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Surgical and Interventional Radiology Antimicrobial Prophylaxis – Adult/Pediatric – Inpatient/Ambulatory

Surgical and Interventional Radiology Antimicrobial Prophylaxis – Adult/Pediatric – Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Infection and Isolation


1
Surgical and Interventional Radiology Antimicrobial
Prophylaxis – Adult/Pediatric –
Inpatient/Ambulatory/Emergency Department
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 3
METHODOLOGY ...................................................................................................................... 4
DEFINITIONS ............................................................................................................................ 4
INTRODUCTION ....................................................................................................................... 4
TABLE 1. SURGICAL PROPHYLAXIS ANTIMICROBIAL DOSING ......................................... 6
TABLE 2. REDOSING INTERVALS .......................................................................................... 7
TABLE 3. RECOMMENDED ADMINISTRATION TIMES .......................................................... 8
TABLE 4. SURGICAL PROPHYLAXIS ANTIMICROBIAL SELECTION AT UWHC ................. 9
TABLE 5. INTERVENTIONAL RADIOLOGY PROPHYLAXIS ANTIMICROBIAL
SELECTION .............................................................................................................................16
RECOMMENDATIONS .............................................................................................................20
UW HEALTH IMPLEMENTATION ............................................................................................49
APPENDIX A. ANTIMICROBIAL SELECTION IN PATIENTS WITH REPORTED Β-
LACTAM ALLERGY OR INTOLERANCE ................................................................................50
APPENDIX B. UW HEALTH ANESTHESIA TABLE FOR OR ANTIBIOTICS:
PREPARATION AND CONSIDERATION FOR IV PUSH ADMINISTRATION ..........................51
APPENDIX C. EVIDENCE GRADING SCHEME ......................................................................54
REFERENCES .........................................................................................................................55
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2
CPG Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS; Drug Policy Manager
Phone Number: 608-265-0341
Email Address: PTrapskin@uwhealth.org

CPG Contact for Content
Name: Lucas Schulz, PharmD, BCPA-AQ ID; Infectious Disease Clinical Coordinator
Phone Number: 608-890-8617
Email Address: LSchulz2@uwhealth.org

Guideline Author and Coordinating Team Member:
Tyler K Liebenstein, PharmD, BCPS-AQ ID
Joshua P Vanderloo, PharmD, BCPS; Drug Policy Program

Review Individuals:
Lucas Schulz, PharmD, BCPS AQ-ID; Jill Strayer, PharmD, BCPS
Barry Fox, MD; Sheryl Henderson, MD; Alex Lepak, MD
Ahmed Al-Niaimi, MD; Michael Bentz, MD; Catharine Garland, MD; Dobie Giles, MD;
Diane Heatley, MD; Gregg Heatley, MD; Bermans Iskandar, MD Greg Kennedy, MD; Katie
Kessler, PA-C; David Kushner, MD; Charles Leys, MD; Amy Liepert, MD; Daniel Resnick,
MD; Deborah Rusy, MD; Scott Springman, MD; Gregory Trost, MD

Committee Approvals:
UWHealth Antimicrobial Use Subcommittee February 2017
UWHealth P&T Committee March 2017

Release Date: March 2017

Next Review Date: March 2019
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3
Executive Summary
Guideline Overview
This document is intended to guide the use of antimicrobial selection and dosing for preoperative
and preprocedural prophylaxis of surgical site infections.

Key Practice Recommendations
To provide antimicrobial prophylaxis recommendations for perioperative or periprocedural in
patients undergoing surgical intervention or radiologic procedures.

Key Revisions (November 2017 Interim Review)
1. Addition of appendix describing preparation and administration of IV push antibiotics
preoperatively

Key Revisions (July 2017 Interim Review)
1. Clarification of interventional radiology procedures and antimicrobial prophylaxis selection.

Key Revisions (2017 Periodic Review)
1. Addition of ciprofloxacin for cardiac procedures if risk of Gram-negative infections.
2. Removal of cefoxitin and cefotetan as options for colorectal surgery prophylaxis.
3. Addition of ampicillin-sulbactam as option in Head and Neck procedures.
4. Clarification of antibiotic selection for ERCP.
5. Adjustment of antibiotic selection for pediatric orthopedic spinal fusions.
6. Addition of maximum doses for all patients fewer than 40 kg.
7. Clarification that redosing interval information is for patients with non-normal renal function.

Companion Documents
Treatment of Patients with Reported Allergies to β-Lactam Antibiotics – Adult – Inpatient – Clinical
Practice Guideline

Scope
Disease Condition: This clinical practice guideline is intended to guide the use of perioperative
antibiotics in adult and pediatric patients undergoing a surgical or interventional radiology
procedure. Intraoperative redosing of antibiotics is also addressed.

