcomes
• To reduce adverse effects
• To reduce the patient's stay in the hospital and the cost.
• To reduce the emergence and inefficiency of antibiotic resistance.

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
Pre-operative considerations

• Surgical wound classification (clean, clean-contaminated, contaminated, dirty-infected) should be considered

when determining the need for, or choice of antibiotic prophylaxis. Antibiotic prophylaxis should not be used
routinely for clean, non-prosthetic uncomplicated surgery.

• Type and site of surgical procedure should be considered for selecting of the appropriate antibiotic that
provides coverage of the expected microbiological flora at the incision site.

• Individual healthcare institutions should consider local resistance patterns of organisms when adopting these
recommendations, the choice of the antimicrobial agent should take into account the local resistance
patterns

• The choice of antimicrobial is further influenced by multiple patient-specific risk factors including:
➢ Pre - existing infection
➢ Recent antimicrobial use
➢ Known colonization with a resistant organism
➢ Prolonged hospitalization
➢ Prostheses
➢ Weight
➢ Renal function
➢ Allergy status
➢ Comorbidities
➢ Immunosuppression

• Prevention of surgical site infections are based on a combination of perioperative antibiotic prophylaxis with
other measures as preoperative preparation, surgical techniques, and postoperative wound care

General Principles of Surgical Prophylaxis

• Decision if prophylaxis is appropriate should be made

• Selection of the appropriate antibiotic according to the pre-operative considerations mentioned above with
the narrowest antibacterial spectrum required. For most procedures, cefazolin is the drug of choice for
prophylaxis for its optimum coverage, efficacy, duration, cost and safety profile.
• Administration of the proper dose at the right time
• Administration of the antibiotics for a short period (one dose if surgery of four hours duration or less)
• Antibiotic prophylaxis should not be used to overcome poor surgical technique
• Preoperative antibiotic prophylaxis should not be continued in the presence of a wound drain for the purpose
of preventing SSI.
• Antibiotic prophylaxis protocols should be reviewed and updated regularly putting in consideration both cost
and hospital antibiotic resistance patterns.

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
Surgical Wound Classification
Surgical wounds are classified according to National Healthcare Safety Network (NHSN) into the following:
• Clean: An uninfected operative wound in which no inflammation is encountered and the respiratory,
alimentary, genital, or uninfected urinary tract is not entered. In addition, clean wounds are primarily closed
and, if necessary, drained with closed drainage.
• Clean-Contaminated: An operative wound in which the respiratory, alimentary, genital, or urinary tracts are
entered under controlled conditions and without unusual contamination. Specifically, operations involving
the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of
infection or major break in technique is encountered.
• Contaminated: Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique
(ex, open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, non-
purulent inflammation is encountered are included in this category.
• Dirty or Infected: Old traumatic wounds with retained devitalized tissue and those that involve existing
clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative
infection were present in the operative field before the operation.

Preoperative dose timing

Antimicrobial therapy should be initiated within the 60 minutes prior to surgical incision as a single dose to optimize
adequate drug tissue levels at the time of initial incision. Other factors should be considered as the half-life of drug
and time of administration. Fluoroquinolones and vancomycin should be administered 120 minutes before surgical
incision due to their longer infusion time.

Repeat Dosing
Single dose should only be given unless otherwise indicated. Redosing in the operation room may be required in
some cases as for antibiotics with short half-life as Cefazolin or cefoxitin in extended procedures in which the
procedure duration exceeds the recommended redosing interval (from the time of initiation of the preoperative
dose). Also, in case of extensive or prolonged bleeding and other factors that may shorten half-life of the
prophylactic antimicrobial used as in extensive e burns.
In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses
after the surgical incision is closed in the operating room, even in the presence of a drain and the same applied to
prosthetic joint arthroplasty.

Duration of Antibiotics
If post-operative dose of antibiotic is required, the duration should be less than 24 hours for most procedures. Some
cardiothoracic procedures require prophylaxis duration of up to 48 hours.

Route of Administration
Parenteral administration (intravenous or intramuscular) is the preferred route for surgical antimicrobial prophylaxis.
Topical prophylaxis is currently not indicated for most wounds, especially those resulting from clean procedures.

