Stanford Antimicrobial Safety and Sustainability Program
Revision date 10/31/2019
SHC Surgical Antimicrobial Prophylaxis Guidelines
I. Purpose/Background
This document is based upon the 2013 consensus guidelines from American Society of Health-System
Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS) and
the Society for Healthcare Epidemiology of America (SHEA) (1). The Stanford Antimicrobial Safety and
Sustainability Program, in conjunction with the anesthesiology and surgical departments, adapted its content to
SHC as part of the 2015 SSI Taskforce.
1. Choice of antibiotics: Please see table I for acceptable choices of antibiotics based upon surgical
procedure. Consider the addition of vancomycin or clindamycin for patients known to be colonized with
MRSA.
2. Dose of antibiotics: Please see Table II for dosing and re-dosing guidelines. We recommend weight-
based dosing of both cefazolin and vancomycin. Cefazolin should be administered every 4 hours;
clindamycin every 8 hours; vancomycin does not require re-dosing given its long half-life. We
recommend clinicians consider re-dosing earlier than specified in Table II if there is excessive intra-
operative blood loss (e.g. >1500 mL). Aminoglycosides and vancomycin should not be re-dosed in this
setting.
3. Timing of the pre-operative antibiotic dose: Guidelines recommend that pre-operative antibiotics be
administered <60 minutes prior to incision. The guidelines have not narrowed the window for pre-
operative antibiotics despite acknowledging that recent data supports that antibiotics administered <30
minutes prior to incision may be more efficacious than those administered >60 minutes. Pre-operative
antibiotics should reach acceptable tissue concentrations prior to the incision time in order to be
effective. Cefazolin (2 grams) given 30 minutes prior to incision exceeds the minimum concentration
needed; however data is lacking regarding the window between 1-30 minutes. (2)
Thus, we recommend that the optimal window for pre-operative antibiotics is ~15 – 45 minutes prior to
incision. Because vancomycin and fluoroquinolones require a prolonged infusion time to avoid
intolerance, especially at higher doses, guidelines recommend that vancomycin infusion may begin 60-
120 minutes prior to incision (it’s long half-life makes this acceptable.)
4. Duration of post-operative antibiotics: We recommend that all patients receive <24 hours of post-
operative antibiotics. In many procedures, no doses after incision closure are necessary. Refer to solid
organ transplant protocols if applicable.
Table I. Preferred Empiric Agent by Surgical Type. (1)
Preferred Agent Beta-lactam allergy
Cardiac Surgery/ Vascular/Thoracic Cefazolin VancomycinP
1
Cardiac Surgery with prosthetic
material
Cefazolin + vancomycin VancomycinP
1
Cardiac device insertion
(e.g., pacemaker implantation)
Cefazolin VancomycinP
1
Gastroduodenal Cefazolin VancomycinP
1
P + gentamicin
Biliary Tract Cefazolin Metronidazole + LevofloxacinS
Colorectal, appendectomy Cefazolin + metronidazole Metronidazole + LevofloxacinS
Stanford Antimicrobial Safety and Sustainability Program
Revision date 10/31/2019
Preferred Agent Beta-lactam allergy
Other general surgery
(e.g. hernia repair, breast)
Cefazolin VancomycinP
1
Cesarean delivery Cefazolin ClindamycinP
1
P + gentamicin
Gynecological (eg hysterectomy) Cefazolin ClindamycinP
1
P + gentamicin
Head & Neck
U
Clean (incision through skin)
U
:
Cefazolin
UClean-contaminatedU:
• Ear/sinonasal procedure:
Cefazolin
• Procedures w/ oral mucosa
breach:
Cefazolin + Metronidazole
UContaminatedU: Cefazolin +
metronidazole
Clindamycin
Neurosurgery
Cefazolin VancomycinP
1
Orthopedics Cefazolin VancomycinP
1
Plastic Surgery Cefazolin VancomycinP
1
UrologyP
2
These are empiric recommendations
when no pre-op urine culture data is
available or cultures were negative.
