Antibiotic regimens

For prophylaxis for cardiac 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 also Duration of prophylaxis. surgical prophylaxis, cardiac cefazolin

For patients colonised or infected with MRSA, or at increased risk of being colonised or infected with MRSA (eg patients undergoing a prosthetic cardiac valve 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 cefazolin:

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)¹; intraoperative redosing may be required. See also Duration of prophylaxis. surgical prophylaxis, cardiac vancomycin

At the time of writing, the optimal antibiotic regimen for prophylaxis for transcatheter aortic valve implantation (TAVI) is not known. High rates of postoperative endocarditis (including endocarditis caused by organisms not susceptible to cefazolin) were reported in a large international cohort², but have not been observed in Australian patients. The antibiotic regimens recommended above may need to be modified according to the organisms causing infection within the institution and their susceptibility patterns—seek expert advice.

For patients with immediate nonsevere or delayed nonsevere hypersensitivity to penicillins, use cefazolin, with or without vancomycin, 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:

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)¹; intraoperative redosing may be required. See also Duration of prophylaxis vancomycin

PLUS

gentamicin (adult and child) 5 mg/kg up to 480 mg intravenously over 3 to 5 minutes, within the 120 minutes before surgical incision³; intraoperative redosing is unlikely to be required (see Duration of prophylaxis). For dosage adjustment in adults with a CrCl 39 mL/min or less, see Principles of gentamicin use for surgical antibiotic prophylaxis ⁴. surgical prophylaxis, cardiac gentamicin

Applying antimicrobials (eg ointments, solutions, powders) to the surgical incision to prevent surgical site infection is not recommended because there is potential for harm (eg hypersensitivity reactions, bacterial resistance) and inadequate evidence to support a benefit.

¹ 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

² Regueiro A, Linke A, Latib A, Ihlemann N, Urena M, Walther T, et al. Association between transcatheter aortic valve replacement and subsequent infective endocarditis and in-hospital death. JAMA 2016;316(10):1083-92. [URL]Return

³ 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

⁴ 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