Clinical Specialty: All medical specialties

Intended Users: Anesthesiologists, surgeons, nurse practitioners, physician assistants, primary
care providers, cardiologists, hospitalists, pharmacists, and nurses

Objective
To provide guidance on selection of preoperative antimicrobials based on specified surgery or
procedure with information on weight-based dosing and redosing intraoperatively.

Target Population
All patients undergoing surgery or procedure which is included in the guideline.

Interventions and Practices Considered
The clinical interventions and practices recommended in this guideline are intended for patients
undergoing surgeries or procedures described in the guideline.

Major Outcomes Considered
• Proportion of patients receiving antimicrobials preoperatively or preprocedurally
• Number of postoperative infections
• Proportion of antimicrobials given within appropriate time window per SCIP guidelines
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4

Methodology
Methods Used to Collect/Select the Evidence
Electronic database searches (i.e. PUBMED) were conducted and workgroup members queried to
collect evidence for review; for the 2017 revision, clinical evidence dating back to January 2014 was
reviewed. Major external guidelines were reviewed for new clinical information. Additionally, hand
searches were performed within selected evidence for other relevant resources. Expert opinion,
clinical experience, and regard for patient safety/experience were also considered during
discussions of the evidence.

Methods Used to Formulate the Recommendations
All recommendations endorsed or developed by the guideline workgroup were reviewed and
approved by other stakeholders or committees.

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup a modified Grading of
Recommendations Assessment, Development and Evaluation (GRADE) methodology. (Appendix
E).
1


Rating Scheme for the Strength of the Evidence/Strength of the Recommendations:
See Appendix E for the rating scheme used within this document.

Recognition of Potential Health Care Disparities
No potential disparities identified.

Definitions
(1) SSI – surgical site infection
(2) MRSA – methicillin-resistant Staphylococcus aureus
(3) MSSA – methicillin-sensitive Staphylococcus aureus
(4) MRSE – methicillin-resistant coagulase-negative staphylococci
(5) IR – interventional radiology
(6) Wound classification
2

i. Clean – An uninfected operative wound in which no inflammation is encountered and the
respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean
wounds are primarily closed and, if necessary, drained with closed drainage. Operative
incisional wounds that follow non-penetrating (blunt) trauma should be included in this
category if they meet the criteria.
ii. Clean-contaminated – Operative wounds in which the respiratory, alimentary, genital (male or
female), or urinary tracts are entered under controlled conditions and without unusual
contamination. Specifically, operations involving the biliary tract, appendix, vagina, and
oropharynx are included in this category, provided no evidence of infection or major break in
technique is encountered.
iii. Contaminated – Open, fresh, accidental wounds. In addition, operations with major breaks in
sterile technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract,
and incisions in which acute, nonpurulent inflammation is encountered including necrotic
tissue without evidence of purulent drainage (e.g., dry gangrene) are included in this category.
iv. Dirty (or infected) – Includes old traumatic wounds with retained devitalized tissue and those
that involve existing clinical infection or perforated viscera. This definition suggests that the
organisms causing postoperative infection were present in the operative field before the
operation.

Introduction
3

Antimicrobial surgical prophylaxis may be considered primary (prevention of an initial infection),
secondary (prevention of recurrence of a preexisting infection, or eradication (elimination of a
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5
colonized organism to prevent infection development); this document presents guidelines for
primary surgical prophylaxis with antimicrobials. Preoperative antimicrobial use is a component of
a multifactorial approach (including basic infection-control strategy, surgical technique, OR
environment, instrument sterilization, preoperative preparation, perioperative management) in
preventing surgical site infections (SSIs). In surgical procedures with high rates of infection and
clean procedures where infection carries severe consequences, antimicrobial prophylaxis may have
benefit.
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6
Table 1. Surgical prophylaxis antimicrobial dosing
3

Antimicrobial < 40 kg
a
40 – 80 kg 81 – 120 kg 121 – 160 kg > 160 kg
Ampicillin 50 mg/kg (max 2 g) 2 g
Ampicillin-sulbactam
50 mg/kg of ampicillin
component (max 3 g)
3 g
Cefazolin 30 mg/kg (max 2 g) 2 g 3 g
Cefepime 50 mg/kg (max 2 g) 2 g
Cefotaxime 50 mg/kg (max 1 g) 1 g 2 g
Cefoxitin 40 mg/kg (max 2 g) 2 g 3 g
Ceftriaxone 50 mg/kg (max 1 g) 1 g 2 g
Cefuroxime 50 mg/kg (max 1.5 g ) 1.5 g 3 g
Ciprofloxacin 10 mg/kg (max 400 mg) 400 mg 600 mg 800 mg
Clindamycin 10 mg/kg (max 600 mg) 600 mg 900 mg 1200 mg
Fluconazole 6 mg/kg (max 400 mg) 400 mg
Gentamicin