Allergy to B-lactam antimicrobials

Beta-lactam antimicrobials, including cephalosporins, are considered the first-choice drugs for most cases of surgical
antimicrobial prophylaxis and are also the most commonly involved drugs when allergic reactions occur. In cases of
life-threatening allergy to beta-lactam antimicrobial, true allergy type 1 immunoglobulin E mediated anaphylactic

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
reactions, vancomycin is considered as acceptable alternative. Cephalosporins and carbapenems can safely be used
in patients with an allergic reaction to penicillins that is not an IgE mediated reaction (e.g., anaphylaxis, urticaria,
bronchospasm) or exfoliative dermatitis (Stevens-Johnson syndrome, toxic epidermal necrolysis). Patients should be
carefully questioned about their history of antimicrobial allergies to determine whether a true allergy exists before
selection of agents for prophylaxis as misdiagnosis with true allergy leads to recommendations for alternative
antimicrobial therapy with the potential of increased costs, and adverse events.

Patients receiving Therapeutic Antimicrobial for an Active Infection before Surgery

• If the antimicrobial agent used to treat the current infection is deemed appropriate for surgical prophylaxis,
an extra dose should be administered within 60 minutes before the surgical incision.
• If the current antimicrobial agent is insufficient for surgical prophylaxis, additional cover per surgical
prophylaxis guidelines is recommended

Responsible team
Complying with antibiotic prophylaxis use protocol in surgical procedures requires the coordination of health care
stuff in the hospital. This includes but is not limited to the entire operating room and perioperative staff members
and other health care members including:
• Heads of surgical departments and the surgeons
• Anesthesiologists
• Head of Pharmacists
• Clinical pharmacy team
• Nursing stuff (preoperative – based nursing stuff)
• Infection prevention and Control head
• Quality control head
• Pharmaceutical Supply department
• Drug Information Center team

Procedures
• The protocol is developed according to the guidelines stated below for the surgical procedures performed in
the hospital.
• The protocol is then discussed in the pharmacy and therapeutics committee, with the participation of the
heads of surgical departments, anesthesiologists, infection prevention and control head and quality control
head then approve the protocol.
• The head of pharmacy ensures that the selected prophylactic antibiotics for prophylaxis are available in the
hospital through coordinating with the supply chain.
• The responsible team publishes and distributes the protocol to all surgical operations departments in the
hospital.
• Education regarding the protocol to be provided to surgeons, anesthesiologists, residents and nursing
personnel before and during the implementation of the protocol.
• The clinical pharmacy team reviews daily patients taking antibiotics for surgical prophylaxis to ensure
compliance with local guidelines and ensure that antimicrobials taken post-operatively are stopped within 24
hours.
• Periodical review audits should be done to measure the adherence to the protocol through setting suitable
process indicators for data. This can be supported through coordination with patient safety and quality team,

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
 and infection prevention and control team with highlighting the responsibilities of team members performing
the audit. These reviews have to be presented and discussed in the antimicrobial stewardship committee or
drug and therapeutics committee to take action to improve nonadherent practice.

Antibiotic audit tools and record forms have been developed to assess the usage of antibiotics in surgical
prophylaxis and the adherence with the policy (regarding the choice of agent, timing of preoperative dose
and duration of post-operative prophylaxis). Useful examples to refer to:
I. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-
safety/hais/tools/surgery/tools/surgical-complication-prevention/antibiotic_audit.docx
II. https://linkinghub.elsevier.com/retrieve/pii/S0929-6646(08)60139-4

• Tracking the consumption of antibiotics used in surgical prophylaxis through DDD can be helpful as a simple
indicator to reflect the compliance with the policy.
• The responsible team updates and reviews the protocol when needed.

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
Recommended dosing and redosing interval for Antimicrobials in Surgical Prophylaxis mentioned in the Guidelines
below

Antimicrobial Preoperative Dosing in Adults Recommended redosing Notes

interval (From Initiation
of Preoperative Dose),
hour
For IV Antibiotics
Ampicillin - 3 g (ampicillin 2g/sulbactam 1 g) 2
Sulbactam
Cefazolin 2 g for patient < 120 kg, and 3 g for 4
patients weighing ≥120 kg
Ciprofloxacin 400 mg NA Requires prolonged infusion time, can be
given 60-120 minutes prior to incision.
Clindamycin 900 mg 6
Gentamicin 5mg/kg IV NA If Creatinine Clearance <20, 2mg/kg (single
dose) or consult pharmacy
Levofloxacin 500 mg NA Requires prolonged infusion time, can be
given 60-120 minutes prior to incision.
Metronidazole 500 mg NA
Vancomycin 15 mg/kg NA Requires prolonged infusion time, can be
given 60-120 minutes prior to incision.
For Oral Antibiotics
Erythromycin base 1g NA
Metronidazole 1g NA
Neomycin 1g NA
Ciprofloxacin 500mg NA
Trimethoprim- 160/800 mg (double strength, DS) NA
Sulfamethoxazole orally

