General principles and indications

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

Staphylococcus aureus colonisation increases the risk of postoperative infection. Screen patients before cardiac surgery for S. aureus carriage (both methicillin-susceptible and methicillin-resistant strains); this is particularly important for patients undergoing procedures that involve median sternotomy. If the results of screening are positive, perform decolonisation. Known methicillin-resistant S. aureus (MRSA) carriage should not delay urgent cardiac surgery.

Cardiopulmonary bypass is commonly used in cardiac surgery. Data from small pharmacokinetic/pharmacodynamic studies demonstrated altered concentrations of antimicrobials with cardiopulmonary bypass; however, the clinical relevance of these findings is unclear, and there are limited data to support alternative dosing strategies when cardiopulmonary bypass is used.

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

Table 1. Cardiac procedures and their requirement for surgical antibiotic prophylaxis

Procedures

Is surgical antibiotic prophylaxis indicated?

all cardiac procedures, including valve replacement, coronary artery bypass surgery, cardiac transplant, transcatheter aortic valve implantation (TAVI) and insertion of a ventricular assist device [NB2]

YES [NB1]

Note:

NB1: For cardiac procedures, there are inadequate data to show that a single dose of prophylaxis is as effective as 24 hours of prophylaxis. Postoperative doses can be considered but prophylaxis (intravenous or oral) should not continue beyond 24 hours, even in the presence of chest drains. See also discussion in Duration of prophylaxis.

NB2: Regimens for surgical antibiotic prophylaxis for the insertion of a ventricular assist device is beyond the scope of these guidelines; refer to local protocols.