Cefazolin
UOpen/laparoscopic involving
intestineU (clean-contaminated, e.g.,
radical cystectomy with ileal
conduit):
• Cefoxitin
If prosthetic material involved in
urologic procedures, should add
one-time dose of gentamicin
GentamicinP
2a
P + ClindamycinP
2b
P
UOpen/laproscopic
(clean:skin incision, does not
involve GU tract):
• Clindamycin
P
2b
UOpen/laparoscopic involving
intestine U(clean-contaminated,
e.g., radical cystectomy with ileal
conduit)
• Metronidazole +
Levofloxacin
If prosthetic material involved in
urologic procedures, should add
one-time dose of gentamicin if not
already given
Heart Transplant Vancomycin + cefazolinP
4
Vancomycin + levofloxacinP
4
Lung or Heart-Lung Transplant Vancomycin + cefepimeP
4
Vancomycin + aztreonamP
4
Liver Transplant Piperacillin/tazobactamP
4
VancomycinP
1
P or clindamycin +
ciprofloxacin
P
4
Notes:
1.
Clindamycin can be used as an alternative to vancomycin. Clindamycin and vancomycin are recommended alternative
agents to cefazolin for patients with beta-lactam allergies. According to our 2018 hospital-wide antibiogram (
31TUlinkU31T), 79% of
MSSA isolates were susceptible to clindamycin, while 100% were susceptible to vancomycin. If practical, we recommend
vancomycin as the preferred choice for those with beta-lactam allergies.
2. Urology notes
Stanford Antimicrobial Safety and Sustainability Program
Revision date 10/31/2019
P
a
P Ciprofloxacin is a reasonable alternative. However, according to the 2018 SHC antibiogram (31Tlink31T), more E. coli isolates
were susceptible to aminoglycosides than fluoroquinolones
P
b
P If significant concern for MRSA, vancomycin should be considered as an alternative to clindamycin. According to our 2018
hospital wide antibiogram, only 55% of MRSA isolates are susceptible to clindamycin, while 100% were susceptible to
vancomycin. In addition, clindamycin has limited urinary penetration. However, vancomycin infusion should be started 60-
120 minutes prior to incision to allow for complete drug administration. (see Table 2)
3. If cultures will be obtained intra-operatively, prophylactic antibiotics should be withheld.
4. In patients with documented infections prior to surgery, prophylaxis should be directed at causative pathogens; consult ID.
Table II: Dosing and re-dosing of antimicrobial agents.(1)
Antimicrobial
Recommended Dose
Re-dosing
(hours)
Notes
Cefazolin
2 grams
> 120 kg = 3 grams
4
Clindamycin
900 mg
6
Vancomycin
< 80 kg = 1 gram
80 – 99 kg = 1.25 grams
100 -120 kg = 1.5 grams
>120 kg = 2 grams
12
Requires prolonged infusion
time, can be given 60
-120
minutes
prior to incision
Ampicillin-sulbactam
3 grams
2
Aztreonam
2 grams
4
Cefepime 2 grams 4
Renal insufficiency: contact OR
pharmacy
Cefotetan
2 grams
6
Cefoxitin
2 grams
2
Ceftriaxone
2 grams
N/A
Cefuroxime
1.5 grams
4
Ciprofloxacin 400 mg 8
Requires prolonged infusion
time, can be given 60
-120
minutes prior to incision
Ertapenem
1 gram
N/A
Gentamicin
5 mg/kg (single dose)
If CrCl <20, 2mg/kg (single
dose) or consult pharmacy
N/A
Stanford Antimicrobial Safety and Sustainability Program
Revision date 10/31/2019
Levofloxacin
500 mg; 750mg if lung
transplant
N/A
Requires prolonged infusion
time, can be given 60
-120
minutes prior to incision
Metronidazole
500 mg
12
Piperacillin-tazobactam 3.375 grams 2
Renal insufficiency: contact OR
pharmacy
Tobramycin
5 mg/kg (single dose)
If CrCl <20, 2mg/kg (single
dose) or consult pharmacy
N/A
Stanford Antimicrobial Safety and Sustainability Program
Revision date 10/31/2019
Table III: Post-op dosing
Antimicrobial
Recommended Dose
(Many procedures require no post-op doses of antimicrobials. If
desired, limit duration to <24 hours post closure.) Refer to solid
organ transplant protocols if applicable.