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
 Antibiotic Use in Surgical Prophylaxis Guideline - Adults
Surgery
Thoracic surgeries
Thoracic (noncardiac procedures):
lobectomy, pneumonectomy, lung
resection, thoracotomy
Vascular surgery in adults
• Arterial surgery involving a
prosthesis, the abdominal aorta, or
a groin incision
• Lower extremity amputation for
ischemia
Cardiac surgery in adults
Cardiac procedures: coronary
artery bypass, cardiac device
insertion procedures (e.g.
Common pathogen Recommended Dosage regimen after surgery
Antibiotics
Staphylococcus Cefazolin 2 g/ 8hrs up to 2 doses
aureus,
Staphylococcus OR Ampicillin-sulbactam 3g/6hrs up to 3 doses
epidermidis, (Alternative if cefazolin unavailable)
streptococci, enteric OR vancomycin
gram-negative bacilli (If allergic to penicillin or cephalosporins, or
risk of MRSA colonization)
OR clindamycin 900 mg/8h up to 2 doses
(Alternative to vancomycin)
Staphylococcus Cefazolin 2 g/ 8hrs up to 2 doses
aureus,
OR Vancomycin
S.epidermidis, enteric
(If allergic to penicillin or cephalosporins, or
gram- negative bacilli
risk of MRSA colonization)
OR clindamycin 900 mg/8h up to 2 doses
(Alternative to vancomycin) Type Ill Fractures (No gross
contamination): Use antibiotic for 48hrs
or 24hrs after wound closure,
Type III fracture (contaminated): Use
antibiotics for 48hrs after wound closure.
Staphylococcus Cefazolin Can range from a single dose to up to 48
aureus, hours after the surgery
OR Vancomycin
CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
pacemaker implantation),
placement of ventricular assist
devices
Gastroduodenal surgery
•Procedures involving entry into
lumen of gastrointestinal (GI) tract bacilli, gram-positive
•Procedures not involving entry
into lumen of GI tract (selective
vagotomy, anti-reflux). High risk
only: (Severe obesity, (GI)
obstruction, decreased gastric
acidity or GI motility, gastric
bleeding, malignancy or
perforation, or
immunosuppression.
Biliary tract surgery (including pancreatic procedures)
Open procedure or laparoscopic
procedure
For high risk (including age>70
years, pregnancy, acute
cholecystitis, nonfunctioning
gallbladder, obstructive jaundice,
common bile duct stones,
immunosuppression)
Laparoscopic procedure (low risk)
Appendectomy
CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
Staphylococcus (If allergic to penicillin or cephalosporins, or
epidermidis risk of Methicillin-resistant Staphylococcus
aureus (MRSA) colonization)
OR Clindamycin
(Alternative to vancomycin)
Enteric gram- negative Cefazolin 2 g/ 8hrs up to 2 doses
cocci
OR Vancomycin + Gentamicin
(If allergic to penicillin or cephalosporins, or
risk of MRSA colonization)
OR Clindamycin + Gentamicin (Reasonable
alternative for patients allergic to penicillins
and cephalosporins)
Enteric gram- negative Cefazolin 2 g/ 8hrs up to 2 doses
bacilli, enterococci, OR Ampicillin-Sulbactam 3g/ 6hrs up to 3 doses
clostridia (If cefazolin unavailable)
OR Vancomycin + Gentamicin
(If allergic to penicillin or cephalosporins, or
risk of MRSA colonization)
OR Clindamycin + Gentamicin (Reasonable
alternative for patients allergic to penicillins
and cephalosporins)
None None
Cefazolin + metronidazole 2 g/ 8hrs up to 2 doses
 Enteric gram- negative OR Clindamycin + Gentamicin
bacilli, anaerobes, (Reasonable alternative for patients allergic
enterococci to penicillins and cephalosporins)
OR Metronidazole + Gentamicin, N/A
(Reasonable alternative for patients allergic
to penicillins and cephalosporins)
Small intestine surgery
Non-obstructed Enteric gram- Cefazolin 2 g/8hrs up to 2 doses
negative bacilli, OR Clindamycin + Gentamicin
gram-positive cocci (Reasonable alternative for patients allergic
to penicillins and cephalosporins)
Obstructed Enteric gram- Cefazolin + metronidazole (preferred) 2 g/8hrs up to 2 doses
negative bacilli, OR Metronidazole + Gentamicin
anaerobes, (Reasonable alternative for patients allergic
enterococci to penicillins and cephalosporins)
Hernia repair
Aerobic gram- Cefazolin 2 g/8hrs up to 2 doses
positive organisms
OR Clindamycin
(reasonable alternative for patients allergic
to penicillins and cephalosporins)
OR Vancomycin
(reasonable alternative for patients allergic
to penicillins and cephalosporins
Colorectal surgery
Enteric gram- Parenteral
negative bacilli, Cefazolin + metronidazole (preferred) 2 g/8hrs up to 2 doses
anaerobes, OR ampicillin-sulbactam
enterococci (If Cefazolin unavailable)
OR Clindamycin + Gentamicin (Reasonable
alternative for patients allergic to penicillins
and cephalosporins)