4 mg/kg
b
5 mg/kg
c
Levofloxacin 10 mg/kg (max 500 mg) 500 mg 750 mg
Metronidazole
d
15 mg/kg (max 1 g) 500 mg 750 mg
Moxifloxacin 400 mg 800 mg
Piperacillin-tazobactam
2-9 mos: 80 mg/kg
9 mos & older: 100 mg/kg
(for both age groups, max
3000 mg piperacillin
component)
3.375 g 4.5 g
Vancomycin 15 mg/kg (max 1 g) 20 mg/kg (max 2000 mg) 2000 mg
a
Consult pediatric pharmacist for neonatal dosing
b
Use patient’s dry weight or estimated dosing weight. If unavailable, may use weight estimate by growth chart and estimated curve
c
If patient’s actual weight is more than 20% greater than ideal body weight, gentamicin dose is based on dosing weight where dosing weight (DW) is DW = IBW +
0.4(actual weight-IBW).
d
Neonates weighing fewer than 1200 g should receive 7.5 mg/kg metronidazole dose

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7
Table 2. Redosing intervals
a,b

3,4

Antimicrobial
Half-life in Adults with
Normal Renal Function
b

Intraoperative Redosing Interval Based on Renal Function
Ampicillin 1-1.9 h
≥50 mL/min 30-49 mL/min 11-29 mL/min ≤10 mL/min or HD
3 h 4 h 6 h 9 h
Ampicillin-sulbactam 0.8-1.3 h
≥50 mL/min 30-49 mL/min 15-29 mL/min ≤15 mL/min or HD
3 h 4 h 6 h 12 h
Cefazolin 1.2-2.2 h
≥50 mL/min 11-49 mL/min ≤10 mL/min or HD
4 h 6 h 12 h
Cefepime
c
2 h
≥60 mL/min ≤ 59 mL/min or HD
4 h 8 h
Cefotaxime 0.9-1.7 h
non-HD HD
3 h 24 h
Cefoxitin 0.7-1.1 h
≥50 mL/min 30-49 mL/min 5-29 mL/min <5 mL/min or HD
3 h in non-obese
2 h in obese
4 h in non-obese
3 h in obese
6 h in non-obese
4 h in obese
12 h in non-obese
8 h in obese
Ceftriaxone 5.4-10.9 h No renal dose adjustment; redose at 24 h

Cefuroxime 1-2 h
≥20 mL/min 11-19 mL/min ≤10 mL/min or HD
4 h 6 h 12 h
Ciprofloxacin 3-7 h
≥10 mL/min ≤10 mL/min or HD
8 h 16 h
Clindamycin 2-4 h No renal dose adjustment; redose at 6 h
Fluconazole 30 h No renal dose adjustment; redose at 24 h
Gentamicin

2-3 h
≥50 mL/min <50 mL/min
Pediatrics: 12 h (for 4 mg/kg); Adults: 24 hr (for 5
mg/kg)
Consult OR Pharmacist
Levofloxacin 6-8 h No renal dose adjustment; redose at 24 h

Metronidazole

6-8 h No renal dose adjustment; redose at 6 h
Moxifloxacin 8-15 h No renal dose adjustment; redose at 24 h
Piperacillin-tazobactam
c
0.7-1.2 h
≥40 mL/min 21-39 mL/min ≤20 mL/min HD
2 h 3 h 4 h 8 h
Vancomycin 4-8 h
≥100 mL/min 60-99 mL/min 30-59 mL/min <30 mL/min
8 h 12 h 24 h Consult OR Pharmacist
Pediatrics: If CrCL >50 mL/min, redose at 6 h due to increased clearance; if CrCL <50 mL/min, consult OR
Pharmacist
a
Redosing should be considered after significant blood loss.
b
Redosing interval is timed from the initiation of the preoperative dose. Patients with renal impairment or failure will have longer antimicrobial half-lives and therefore longer redosing
intervals. For antimicrobials with a short half-life (e.g. cefazolin) in patients with normal renal function, redosing in the operating room is recommended at an interval of two times the
half-life of the agent
c
If given for prophylaxis only, administer piperacillin-tazobactam, cefepime, or meropenem for prophylaxis over 30 minutes. If given for treatment, it is reasonable to continue
prolonged infusions of piperacillin-tazobactam, cefepime, or meropenem at the redosing interval.
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8
Table 3. Recommended administration times
3,4

