Principles for antimicrobial prophylaxis of surgical site infections (SSIs)
Last reviewed January 2024
Dosing and re-dosing recommendations for antimicrobials commonly used for surgical prophylaxis
Antimicrobial |
Adult dose | Pediatric dose* (max dose should not exceed the recommended adult dose) |
Intra-operative re-dosing (from time of administration of pre-op dose) |
---|---|---|---|
Cefazolin | 2 g Consider 3g if weight above 120 kg |
30 mg/kg/dose |
Every 4 h (Max 6 g/24h) |
Aminoglycoside: Tobramycin |
2.5 mg/kg (Round to nearest 20 mg) |
2.5 mg/kg/dose Max 120mg/dose |
At 6h x 1 (if CrCl greater than or equal to 60 ml/min) Pediatrics: none required |
Metronidazole | 500 mg | 15 mg/kg/dose Max 500mg/dose |
At 12 hrs x 1 Pediatrics: see IWK Firstline App |
Vancomycin |
15 mg/kg round nearest 250 mg Administer:
|
15 mg/kg/dose |
At 12h x 1 (if CrCl greater than or equal to 60 ml/min) Pediatrics: see IWK Firstline App |
*For more detailed pediatric recommendations, please refer to the IWK Firstline App
Last reviewed January 2024
Systemic surgical prophylaxis recommendations:
Note: for detailed pediatric recommendations, please refer to the IWK Spectrum App
Type of Surgery | Recommended Antimicrobial(s) |
Alternative Antimicrobial(s) if anaphylaxis to cefazolin or severe delayed reaction to any beta-lactam such as SJS/TEN, DRESS, AGEP |
---|---|---|
Cardiac | ||
Coronary artery bypass (CABG), |
cefazolin | vancomycin |
Ventricular assist devices Device insertion (e.g., pacemaker) |
cefazolin | vancomycin |
Cardiac catheterization Transesophageal echocardiogram |
none | none |
General | ||
Gastroduodenal/esophageal | cefazolin | vancomycin + aminoglycoside |
PEG insertion | cefazolin | vancomycin |
Biliary tract - laparoscopic procedure – Low risk | none | none |
Biliary tract - laparoscopic procedure – High risk |
cefazolin | vancomycin + aminoglycoside |
Biliary tract - open procedure | cefazolin | vancomycin + aminoglycoside |
Colorectal, small bowel, appendectomy Pancreaticoduodenectomy |
cefazolin + metronidazole |
vancomycin + aminoglycoside + metronidazole |
Hernia repair - Hernioplasty, herniorrhaphy | cefazolin | vancomycin |
Low risk anorectal procedures: hemorrhoidectomy, fistulotomy, sphincterotomy | none | none |
Thoracic | ||
Non-cardiac procedures (e.g., lobectomy, pneumonectomy, lung resection, and thoracotomy) Video-assisted thoracoscopic surgery |
cefazolin | vancomycin |
Thoracentesis or chest tube insertion for non-traumatic indications (e.g., spontaneous pneumothorax) | none | none |
Head and Neck | ||
Clean: no incision through oral/nasal/pharyngeal mucosa (e.g., parotidectomy, thyroidectomy, and submandibular gland excision) | none | none |
Clean with placement of prosthetic material (excludes tympanostomy tubes that do not require prophylaxis) | cefazolin | vancomycin |
Clean-contaminated (incision through oral/pharyngeal mucosa): cancer surgery and other clean-contaminated procedures with the exception of tonsillectomy and functional endoscopic sinus procedures | cefazolin + metronidazole |
vancomycin + metronidazole |
Neurosurgery | ||
Elective craniotomy, stereotactic brain biopsy, cerebrospinal fluid-shunting procedures, ICP monitor, external ventricular drain, and implantation of intrathecal pumps | cefazolin | vancomycin |
Orthopedic | ||
Arthroscopy without graft implantation | none | none |
Spinal procedures with and without instrumentation, hip fracture repair, Implantation of internal fixation devices (e.g., nails, screws, plates, wires), and total joint replacement | cefazolin | vancomycin |
Urologic | ||
In addition to the prophylaxis recommendations below, obtain urine culture prior to stone removal or invasive procedures involving mucosal bleeding/trauma. If bacteria are found in the culture, treat based on sensitivities prior to performing the procedure. | ||
Cystoscopy/Shock-wave lithotripsy
|
none | |
Cystoscopy/Shockwave lithotripsy: Risk factors:
|
If no hospitalization in last year, recent antibiotic use from the class, or other risks for resistance:
|
|
If risk of Gram-negative bacteria resistance (including prolonged hospitalization, infection or colonization with resistant bacteria, or recent fluoroquinolone/TMP-SMX use) select one of the following instead:
or
|
||
Transrectal prostate biopsy |
Give 1-2 hours pre-procedure:
If risk of Gram-negative bacteria resistance:
add
or
|
|
Percutaneous renal surgery | cefazolin | vancomycin |
Open or Laparoscopic: without entry into bowel/vagina |
cefazolin | vancomycin + tobramycin |
Open or Laparoscopic: involving manipulation of bowel/vagina |
cefazolin + metronidazole |
vancomycin + aminoglycoside + metronidazole |
Vascular | ||
Arterial surgery Graft placement or repair |
cefazolin | vancomycin |
Plastics | ||
Clean without risk factors | none | none |
Clean - high risk
|
cefazolin | vancomycin |
Breast surgery | cefazolin | vancomycin |
Obstetrical/Gynecological | ||
Caesarean section | cefazolin | vancomycin + aminoglycoside |
Hysterectomy | cefazolin +/- metronidazole |
vancomycin + aminoglycoside +/- metronidazole |