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
 OR Metronidazole + Gentamicin (reasonable
alternative for patients allergic to penicillins
and cephalosporins)
Oral (used in conjunction with mechanical bowel preparation):
Neomycin PLUS erythromycin base or metronidazole: Adult dose: In addition to
mechanical bowel preparation: neomycin (1 g) plus erythromycin base (1 g) OR
neomycin (1 g) plus metronidazole (1 g). The oral regimen should be given as 3 doses
over approximately 10 hours the afternoon and evening before the operation.
Genitourinary Procedures
Diagnostic procedures: Enteric gram- Ciprofloxacin None
•Cystoscopy or Ureteroscopy for negative bacilli,
OR Trimethoprim-Sulfamethoxazole
high risk patients enterococci
• Cystoscopy with manipulation
(e.g. Transrectal prostate biopsy) or
upper tract instrumentation (e.g.
Ureteroscopy, shock wave
lithotripsy)
Open/laparoscopic surgery - Clean Enteric gram- Cefazolin
with or without entry to urinary negative bacilli, OR Vancomycin or Clindamycin
tract enterococci (For patients allergic to penicillin and
cephalosporins)
Open/laparoscopic surgery Enteric gram- Cefazolin + Gentamicin
involving implanted prostheses negative bacilli,
OR Vancomycin+ Gentamicin
enterococci
or Clindamycin + Gentamicin
(For patients allergic to penicillin and
cephalosporins)
Open/laparoscopic surgery: Clean- Enterobacteriaceae Cefazolin + Metronidazole
contaminated Enterococci OR Clindamycin
Staphylococci (For patients allergic to penicillin and
cephalosporins)

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
 Orthopedic procedures
Clean operation involving hand,
knee, or foot with no implant of
foreign material
Spinal procedures
Hip fracture
Internal fixation
Total joint replacement
Removal of orthopedic hardware
used for treatment of lower
extremity fracture
Neurosurgery
Elective craniotomy
Cerebrospinal fluid shunting
procedures
Implantation of intrathecal pumps
Head and neck surgery
Clean
Clean with placement of prosthesis
(excludes tympanostomy tube
placement)
Clean-contaminated
None
Staphylococcus Cefazolin - Open fractures type I or II: use
aureus, Vancomycin antibiotics for 24 hours
Staphylococcus (If allergic to penicillin or cephalosporins, or - Open fractures type III
epidermidis risk of MRSA colonization) If no gross contamination: use
antibiotics for 24 hours or 48 hours after
Clindamycin wound closure. If contaminated, use for
(Alternative to vancomycin) 48 hours after wound closure
Staphylococcus Cefazolin Limit post-surgical antibiotic
aureus, S. epidermidis Vancomycin prophylaxis duration to 24 hours
(If allergic to penicillin or cephalosporins,
or risk of MRSA colonization)
Clindamycin
(Alternative to vancomycin)
None None None
Staphylococcus Cefazolin (preferred)
aureus, Epidermidisa, Vancomycin
streptococci (If allergic to penicillin or cephalosporins,
MRSA colonization or MRSA infections
predominant post-operative)
Clindamycin (can be used as an alternative
to vancomycin)
Anaerobes Cefazolin + Metronidazole (preferred) Limit doses to 24- 48 hours after
Enteric gram-negative surgery
Bacilli Ampicillin sulbactam
S. aureus (If Cefazolin unavailable)
Clindamycin
Alternative in patients allergic to penicillins
or cephalosporins.
CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
 Breast surgery
Reduction mammoplasty, None
Mammoplasty, Lumpectomy
Prophylactic mastectomy
Breast cancer procedures (e.g., Staphylococcus Cefazolin 2g/8hrs up to 2 doses
axillary node dissection, aureus, OR vancomycin (If allergic to penicillin or
mastectomy for known breast Staphylococcus, cephalosporins, risk of MRSA colonization)
cancer) epidermidis,
streptococci OR clindamycin (alternative to vancomycin)