Antimicrobial Recommended Administration Time
Ampicillin 30 minutes; Do not push
Ampicillin-sulbactam 30 miutes; Do not push
Cefazolin
30 minutes; max rate 5 minutes
Pediatrics: Infuse over 10-60 min at conc of 20 mg/mL
Cefepime 30 minutes
Cefotaxime
15-30 minutes at 20-60 mg/mL concentration; Do not push
3-5 minutes at 200 mg/mL concentration; Do not push
Cefoxitin
Adults
30 minutes; max rate over 3-5 minutes at concentration of 100 mg/mL
Pediatrics
10-60 minutes at maximum concentration of 40 mg/mL
3-5 minutes at maximum concentration of 100 mg/mL
Ceftriaxone 30 minutes; Do not push
Cefuroxime 30 minutes; max rate 3-5 minutes
Ciprofloxacin 60 minutes; Do not push
Clindamycin No faster than 30 mg/min or 1200 mg/hr; Do not push
Fluconazole 60-120 minutes; No faster than 200 mg/hr; Do not push
Gentamicin

< 250 mg: 30 minutes; Do not push
≥ 250 mg: 60 minutes; Do not push
Levofloxacin
≤ 500 mg: 60 minutes; Do not push
> 500 mg: 90 minutes; Do not push
Metronidazole

30-60 minutes; Do not push
Moxifloxacin 60 minutes; Do not push
Piperacillin-tazobactam 30 minutes; Do not push
Vancomycin
a

Adults
No faster than 1000 mg/60 minutes; Do not push
Pediatrics
At least 60 minutes; Do not push
a
It is not known whether starting the procedure (e.g. skin incision) prior to completion of the vancomycin infusion results in equivalent SSI reduction outcomes as
infusing the entire dose prior to incision. The best practice is to infuse the entire dose prior to incision. However, based on pharmacokinetic evaluation, it may be
acceptable to start the procedure after a minimum of two-thirds of the vancomycin dose has been infused in patients weighing fewer than 120 kg (the remainder of
the dose should continue infusing as the procedure is in progress). For patients weighing 120 kg or more, the entire dose should be infused prior to incision. For
any procedure utilizing the application of a tourniquet, the entire dose should be infused prior to tourniquet inflation.
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9
Table 4. Surgical prophylaxis antimicrobial selection at UWHC
Procedure First Line
History of MRSA
(documented or
reported)
Patients with IgE-mediated
or severe reaction to β-
lactam
Patients with IgE-mediated or severe
reaction to β-lactam AND history of
MRSA (documented or reported)
C
a
r
d
i
a
c

CABG procedures, valve repairs, and
placement of temporary or permanent
implantable cardiac devices (including
ventricular assist devices)
Cefazolin OR
Cefuroxime
Vancomycin +
Cefazolin OR
Cefuroxime
Vancomycin OR
Clindamycin
Consider addition of
aztreonam if risk for Gram-
negative infections
Vancomycin OR
Clindamycin
Consider addition of aztreonam if risk
for Gram-negative infections
Consider addition of vancomycin to regimen if risk of MRSE infection with implanted prosthetic material (if vancomycin is not
already component of selected regimen)
C
a
r
d
i
a
c

D
e
v
i
c
e

I
n
s
e
r
t
i
o
n

Permanent pacemaker, implantable
cardioverter defibrillator, or cardiac
resynchronization device
Cefazolin OR
Cefuroxime
Vancomycin +
Cefazolin OR
Cefuroxime
Vancomycin OR
Clindamycin
Consider addition of
aztreonam if risk for Gram-
negative infections
Vancomycin OR
Clindamycin
Consider addition of aztreonam if risk
for Gram-negative infections
Consider addition of vancomycin to regimen if risk of MRSE infection with implanted prosthetic material (if vancomycin is not
already component of selected regimen)
Cardiac catheterization or
transesophageal echocardiogram
No antimicrobial prophylaxis recommended
T
h
o
r
a
c
i
c

Noncardiac thoracic procedures include
lobectomy, pneumonectomy,
thoracoscopy, lung resection,
thoracotomy, and video-assisted
thoracoscopic surgery
Cefazolin OR Ampicillin-
sulbactam
Vancomycin +
Cefazolin OR
Ampicillin-sulbactam
Vancomycin OR Clindamycin Vancomycin OR Clindamycin
G
a
s
t
r
o
d
u
o
d
e
n
a
l

Resection with or without vagotomy for
gastric or duodenal ulcers, resection for
gastric carcinoma, revision required to
repair strictures of the gastric outlet,
PEG insertion, perforated ulcer
procedures, pancreaticoduodenectomy,
and bariatric surgical procedures
Cefazolin Vancomycin + Cefazolin
(1) Vancomycin OR
Clindamycin
+
Gentamicin OR
Ciprofloxacin

(2) Moxifloxacin
Vancomycin OR Clindamycin
+
Gentamicin OR
Ciprofloxacin OR
Moxifloxacin
Endoscopic Retrograde
Cholangiopancreatography (ERCP)
Ceftriaxone Ceftriaxone Gentamicin Gentamicin
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10
Procedure First Line
History of MRSA
(documented or
reported)
Patients with IgE-mediated
or severe reaction to β-
lactam
Patients with IgE-mediated or severe
reaction to β-lactam AND history of
MRSA (documented or reported)
B
i
l
i
a
r
y