Cefazolin
2 grams q8h up to 2 doses or see Transplant Protocols if applicable
Clindamycin
900 mg q8h up to 2 doses
Vancomycin
1 grams q12h up to 1 dose or see Transplant Protocols if applicable
Ampicillin-sulbactam
3 grams q6h up to 3 doses
Aztreonam
2 grams q8h up to 2 doses
Cefepime
Lung transplant: 2g q8h extended infusion (see Transplant Manual for
duration)
Cefotetan
2 grams q12h up to 1 dose
Cefoxitin
2 grams q6h up to 3 doses
Ceftriaxone
No post-op doses needed (q24h hour dosing)
Cefuroxime
1.5 grams q8h up to 2 doses
Ciprofloxacin
400 mg q12h up to 1 dose
Gentamicin
No post-op doses needed (q24h hour dosing)
Levofloxacin
No post-op doses needed (q24h hour dosing)
Metronidazole
500 mg q8h up to 2 doses
Piperacillin-tazobactam
3.375g q8h extended infusion up to 2 doses or see Transplant Protocols if
applicable
Tobramycin
No post-op doses needed (q24h hour dosing)
Stanford Antimicrobial Safety and Sustainability Program
Revision date 10/31/2019
II. References:
1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice
guidelines for antimicrobial prophylaxis in surgery. Am J Heal Pharm. 2013;70(3):195–283.
2. Douglas A, Udy A a., Wallis SC, Jarrett P, Stuart J, Lassig-Smith M, et al. Plasma and tissue
pharmacokinetics of cefazolin in patients undergoing elective and semielective abdominal aortic
aneurysm open repair surgery. Antimicrob Agents Chemother. 2011;55(11):5238–42.
3. Abbo LM and Grossi PA, Surgical site infections: Guidelines from the American Society of
Transplantation Infectious Diseases Community of Practice, Clin Transplant. 2019 Sep;33(9):e13589.
doi: 10.1111/ctr.13589. Epub 2019 May 23.
III. Document Information:
A. Original Author/Date: Marisa Holubar MD MS, Emily Mui PharmD, Stan Deresinski MD, Lina
Meng PharmD, Lucy Tompkins MD PhD 6/2/2016
B. Gatekeeper: Antimicrobial Stewardship Program
C. Review and Renewal Requirement
This document will be reviewed every three years and as required by change of law or practice
D. Revision/Review History:
Surgical review: Jonathan Berek MD, Jack Boyd MD, James Chang MD, Stuart Goodman MD
PhD, Mary Hawn MD, Griff Harsh MD, Serena Hu MD, John Morton MD, Andrew Shelton MD,
Lawrence Shuer MD, Eila Skinner MD, Gary Steinberg MD PhD, Mark Welton MD 8/19/2016
Anesthesiology review: Ron Pearl MD PhD, Cliff Schmiesing MD 8/19/2016
Pharmacy review: Manya Sarram 8/19/2016; SOT team/Heart Transplant Quality Council
10/16/2019.
E. Approvals
SASS/SSI taskforce updated – 8/19/2016
Approved Antibiotic Subcommittee – 6/2/2016, 8/17/2017, 10/31/2019 pending
Approved by P&T Committee – 6/17/2016, 9/15/2017
This document is intended only for the internal use of Stanford Health Care (SHC). It may not be copied or otherwise used, in whole, or in
part, without the express written consent of SHC. Any external use of this document is on an AS IS basis, and SHC shall not be
responsible for any external use.
Stanford Health Care
Stanford, CA 94305