Disease Site Breast. Less than 120 kg: Cefazolin 2 grams IV Greater than or equal to 120 kg: Cefazolin 3 grams IV. Head & Neck

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1 Patients scheduled for surgery should have the following antibiotics administered prior to their procedure 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 patient has multiple known antibiotic drug allergies, administer antibiotics as clinically indicated. Discontinue all antibiotics within 2 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.) All of these require appropriate documentation. See Appendix A for intraoperative re-dosing recommendations. Disease Site Breast Head & Neck (ENT Clean) GI (Clean) Melanoma Plastics Head & Neck (ENT Clean Contaminated) Neurosurgery Vascular Orthopedics No Penicillin Allergy Less than 120 kg: Cefazolin 2 grams IV Skull base ONLY: All other types: Less than 120 kg: Cefazolin 2 grams IV Pelvic surgery ONLY: Cefoxitin 2 grams IV All other types: Patients with Penicillin Allergy Levofloxacin 500 mg IV And Clindamycin 600 mg IV

2 Patients scheduled for surgery should have the following antibiotics administered prior to their procedure 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 patient has multiple known antibiotic drug allergies, administer antibiotics as clinically indicated. Discontinue all antibiotics within 2 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.) All of these require appropriate documentation. See Appendix A for intraoperative re-dosing recommendations. Disease Site No Penicillin Allergy Patients with Penicillin Allergy GI Gynecologic Thoracic, Pulmonary, Esophageal Genitourinary Gastric, Pancreas, or Liver: Cefoxitin 2 grams IV Colorectal: Ertapenem 1 gram IV Greater than or equal to 120 kg: Cefazolin 3 grams IV Or Cefoxitin 2 grams IV Endoscopy or Procedures: Greater than or equal to 120 kg: Cefazolin 3 grams IV Or Cefoxitin 2 grams IV Or Ciprofloxacin 00 mg IV Or Gentamicin 1.5 mg/kg IV Implanted prosthesis: Gentamicin 5 mg/kg IV Ciprofloxacin 00 mg IV And Metronidozole 500 mg IV And Ciprofloxacin 00 mg IV Vancomycin 1 gram IV And Ciprofloxacin 00 mg IV Extended coverage (Option 1) And Gentamicin 1.5 mg/kg IV Or Ciprofloxacin 00 mg IV Limited coverage (Option 2) Ciprofloxacin 00 mg IV or PO Vancomycin 1 gram IV MRSA screening should be performed on patients hospitalized within 30 days of procedure, transferred from skilled nursing facilities, with percutaneous lines/catheters, or with HIV. Any surgical patient with a history of MRSA infection or positive MRSA screening should receive Vancomycin 1 gram IV as part of surgical prophylaxis. If Vancomycin is being ordered based on standard disease site recommendations, a second dose is not necessary.

3 Appendix A: Recommended IntraOp Redosing Intervals for Commonly Used Antimicrobials for Surgical Prophylaxis for Patients with Normal Renal Function 1 Antimicrobial Ampicillin-sulbactam Cefazolin Cefoxitin Ciprofloxacin 3 Clindamycin Ertapenem Gentamicin Levofloxacin 3 Metronidazole Vancomycin Half-life in Adults with Normal Renal Function, hr Recommended Redosing Interval (From initiation of Preoperative Dose), hr Patients with impaired renal function need individualized initial and secondary antibiotic dosing based on GFR and case type. 2 For antimicrobials with a short half-life (e.g., cefazolin, cefoxitin) used before long procedures, redosing in the operating room is recommended at an interval of approximately two times the half-life of the agent in patients with normal renal function. Recommended redosing intervals marked as not applicable (NA) are based on typical case length; for unusually long procedures, redosing may be needed. 3 While fluoroquinolones have been associated with an increased risk of tendinitis/tendon rupture in all ages, use of these agents for single-dose prophylaxis is generally safe. In general, 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.(actual weight IBW).

4 SUGGESTED READINGS American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins. (2006). ACOG Practice Bulletin No. 7 Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol. 108(1): American Society of Health-System Pharmacists. (2013). ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 70: Bratzler DW, Houck PM, for the Surgical Infection Prevention Guidelines Writers Group. (200). Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. CID. 38: Dellinger EP, Gross PA, Barrett TL, et al. (199). Quality standard for antimicrobial prophylaxis in surgical procedures. Clin Infect Dis. 18: Edwards BL, Stukenborg GJ, Brenin DR, et al. (201). Use of prophylactic antibiotics during surgical drain presence following mastectomy. Ann Surg Oncol. 21: doi: /s Gilbert DN, Moellering RC Jr. (2011). The Sanford Guide to Antimicrobial Therapy. 1 st ed. Hyde Park, VT: Antimicrobial Therapy Inc. pp Itani KMF, Wilson SE, Awad SS, et al. (2006). Ertapenem versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med. 355 (25): Mangram AJ, Horan TC, Pearson ML, et al. (1999). Guidelines for prevention of surgical site infection. Infect Control Hosp Epidemiol. 20: No author listed. Treatment Guidelines from the Medical Letter. Antimicrobial Prophylaxis for Surgery. Med Lett Drugs Ther 2009; issue 82 article code 82a Page CP, Bohnen JM, Fletcher JR, et al. (1993). Antimicrobial prophylaxis for surgical wounds. Arch Surg. 128: Phillips BT, Bishawi M, Dagum AB, et al. (2013). A systemic review of antibiotic use and infection in breast reconstruction: what is the evidence? Plast Reconstr Surg. 131(1):1-13. doi: /prs.0b013e c39

5 DEVELOPMENT CREDITS This practice algorithm is based on majority expert opinion of the Faculty at the University of Texas, M.D. Anderson Cancer Center. A multidisciplinary approach was used and included input from the following surgical oncologists and infectious diesase specialists: Thomas Aloia, MD Justin Earl Bird, MD Roy Chemaly, MD Ŧ Collin Dinney, MD David Gershenson, MD Linda Graviss, MT Valerae Lewis, MD Geoffrey Robb, MD Raymond Sawaya, MD Stephen Swisher, MD George Michael Viola, MD Jeffrey Weinberg, MD Randal Weber, MD Ŧ Core Developer

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