T
r
a
c
t

Cholecystectomy, exploration of
common bile duct, and
choledochoenterostomy
Cefazolin OR Ampicillin-
sulbactam
Vancomycin +
Cefazolin OR
Ampicillin-sulbactam

Metronidazole +
Ciprofloxacin OR Gentamicin
Vancomycin +
Metronidazole +
Ciprofloxacin OR Gentamicin
A
p
p
e
n
d
e
c
t
o
m
y

Uncomplicated appendicitis
Cefoxitin OR Cefazolin
and Metronidazole
Vancomycin +
Cefoxitin OR
Cefazolin and
Metronidazole

Metronidazole +
Ciprofloxacin OR Gentamicin
Vancomycin + Metronidazole +
Ciprofloxacin OR Gentamicin
S
m
a
l
l

I
n
t
e
s
t
i
n
e

Nonobstructed:
incision or resection of the small
intestine, enterectomy with or without
intestinal anastomosis or enterostomy,
intestinal bypass, and stricturoplasty
Cefazolin Vancomycin + Cefazolin
Ciprofloxacin and
Metronidazole
Vancomycin +
Ciprofloxacin and Metronidazole
Obstructed:
incision or resection of the small
intestine, enterectomy with or without
intestinal anastomosis or enterostomy,
intestinal bypass, and stricturoplasty
Cefazolin and
Metronidazole OR
Cefoxitin

Vancomycin +
Cefazolin and
Metronidazole OR
Cefoxitin
Ciprofloxacin and
Metronidazole
Vancomycin +
Ciprofloxacin and Metronidazole
H
e
r
n
i
a

R
e
p
a
i
r

Hernioplasty and herniorrhaphy Cefazolin Vancomycin + Cefazolin Vancomycin OR Clindamycin Vancomycin OR Clindamycin
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11
Procedure First Line
History of MRSA
(documented or
reported)
Patients with IgE-mediated
or severe reaction to β-
lactam
Patients with IgE-mediated or severe
reaction to β-lactam AND history of
MRSA (documented or reported)
C
o
l
o
r
e
c
t
a
l


Cefazolin and
Metronidazole
Vancomycin +
Cefazolin and
Metronidazole
Levofloxacin and
Metronidazole
Vancomycin +
Levofloxacin and Metronidazole
H
e
a
d

a
n
d

N
e
c
k

Clean:
thyroidectomy and lymph node
excisions
No antimicrobial prophylaxis recommended
Throat/oral cavity procedures Ampicillin-sulbactam
Vancomycin +
Ampicillin-sulbactam
Clindamycin Vancomycin + moxifloxacin
Other procedures needing only skin
coverage
Cefuroxime
Vancomycin +
Cefuroxime
Vancomycin Vancomycin
N
e
u
r
o
s
u
r
g
e
r
y

Cerebrospinal fluid-shunting
procedures
Cefuroxime
Vancomycin +
Cefuroxime
Levofloxacin and Vancomycin Levofloxacin and Vancomycin
Elective craniotomy
Cefazolin OR
Cefuroxime
Vancomycin + Cefazolin
OR
Cefuroxime
Vancomycin Vancomycin
Other, including implantation of
intrathecal pumps
Cefazolin OR
Cefuroxime
Vancomycin + Cefazolin
OR
Cefuroxime
Levofloxacin and Vancomycin Levofloxacin and Vancomycin
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12
Procedure First Line
History of MRSA
(documented or
reported)
Patients with IgE-mediated
or severe reaction to β-
lactam
Patients with IgE-mediated or severe
reaction to β-lactam AND history of
MRSA (documented or reported)
G
y
n
e
c
o
l
o
g
i
c
a
l

Vaginal and abdominal (open and
laparoscopic) hysterectomy
Cefoxitin OR
Ampicillin-sulbactam
Vancomycin +
Cefoxitin OR
Ampicillin-sulbactam
(1) Vancomycin + Gentamicin
OR Ciprofloxacin
(2) Metronidazole +
Gentamicin OR Ciprofloxacin
(1) Vancomycin + Gentamicin OR
Ciprofloxacin
(2) Vancomycin + Metronidazole +
Gentamicin OR Ciprofloxacin
HSG or chromotubation in patients with
a history of pelvic infection or dilated
fallopian tube
Dilated fallopian tubes: doxycycline 100 mg PO BID for 5 days
History of pelvic infection: preoperative doxycycline
Surgical abortion
Doxycycline 100 mg PO one hour before surgery and 200 mg once after surgery OR
metronidazole 500 mg PO BID for 5 days
Urogynecologic procedures
Cefoxitin OR
Cefuroxime OR
Ampicillin-sulbactam
Vancomycin +
Cefoxitin OR
Cefuroxime OR
Ampicillin-sulbactam
Metronidazole + Gentamicin
OR Ciprofloxacin
1) Vancomycin + Gentamicin OR
Ciprofloxacin
(2) Vancomycin + Metronidazole +
Gentamicin OR Ciprofloxacin
Vaginal and urethral sling
Cefoxitin OR Cefazolin +
Metronidazole
Vancomycin + Cefazolin
and Metronidazole OR
Cefoxitin
Metronidazole + Gentamicin
OR Ciprofloxacin
Vancomycin + Metronidazole and
Gentamicin OR Ciprofloxacin
Cesarean sections Cefazolin Vancomycin + Cefazolin Clindamycin and Gentamicin
Vancomycin + Clindamycin and
Gentamicin
O
p
h
t
h
a
l
m
i
c