Gynecological Procedures
Procedure Preferred Regimen Alternative regimen
Hysterectomy, Pelvic reconstruction procedures, including colporrhaphy or Cefazolin Clindamycin PLUS Gentamicin: (if obese
those involving mesh or vaginal sling placement or over-weight based on adjusted body
weight)
Cesarean delivery Cefazolin Clindamycin: mg IV PLUS Gentamicin: (if
(Intact membranes, not in labor) obese or over-weight based on adjusted
body weight)
Cesarean delivery (in labor, ruptured membrane) Cefazolin PLUS Clindamycin IV PLUS Gentamicin: (if
Azithromycin obese or over-weight based on adjusted
body weight) PLUS Azithromycin: 500 mg
IV
Uterine evacuation (Including surgical abortion, suction, dilation and Doxycycline
curettage (D & C), and dilation and evacuation (D&E)
Laparotomy without entry into bowel or vagina Cefazolin
Hysterosalpingogram Not recommended
Laparoscopy (Diagnostic, tubal sterilization, operative except for
hysterectomy)
Other transcervical procedures: Cystoscopy, Hysteroscopy (Diagnostic or
operative) Intrauterine device insertion, Endometrial biopsy, Oocyte
retrieval, D & C for nonpregnancy indication, Cervical tissue biopsy

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
Solid Organ Transplantation

Procedure Pre-operative Post-operative Duration

Liver transplantation (low risk; all patients) Ampicillin/sulbactam 1 dose Ampicillin/sulbactam 3g For 24 hours
Liver transplant (high risk) or Small Bowel transplant Considered Piperacillin/tazobactam 4.5 g IV 1 Piperacillin/tazobactam For 24 hours
high risk if patient meets the following criteria: retransplant, dose over 30 minutes 4.5 g IV q8h (over 4
requiring dialysis pretransplant, CMV+ donor/CMV recipient, Hours)
surgical choledochojejunostomy
Kidney transplant (*NOTE*: Do not adjust doses for renal Cefazolin 1 g (2g if over 80 kg) IV x Cefoxitin 1 g (2g if over For 24 hours
Dysfunction) 1 dose 80 kg) IV q12h

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
 Antibiotic Use for Surgical Prophylaxis Guideline – Pediatrics

General principles for Prescribing

• Vancomycin and ciprofloxacin are to be initiated 60 to 120 minutes prior to incision and all other antibiotics are to be initiated within
60 minutes of incision
• If severe blood loss: repeat antibiotic dose for: Cefuroxime, clarithromycin, co-amoxiclav (at full prophylactic dose), Gentamicin (at half
prophylactic dose) and do not re-dose metronidazole and teicoplanin.
• Vancomycin prophylaxis 15 mg/kg IV (maximum 2,000 mg/dose) 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, hemodialysis patients)
• Discontinue all antibiotics within 24 hours of first dose except for: 1) Treatment of established infection, 2) Prophylaxis of prosthesis in
the setting of postoperative co-located percutaneous drains, 3) Intraoperative findings that raise the wound classification above 2
(e.g., spillage of enteric contents, purulent fluid, etc.).

