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Procedure	Prophylactic Drug(s)	Cephalosporin to Cover MRSA)
Cardiothoracic
Median sternotomy	Cefazolin or Cefuroxime or Vancomycin	1-2 g IV preoperatively (± q4-8h x 1-3 d) 1.5 g IV preoperatively (± q8h x 1-3 d) 1 g IV preoperatively (q12h x 1-3 d)
Pacemaker	None or Cefazolin or	1-2 g IV preoperatively ( ± q8h x 24 h)
insertion	Vancomycin
Pneumonectomy or lobectomy	Cefazolin or Vancomycin	1-2 g IV preoperatively ( ± q8h x 24 h postoperatively) 1 g IV preoperatively ( ± q12h x 24 h postoperatively)
Peripheral vascular	Cefazolin or Vancomycin	1-2 g IV preoperatively ( ± q8h x 24 h postoperatively) 1 g IV preoperatively ( ± q12h postoperatively)
General Surgery
Cholecystectomy	None or Cefazolin or Clindamycin + gentamicin	1-2 g IV preoperatively ± q12h x 1-3 d 600 mg IV preoperatively ( ± q8h x 24 h) 1.5 mg/kg IV preoperatively ( ± q8h x 24 h)
Cholangitis Herniorrhaphy Colon surgery	None Oral (alone or with IV) Neomycin + erythromycin + laxative IV Cefoxitin or Cefazolin + metronidazole Clindamycin + gentamicin or Ciprofloxacin	Treat for infection per Table 10.2 1 g PO of each antibiotic at 1 PM, 2 PM, 11 PM preoperatively; 4L polyethylene glycol electrolyte solution PO over 2h at 10 AM preoperatively 1-2 g IV preoperatively ( ± q4h x 3) 1-2 g IV preoperatively plus 0.5-1.0 gIV 600 mg IV x 1 1.5 mg/kg IV x 1 400 mg IV x 1
Gastrectomy	Cefazolin or Gentamicin + clindamycin or Ciprofloxacin	1 g IV preoperatively if high risk 120 mg IV preoperatively 600 mg IV preoperatively 400 mg IV preoperatively
Appendectomy	Cefoxitin or Cefazolin + metronidazole Alternative: Ciprofloxacin + clindamycin	2 g IV preoperatively ( ± q6h x 3 doses if nonperforated) and for 3-5 d if perforated 1-2 g IV and q8h x 3 doses if nonperforated, and for 3-5 d if perforated 500 mg IV preoperatively once if nonperforated or preoperatively and q8h IV x 3-5 d if perforated 400 mg preoperatively q6h x 3 doses if nonperforated, or for 3-5 d if perforated 900 mg IV preoperatively once if nonperforated or preoperatively and q8h IV if perforated
Procedure	Prophylactic Drug(s)	Drug Regimen (Usually Given During Hour Prior to Surgery;9 One Dose Preoperative is Adequate in Most Situations; Vancomycin Should be Substituted for Cephalosporin to Cover MRSA)
Mastectomy	None
Penetrating abdominal trauma	Cefoxitin	2 g IV upon hospital admission, and 2 g IV q6h x 2-5 d if GI perforation found
Ruptured viscus	Cefoxitin + gentamicin or Clindamycin + gentamicin	2 g IV pre-op 1 g IV q8h x>5 d mg/kg IV q8h x>5 d 900 mg IV q8h x>5 d mg/kg IV q8h x>5 d
Gynecologic
Caesarean section (esp high risk)	Cefazolin or Cefoxitin or Metronidazole or Clindamycin + gentamicin or levofloxacin	1-2 g IV after clamping cord ( ± 6 and 12 h later) 2 g IV after clamping cord 500 mg IV after clamping cord 600 mg IV after clamping cord 1.5 mg/kg IV 750 mg IV
Dilatation and curettage	None
Instillation abortion, 2nd trimester	Cefazolin or Metronidazole	1-2 g IV preprocedure and 6 and 12 h postprocedure 500 mg PO preprocedure ( ± q4h for 2 doses postprocedure)
Induced abortion, 1st trimester	Penicillin or Doxycycline	2 MU IV before ( ± 3 h postprocedure) 100 mg PO pre- and 200 mg 30 min postprocedure
Hysterectomy, abdominal or vaginal	Cefazolin or Cefoxitin or Metronidazole or Clindamycin + gentamicin or levofloxacin	g preoperatively and 6 and 12 h later g IV preoperatively 500 mg IV 600 mg preoperatively 1.5 mg/kg preoperatively or 750 mg IV
Head and Neck
Tonsillectomy	None
Radical resection Neurosurgical	Cefazolin or Clindamycin + gentamicin	2 g IV preoperatively ( ± q8h x 2 doses) 600 mg IV preoperatively ( ± q8h x 2 doses) 1.5 mg/kg IV preoperatively ( ± q8h x 2 doses)
CSF Shunts	None or Cefazolin or Vancomycin	1-2 g IV preoperatively 1 g IV preoperatively
Craniotomy	Clindamycin or Vancomycin + gentamicin	600 mg IV preoperatively ( ± 4 h x 1-3 d postoperatively if high risk) 500 mg IV preoperatively 1.5 mg/kg IV preoperatively
		Drug Regimen (Usually Given During Hour Prior to Surgery;9 One Dose Preoperative is Adequate in Most Situations;
Procedure Prophylactic Drug(s)		Vancomycin Should be Substituted for Cephalosporin to Cover MRSA)
Orthopedic
Arthroplasty and Cefazolin or replacement Vancomycin or Clindamycin		1-2 g IV preoperatively ( ± q8h x 3-4 doses) 1 g IV preoperatively ( ± q12h x 3-6 doses) 600 mg IV preoperatively ( ± q6h x 3-4 doses
Open reduction of Cefazolin or closed fracture Vancomycin		1-2 g IV preoperatively ( ± q8h x 3 doses) 1g IV ± 1 g IV q12h x 2 doses
Reduction of open Cefazolin or fracture Vancomycin		1-2 g upon admission ( ± q8h x 10 d) 1 g IV ± 1 g IV q12h x doses
Laminectomy or None or spinal fusion Cefazolin or Vancomycin Urology		1-2 g IV preoperatively ( ± q8h x 3d) 1 g IV preoperatively ( ± q12h x 3d)
Prostatectomy None Ciprofloxacin		400 mg IV if documented organism
GI, gastrointestinal; IV, intravenous; MRSA, methicillin resistant staphylococcus aureus; PO, by mouth Antimicrobial prophylaxis for surgery: (An advisory statement from the National Surgical Infections Prevention Project, Clinical Infectious Diseases 2004;38:1706-15.) aProphylactic drugs should ideally be given during the 1 hour period prior to surgery. (Vancomycin or quinolones can be given 2 hours prior to surgery.) For prolonged procedures or when blood loss is extensive, subsequent doses may be necessary at intervals 1-2 times the half-life of the drug. Postoperative antibiotics are rarely documented to be necessary, although two or more postoperative doses are FDA approved for many regimens. Thus many experts try to avoid continuing antibiotic prophylaxis postoperatively unless the surgical field is contaminated, e.g., a perforated viscus. The one exception is cardiothoracic surgery: continuation for 72 hours postoperatively is recommended.