Laparoscopic procedures that involve no direct access from the abdominal cavity to the uterine cavity or vagina | none | none |
Last reviewed January 2024
1. University of Toronto Best Practice in Surgery Program.http://bestpracticeinsurgery.ca/wp-content/uploads/2017/11/SSI-BPS-CPG-Nov20.pdf
2. World Health Organization. Global Guidelines for the Prevention of Surgical Site Infection.https://www.who.int/gpsc/ssi-prevention-guidelines/en/
Last reviewed January 2024
Last reviewed November 2024
Table 1. Gustilo-Anderson Classification of Open Fractures
Type | Details |
I | Open fracture with a wound less than 1 cm long, low energy, without gross contamination |
II | Open fracture with a wound 1–10 cm long, low energy, without gross contamination or extensive soft-tissue damage, flaps, or avulsions |
III-A | Open fracture with a wound greater than 10 cm with adequate soft-tissue coverage, or any open fracture due to high-energy trauma or with gross contamination, regardless of the size of the wound |
III-B | Open fracture with extensive soft-tissue injury or loss, with periosteal stripping and boneexposure that requires soft-tissue coverage in the form of muscle rotation or transfer |
III-C | Open fracture associated with arterial injury requiring repair |
Last reviewed November 2024
Table 2. Fracture Scenario and Corresponding Suspected Microorganisms
Scenario | Microorganisms |
Type I or Type II fracture | Gram-positive cocci (S. epidermidis, S. aureus, β-hemolytic streptococci) +/- Gram-negative bacilli |
Type III-A, III-B, or III-C fracture | Gram-positive cocci (S. epidermidis, S. aureus, β-hemolytic streptococci) + Gram-negative bacilli |
Known MRSA colonization, previous MRSA infection, known injection drug use |
MRSA |
Additional contamination considerations | |
Soil/stool/sewage water or farm related injury | Clostridium species |
Freshwater | Aeromonas hydrophila, Pseudomonas and Plesiomonas species, Erysipelothrix rhusiopathiae, Mycobacterium marinum, and other microbes |
Saltwater | Vibrio species |
Last reviewed November 2024
Last reviewed November 2024
Table 3. Fracture Scenario and Corresponding Empiric Treatment Options
Fracture Type | Type I, Type II | Type IIIA, Type IIIB, Type IIIC |
Grade-guided prophylaxis |
|
|
Risk factors for MRSA | Add vancomycin 15 mg/kg IV q12h (or if cefazolin used for grade-guided prophylaxis, replace cefazolin with vancomycin) | |
Additional Prophylaxis for Contamination | ||
Soil/stool/sewage water or farmrelated injuries |
Add Metronidazole 500 mg po/IV q8h If on Piperacillin-Tazobactam: No addition needed |
|
Freshwater |
Add Ciprofloxacin 750 mg PO q12h or Ciprofloxacin 400 mg IV q8h
If on Piperacillin-Tazobactam: No addition needed If on Cefazolin + Tobramycin: No addition needed |
|
Saltwater |
Use Piperacillin-Tazobactam 4.5 g IV q6h and Doxycycline 100 mg PO BID; recommended for all open fractures with saltwater contamination
If anaphylaxis to penicillin or history of severe delayed skin reaction/organ dysfunction to any beta-lactam antimicrobial: |
*(If actual body weight more than 30 % above ideal body weight, use dosing body weight for tobramycin – see Firstline for details)
Last reviewed November 2024
Last reviewed November 2024
1. Carsenti-Etesse H, et al. Epidemiology of bacterial infection during management of open leg fractures. Eur J ClinMicrobiol Infect Dis. 1999;18(5):315Y323.
2. Garner MR, et al. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. J Am Acad Orthop Surg. 2020 Apr 15;28(8):309-315. doi: 10.5435/JAAOS-D-18-00193. PMID: 31851021.
3. Goldman AH, et al. J Am Acad Orthop Surg. 2023 Jan 1;31(1):e1-e8. doi: 10.5435/JAAOS-D-22-00792. Epub 2022 Nov 3. PMID: 36548150.
4. Gustilo RB, et al. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453-458.
5. Gustilo RB, et al. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 1984;24:742-746.
6. Sunnybrook “Antibiotic prophylaxis for open fractures’ Prophylaxis Guidelines - Antimicrobial Stewardship - Sunnybrook Hospital
7. EAST Open Fractures, Prophylactic Antibiotic Use in — Update Open Fractures, Prophylactic Antibiotic Use in — Update - Practice Management Guideline (east.org)
8. Robinson D, et al. Microbiologic flora contaminating open fractures: its significance in the choice of primary antibiotic agents and the likelihood of deep wound infection. J Orthop Trauma. 1989;3: 283–286.
9. Rodriguez L, et al. Evidence-based protocol for prophylactic antibiotics in open fractures: Improved antibiotic stewardship with no increase in infection rates. Journal of Trauma and Acute Care Surgery 77(3):p 400-408, September 2014.
10. Standardized Antibiotic Prophylaxis Protocol for Acute Open Fractures in the Emergency Department and on the Orthopaedic Trauma Service - Microsoft Word - Open Frx Abx Protocol -for distribution V2.1.docx (stanford.edu)
11. Suzuki T, et al. Type III Gustilo–Anderson open fracture does not justify routine prophylactic Gramnegative antibiotic coverage. Sci Rep 13, 7085 (2023). https://doi.org/10.1038/s41598-023-34142-7
12. University of Nebraska Medical Center “Antibiotic Prophylaxis in Open Fractures” surgical-antibioticprophylaxis-in-open-fractures-guideline.pdf (unmc.edu)
Last reviewed November 2024