Antibiotic recommended Dosing in Pediatrics Redosing interval

Cefazolin 30 mg/kg (maximum 2,000 mg for patients < 120 kg, and 3,000 mg for 4hours
patients ≥ 120 kg) IV
Vancomycin 15 mg/kg (max 2,000 mg) IV NA
Ampicillin/Sulbactam 50 mg/kg of the ampicillin component (maximum 2,000 mg) 3 hours
Cefoxitin 40 mg/kg (maximum 2,000 mg) IV 2 hours
Metronidazole 15 mg/kg NA
Neonates weighing <1200 g should receive a single 7.5-mg/kg dose
Clindamycin 10 mg/kg (max 900 mg) IV 6 hours
Gentamicin 2.5 mg/kg (max 80 mg) IV NA

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
 Procedure Site
Cardiothoracic and Vascular
Head and Neck
Neurosurgery
Upper Gastrointestinal
Lower Gastrointestinal
Ophthalmology
Orthopedics
Plastic Surgery
Head Trauma
Exceptionally varied; no prospective,
comparative data in children; agents
should focus on skin flora (S
epidermidis, S aureus) as well as the
flora may include enteric gram-negative
bacilli, anaerobes (including Clostridia
spp), and fungi.
Genitourinary
(only requires prophylaxis for children
with suspected active UTI or those
having foreign
material placed) Enteric gram-negative
bacilli, enterococci
CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
Antibiotic recommended Alternative
Cefazolin Clindamycin IV or Vancomycin IV
Clean: Cefazolin IV Clindamycin IV or Vancomycin IV
Clean Contaminated: Ampicillin/Sulbactam
Cefazolin IV Vancomycin IV
Cefazolin Clindamycin IV or Vancomycin IV
Cefoxitin IV or Cefazolin IV plus metronidazole Clindamycin IV plus Gentamicin IV or
Clean: Cefazolin IV Clindamycin IV or Vancomycin IV
Clean Contaminated: Ampicillin/Sulbactam IV
Pelvic Surgery: Cefoxitin IV Clindamycin IV or Vancomycin IV
Implanted Orthopedic Prosthesis: Cefazolin IV
plus Gentamicin IV
All others: Cefazolin IV
Clean: no preoperative antibiotics Clindamycin Clindamycin IV
IV
Clean Contaminated (through oral cavity):
Ampicillin/Sulbactam IV
Cefazolin (for skin) Vancomycin (for skin), if MRSA likely
Cystoscopy, Open or laparoscopic surgery: TMP/SMX (if low local resistance), OR
cefazolin Select a 2nd (cefuroxime) or 3rd generation
cephalosporin or fluoroquinolone
(ciprofloxacin) if
the child is known to be colonized with
cefazolin-resistant, TMP/SMX-resistant strains
References
1. IDSA/ASHP/SIS/SHEA Clinical practice guidelines for antimicrobial prophylaxis in surgery. 2013.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG,
Slain D, Steinberg JP, Weinstein RA; American Society of Health-System Pharmacists (ASHP); Infectious
Diseases Society of America (IDSA); Surgical Infection Society (SIS); Society for Healthcare Epidemiology of
America (SHEA). Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt).
2013 Feb;14(1):73-156. doi: 10.1089/sur.2013.9999. Epub 2013 Mar 5. PMID: 23461695.
2. UpToDate [Internet]. Uptodate.com.2022 [Aug 2022]. Available from:
https://www.uptodate.com/contents/management-of-acute-appendicitis-in-adults.
3. Stanford Health Care Surgical Antimicrobial Prophylaxis Guidelines. Stanford Antimicrobial Safety and Sustainability
Program Revision date 10/31/2019
https://med.stanford.edu/content/dam/sm/bugsanddrugs/documents/clinicalpathways/SHC-Surgical-Prophylaxis-
ABX-Guideline.pdf
4. The Nebraska medical center Clarkson and hospital:
https://www.unmc.edu/intmed/_documents/id/asp/surgical-antimicrobial-surgical-prophylaxis.pdf
5. Nelson’s book for Antibiotics pediatrics
6. The university of Texas- MD Anderson cancer center: Surgical Antibiotic prophylaxis pediatric last revised
06/20/2023
https://www.mdanderson.org/content/dam/mdanderson/documents/for-physicians/algorithms/clinical-
management/clin-management-surgical-antibiotic-prophylaxis-pedi-web-algorithm.pdf
7. 9 ANTIMICROBIAL STEWARDSHIP From Principles to Practice © 2018 British Society for Antimicrobial Chemotherapy
8. NATIONAL GUIDELINES FOR ANTIMICROBIAL PROPHYLAXIS IN SURGERY- Policy No. 1 February 2022- Egyptian Drug
Authority (EDA)

CAPA, MOHP: Issue No.7, (Antibiotic Use for Surgical Prophylaxis) July.2023
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