Cataract extractions, vitrectomies,
keratoplasties, intraocular lens
implantation, glaucoma procedures,
strabismus procedures, retinal
detachment repair, laser in situ
keratomileusis, and laser-assisted
subepithelial keratectomy
Topical neomycin-polymixin B-gramicidin or topical fluoroquinolone (gatifloxacin or moxifloxacin): 1 drop every 5-15 minutes for 5
doses

Optional at end of procedure: subconjunctival cefazolin 100 mg or intracameral cefazolin 1-2.5 mg or intracameral cefuroxime 1
mg (or vancomycin if IgE-mediated reaction or severe non-IgE-mediated reaction to β-lactam)
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13
Procedure First Line
History of MRSA
(documented or
reported)
Patients with IgE-mediated
or severe reaction to β-
lactam
Patients with IgE-mediated or severe
reaction to β-lactam AND history of
MRSA (documented or reported)
O
r
t
h
o
p
e
d
i
c

Clean orthopedic procedures not
involving implantation of foreign
material: knee, hand, and foot
procedures, arthroscopy, and other
procedures without instrumentation or
implantation of foreign materials
No antimicrobial prophylaxis recommended
Spinal procedures with or without
instrumentation (including fusions,
laminectomies, minimally invasive disk
procedures)
Hip fracture repair (including those
requiring internal fixation)
Total joint replacement (total hip, elbow,
knee, ankle, or shoulder replacement)
Cefazolin OR
Cefuroxime
Vancomycin + Cefazolin
OR
Cefuroxime
Vancomycin OR Clindamycin
Vancomycin OR Clindamycin

Consider addition of gentamicin if at risk
for Gram-negative infections
Pediatric spinal
fusions
Cervical and
upper thoracic
Cefazolin OR
Cefuroxime
Vancomycin OR
Clindamycin +
Cefazolin OR
Cefuroxime
Vancomycin OR Clindamycin Vancomycin OR Clindamycin
Lower thoracic
and lumbar
Cefepime AND
Vancomycin for 24
hours, followed by
Cefuroxime until drains
removed
Cefepime AND
Vancomycin for 24
hours, followed by
Cefuroxime AND
Vancomycin until drains
removed
Vancomycin OR Clindamycin +
Gentamicin
Vancomycin OR Clindamycin +
Gentamicin
U
r
o
l
o
g
i
c

Clean without entry into urinary tract Cefazolin Vancomycin + Cefazolin Vancomycin OR Clindamycin Vancomycin OR Clindamycin
Clean with entry into urinary tract Cefazolin Vancomycin + Cefazolin
Ciprofloxacin OR
Gentamicin ± Clindamycin
Vancomycin + Ciprofloxacin OR
Gentamicin ± Clindamycin
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11/2017CCKM@uwhealth.org


14
Procedure First Line
History of MRSA
(documented or
reported)
Patients with IgE-mediated
or severe reaction to β-
lactam
Patients with IgE-mediated or severe
reaction to β-lactam AND history of
MRSA (documented or reported)
Clean-contaminated with or without
entry into the urinary tract
Cefazolin and
Metronidazole OR
Cefoxitin
Vancomycin +
Cefazolin and
Metronidazole OR
Cefoxitin
Ciprofloxacin OR
Gentamicin +
Metronidazole OR Clindamycin
Vancomycin +
Ciprofloxacin OR
Gentamicin +
Metronidazole OR Clindamycin
Lower tract instrumentation with risk
factors for infection, but without breach
or incision of skin (e.g. stone removal)
Ciprofloxacin OR
Gentamicin OR
Cefazolin OR
Trimethoprim-
sulfamethoxazole
± Ampicillin
Vancomycin (for known
MRSA in urine) +
Ciprofloxacin OR
Gentamicin OR
Cefazolin OR
Trimethoprim-
sulfamethoxazole
± Ampicillin
Vancomycin ±
Ciprofloxacin OR
Gentamicin OR
Trimethoprim-
sulfamethoxazole
Vancomycin ±
Ciprofloxacin OR
Gentamicin OR
Trimethoprim-sulfamethoxazole
Clean without entry into urinary tract
involving implanted prosthesis
Cefazolin ± gentamicin
OR
Ampicillin-sulbactam
Vancomycin +
Cefazolin ± gentamicin
OR
Ampicillin-sulbactam

