Surgical prophylaxis for vascular surgery

Consider the principles for appropriate prescribing of surgical antibiotic prophylaxis (see Principles for appropriate prescribing of surgical antibiotic prophylaxis). See Vascular surgery procedures and their requirement for surgical antibiotic prophylaxis for the recommendations for surgical prophylaxis for vascular surgery¹ .

For elective implantation of prosthetic material, consider Staphylococcus aureus screening (for both methicillin-susceptible and methicillin-resistant strains). If the results of screening are positive, perform decolonisation.

If the patient is already receiving antibiotic treatment for an established infection, 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; if an ischaemic limb is being amputated, this should include anaerobes. 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.

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

Table 1. Vascular surgery procedures and their requirement for surgical antibiotic prophylaxis
Procedures	Is surgical antibiotic prophylaxis indicated?
varicose vein procedures brachial or carotid artery procedures not involving insertion of prosthetic material	NO
vascular reconstructive surgery involving the abdominal aorta or lower limbs	YES
limb amputation	YES; however, if the patient is being treated with antibiotic therapy for an infected limb, additional antibiotic prophylaxis may not be required (see above)

If prophylaxis is indicated for vascular 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, vascular cefazolin

PLUS for amputation of an ischaemic limb

metronidazole 500 mg (child: 12.5 mg/kg up to 500 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, vascular metronidazole

For patients colonised or infected with methicillin-resistant S. aureus (MRSA), or at increased risk of being colonised or infected with MRSA (eg patients undergoing a vascular procedure that is a reoperation [return to theatre or early revision]; see also Risk factors for infection with methicillin-resistant Staphylococcus aureus), add vancomycin to the above regimen:

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)² ; intraoperative redosing may be required (see here). Do not give additional doses once the procedure is completed. surgical prophylaxis, vascular vancomycin

For patients with immediate nonsevere or delayed nonsevere hypersensitivity to penicillins, the above regimens are suitable. 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:

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 vancomycin

PLUS

gentamicin (adult and child) 2 mg/kg up to 180 mg intravenously over 3 to 5 minutes, within the 120 minutes before surgical incision⁴ ⁵ ⁶; intraoperative redosing is unlikely to be required (see here). Do not give additional doses once the procedure is completed surgical prophylaxis, vascular gentamicin

PLUS for amputation of an ischaemic limb

metronidazole 500 mg (child: 12.5 mg/kg up to 500 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. metronidazole

A single preoperative dose of surgical antibiotic prophylaxis (with or without intraoperative doses) is sufficient to prevent postoperative infection. Although a single randomised controlled trial⁷ demonstrated a benefit when surgical prophylaxis for vascular surgery was continued until all lines were removed, the World Health Organization concluded that postoperative doses were not warranted because of the low quality of the study and the significant evidence to suggest that postoperative doses are not required for the significant majority of procedures. Extended prophylaxis is associated with an increased risk of adverse effects, including subsequent infection with resistant pathogens or Clostridioides difficile. Postoperative doses are not recommended.

¹ The safety and efficacy of intraoperative irrigation with antimicrobial solutions, or soaking surgical implants (eg vascular grafts, mesh) with antimicrobial solutions before insertion, has not been established. There is concern about the development of resistance; in particular, rifampicin should not be used as a single drug. There is also potential for adverse effects. Consequently, these practices cannot be recommended. Return

² It is the consensus view of the Antibiotic Expert Groups that the vancomycin infusion should be started at least 15 minutes before the procedure 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

³ It is the consensus view of the Antibiotic Expert Groups that the vancomycin infusion should be started at least 15 minutes before the procedure 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

⁴ If there is at least a moderate likelihood that the procedure will continue for longer than 6 hours, see Principles of gentamicin use for surgical antibiotic prophylaxis for dosing.Return

⁵ 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

⁶ 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

⁷ Hall JC, Christiansen KJ, Goodman M, Lawrence-Brown M, Prendergast FJ, Rosenberg P, et al. Duration of antimicrobial prophylaxis in vascular surgery. Am J Surg 1998;175(2):87-90. [URL]Return