Major ear surgery, complex septorhinoplasty, revision sinus surgery, laryngectomy or tympanomastoid surgery

The recommendations below are appropriate for most patients undergoing major ear surgery, complex septorhinoplasty, revision sinus surgery, laryngectomy or tympanomastoid surgery. However, if a patient is undergoing major ear surgery, complex septorhinoplasty or revision sinus surgery, and the procedure is contaminated or dirty (see Centers for Disease Control and Prevention stratification of surgical wounds) or undertaken in the setting of current or recent infection, the optimal antibiotic regimen is uncertain. The patient may already be treated with antimicrobial therapy and the prophylaxis regimens recommended below may require adjustment; the choice of prophylaxis should be guided by recent culture and susceptibility test results—seek expert advice.

For prophylaxis for major ear surgery, complex septorhinoplasty, revision sinus surgery, laryngectomy or tympanomastoid 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 completed¹ surgical prophylaxis, ear nose and throat: except hearing implants cefazolin

PLUS

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 completed¹ surgical prophylaxis, ear nose and throat metronidazole

PLUS for patients undergoing laryngectomy who are colonised or infected with MRSA or at increased risk of being colonised or infected with MRSA (see Risk factors for infection with methicillin-resistant Staphylococcus aureus)

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 )¹. surgical prophylaxis, ear nose and throat: except hearing implants 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:

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 completed¹ surgical prophylaxis, ear nose and throat clindamycin

PLUS for laryngectomy or tympanomastoid surgery

gentamicin (adult and child) 2 mg/kg up to 180 mg intravenously over 3 to 5 minutes, within the 120 minutes before surgical incision³ ⁴; intraoperative redosing is unlikely to be required (see here ). Do not give additional doses once the procedure is completed¹. surgical prophylaxis, ear nose and throat gentamicin

For patients with immediate severe or delayed severe hypersensitivity to penicillins who are undergoing laryngectomy and are colonised or infected with methicillin-resistant Staphylococcus aureus (MRSA), or at increased risk of being colonised or infected with MRSA (see Risk factors for infection with methicillin-resistant Staphylococcus aureus), add vancomycin (see dosage above) to the above regimen. Vancomycin is not needed if clindamycin is expected to have adequate activity against MRSA based on local epidemiology or recent MRSA culture results.

¹ Although a single preoperative dose of surgical antibiotic prophylaxis is expected to be sufficient to prevent postoperative infection following laryngectomy, there is insufficient evidence (especially for salvage laryngectomy) 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.Return

² 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

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