Biliary surgery, including laparoscopic surgery

Consider the principles for appropriate prescribing of surgical antibiotic prophylaxis (see Principles for appropriate prescribing of surgical antibiotic prophylaxis) and the general principles of surgical antibiotic prophylaxis for abdominal surgery. See Biliary procedures and their requirement for surgical antibiotic prophylaxis for the recommendations for surgical prophylaxis for biliary surgery, including laparoscopic surgery.

If the patient is being treated with antibiotic therapy for acute cholecystitis, it is not necessary to give additional antibiotic prophylaxis provided the treatment regimen has activity against the organism(s) most likely to cause postoperative infection. However, adjust the timing of the treatment dose to achieve adequate plasma and tissue concentrations at the time of surgical incision and for the duration of the procedure. See Surgical antibiotic prophylaxis for patients receiving treatment for established infection.

For a printable summary table of the indications and regimens for surgical antibiotic prophylaxis, see here.

Table 1. Biliary procedures and their requirement for surgical antibiotic prophylaxis
Procedures	Is surgical antibiotic prophylaxis indicated?
laparoscopic surgery	ONLY IF the patient has risk factors for postoperative infection (eg older than 70 years, diabetes, obstructive jaundice, common bile duct stones, acute cholecystitis, nonfunctioning gallbladder)
open cholecystectomy	YES; however, if the patient is being treated with antibiotic therapy for acute cholecystitis, additional antibiotic prophylaxis may not be required (see above)

If prophylaxis is indicated for biliary surgery, use:

cefazolin 2 g (child: 30 mg/kg up to 2 g) intravenously, within the 60 minutes before surgical incision; intraoperative redosing may be required (see here ). Do not give additional doses once the procedure is completed. surgical prophylaxis, biliary cefazolin

For patients with immediate nonsevere or delayed nonsevere hypersensitivity to penicillins, use cefazolin as above. See also Surgical antibiotic prophylaxis for patients with a penicillin or cephalosporin allergy.

For patients with immediate severe or delayed severe hypersensitivity to penicillins, use:

gentamicin (adult and child) 2 mg/kg up to 180 mg intravenously over 3 to 5 minutes, within the 120 minutes before surgical incision¹ ²; intraoperative redosing is unlikely to be required (see here ). Do not give additional doses once the procedure is completed surgical prophylaxis, biliary gentamicin

PLUS EITHER

1 vancomycin (adult and child) 15 mg/kg up to 2 g intravenously, started within the 120 minutes before surgical incision (recommended rate 10 mg/minute)³; intraoperative redosing may be required (see here ). Do not give additional doses once the procedure is completed surgical prophylaxis, biliary vancomycin

OR

2 clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, within the 120 minutes before surgical incision; intraoperative redosing may be required (see here ). Do not give additional doses once the procedure is completed. surgical prophylaxis, biliary clindamycin

¹ If the patient is obese (for adults, body mass index 30 kg/m² or more), use adjusted body weight (see ../Aminoglycoside-use-in-special-patient-groups/c_ABG_Aminoglycoside-use-in-special-patient-groups_topic_5.html#c_ABG_Aminoglycoside-use-in-special-patient-groups_topic_5__fig-504) to calculate the dose.Return

² Do not use gentamicin for surgical prophylaxis in adults with a CrCl less than 20 mL/min; seek expert advice. For children with kidney impairment, seek expert advice on gentamicin use.Return

³ It is the consensus view of the Antibiotic Expert Groups that the vancomycin infusion should be started at least 15 minutes before surgical incision to ensure adequate blood and tissue concentrations at the time of incision and allow potential infusion-related toxicity to be recognised before induction of anaesthesia.Return