Vancomycin ± Gentamicin OR
Clindamycin ± Gentamicin
Vancomycin ± Gentamicin OR
Clindamycin ± Gentamicin
V
a
s
c
u
l
a
r

Brachiocephalic procedures without
implantation of prosthetic graft material
(including carotid endarterectomy,
brachial artery repair)
No antimicrobial prophylaxis recommended
Vascular procedures that involve
implantation of prosthetic material and
procedures with a higher risk of
infection (aneurysm repair,
thromboendarterectomy, vein bypass)
Cefazolin Vancomycin + Cefazolin Vancomycin OR Clindamycin Vancomycin OR Clindamycin
Consider addition of vancomycin to regimen if risk of MRSE infection with implanted prosthetic material (if vancomycin is not
already component of selected regimen)
P
l
a
s
t
i
c

S
u
r
g
e
r
y


Clean procedures without additional
postoperative infection risk factors
No antimicrobial prophylaxis recommended
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15
Procedure First Line
History of MRSA
(documented or
reported)
Patients with IgE-mediated
or severe reaction to β-
lactam
Patients with IgE-mediated or severe
reaction to β-lactam AND history of
MRSA (documented or reported)
Clean procedures with risk factors,
clean-contaminated procedures, or
selected breast cancer procedures
(breast implant exchange or other
implant procedures)
Cefazolin
Vancomycin +
Cefazolin
Vancomycin OR Clindamycin Vancomycin OR Clindamycin
Mastectomy or breast tissue expander
procedure
Cefazolin and
vancomycin
Vancomycin + Cefazolin Vancomycin OR Clindamycin Vancomycin OR Clindamycin
T
r
a
u
m
a

Open fractures
Type I and II Cefazolin Vancomycin + Cefazolin Vancomycin Vancomycin
Type III Ceftriaxone ± Gentamicin
Vancomycin +
Ceftriaxone ±
Gentamicin
Vancomycin and Gentamicin Vancomycin and Gentamicin
Fecal or farm
related-injuries
Add metronidazole to the appropriate regimen for Type I, II, or III fracture
Penetrating abdominal wounds
Cefoxitin OR Cefuroxime
and Metronidazole
Vancomycin + Cefoxitin
OR Cefuroxime and
Metronidazole
Vancomycin and Ciprofloxacin
and Metronidazole
Vancomycin and Ciprofloxacin and
Metronidazole

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16
Table 5. Interventional radiology prophylaxis antimicrobial selection
Procedure First Line
History of MRSA
(documented or
reported)
Patients with IgE-mediated
or severe reaction to β-
lactam
Patients with IgE-mediated or severe
reaction to β-lactam AND history of
MRSA (documented or reported)
V
a
s
c
u
l
a
r

i
n
t
e
r
v
e
n
t
i
o
n
s


Diagnostic angiography, routine angioplasty,
thrombolysis, arterial closure device
placement, or arterial stent placement
No antimicrobial prophylaxis recommended
Arterial stent placement with high risk of
infection
Cefazolin
Vancomycin +
Cefazolin
Vancomycin OR
Clindamycin
Vancomycin OR Clindamycin
E
n
d
o
g
r
a
f
t

P
l
a
c
e
m
e
n
t

Aortic endograft, peripheral endograft Cefazolin
Vancomycin +
Cefazolin
Vancomycin OR
Clindamycin
Vancomycin OR Clindamycin
S
u
p
e
r
f
i
c
i
a
l

V
e
n
o
u
s

I
n
s
u
f
f
i
c
i
e
n
c
y

T
r
e
a
t
m
e
n
t

Endovascular thermal ablation, lower
extremity sclerotherapy, ambulatory
phlebectomy
No antimicrobial prophylaxis recommended
Upper extremity, torso, head/neck
sclerotherapy
Cefazolin
Vancomycin and
Cefazolin OR
Clindamycin
Vancomycin OR
Clindamycin
Vancomycin OR Clindamycin
I
V
C

F
i
l
t
e
r

P
l
a
c
e
m
e
n
t

No antimicrobial prophylaxis recommended
C
e
n
t
r
a
l

V
e
n
o
u
s

A
c
c
e
s
s

Central venous catheter placement: PICC
line, tunneled and cuffed lines, non-
tunneled/temporary lines, hemodialysis or
pheresis lines)
No antimicrobial prophylaxis recommended
Central venous catheter: port placement Cefazolin
Vancomycin +
Cefazolin
Vancomycin OR
Clindamycin
Vancomycin OR Clindamycin
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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17
Procedure First Line
History of MRSA
(documented or
reported)
Patients with IgE-mediated
or severe reaction to β-
lactam
Patients with IgE-mediated or severe
reaction to β-lactam AND history of
MRSA (documented or reported)
E
m
b
o
l
i
z
a
t
i
o
n

a
n
d

c
h
e
m
o
e
m
b
o
l
i
z
a
t
i
o
n

Embolization of tumor
and/or solid organ with
the intent to create an
infarct or there is a high
likelihood of infarct

Chemoembolization
Hepatic artery
embolization
(HAE), bland
embolization, and
portal vein
embolization
(PVE)
Ampicillin-
sulbactam OR
Cefazolin and
Metronidazole
OR Cefoxitin OR
Ampicillin and
Gentamicin OR
Ceftriaxone
Vancomycin +
Ampicillin-sulbactam OR
Cefazolin and
Metronidazole OR
Cefoxitin OR Ampicillin
and Gentamicin OR
Ceftriaxone
Vancomycin OR
Clindamycin + Gentamicin +
Metronidazole
Vancomycin OR
Clindamycin + Gentamicin +
Metronidazole
Renal Ceftriaxone
Vancomycin +
Ceftriaxone
U
t
e
r
i
n
e

A
r
t
e
r
y

E
m
b
o
l
i
z
a
t
i
o
n


Cefazolin OR
Cefoxitin OR
Clindamycin and
Gentamicin OR
Ampicillin-
sulbactam
Vancomycin +
Cefazolin OR Cefoxitin
OR Clindamycin and
Gentamicin OR
Ampicillin-sulbactam

Vancomycin OR
Clindamycin and Gentamicin
Vancomycin OR Clindamycin and
Gentamicin
T
I
P
S


Ceftriaxone OR
Ampicillin-
sulbactam
Vancomycin +
Ceftriaxone OR
Ampicillin-sulbactam
Vancomycin OR
Clindamycin + Gentamicin
Vancomycin OR
Clindamycin + Gentamicin
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18
Procedure First Line
History of MRSA
(documented or
reported)
Patients with IgE-mediated
or severe reaction to β-
lactam
Patients with IgE-mediated or severe
reaction to β-lactam AND history of
MRSA (documented or reported)
G
a
s
t
r
o
s
t
o
m
y

a
n
d

G
a
s
t
r
o
j
e
j
u
n
o
s
t
o
m
y

T
u
b
e

P
l
a
c
e
m
e
n
t


Gastrostomy and gastrojejunostomy tube
placement
No antimicrobial prophylaxis recommended
Decompressive gastrostomy tube placement

Cefazolin Vancomycin + Cefazolin
(1) Vancomycin OR
Clindamycin + Gentamicin
OR Ciprofloxacin

(2) Moxifloxacin
Vancomycin OR Clindamycin +
Gentamicin OR Ciprofloxacin OR
Moxifloxacin
L
i
v
e
r

a
n
d

B
i
l
i
a
r
y

I
n
t
e
r
v
e
n
t
i
o
n
s

Biliary drainage
Ceftriaxone OR
Ampicillin-
sulbactam OR
Cefoxitin OR
Ampicillin and
Gentamicin
Vancomycin +
Ceftriaxone OR
Ampicillin-sulbactam OR
Cefoxitin OR
Ampicillin and
Gentamicin
Vancomycin OR
Clindamycin + Gentamicin
Vancomycin OR Clindamycin +
Gentamicin
G
e
n
i
t
o
u
r
i
n
a
r
y

Percutaneous nephrostomy tube placement,
tube exchange, ureteral stents
Cefazolin OR
Ceftriaxone OR
Ampicillin-
sulbactam OR
Ampicillin and
Gentamicin
Vancomycin +
Cefazolin OR
Ceftriaxone OR
Ampicillin-sulbactam OR
Ampicillin and
Gentamicin
Vancomycin and Gentamicin Vancomycin and Gentamicin
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19
Procedure First Line
History of MRSA
(documented or
reported)
Patients with IgE-mediated
or severe reaction to β-
lactam
Patients with IgE-mediated or severe
reaction to β-lactam AND history of
MRSA (documented or reported)
T
u
m
o
r

A
b
l
a
t
i
o
n

Liver
Ampicillin-
sulbactam
Vancomycin +
Ampicillin-sulbactam
Vancomycin Vancomycin Renal Ceftriaxone
Vancomycin +
Ceftriaxone
Bone Cefazolin Vancomycin + Cefazolin
P
e
r
c
u
t
a
n
e
o
u
s

A
b
s
c
e
s
s

D
r
a
i
n
a
g
e


Cefoxitin OR
Ceftriaxone OR
Ampicillin-
sulbactam
Vancomycin AND
Cefoxitin OR
Ceftriaxone OR
Ampicillin-sulbactam

Gram-positive coverage:
Vancomycin OR
Clindamycin

Gram-negative coverage:
Gentamicin
Gram-positive coverage: Vancomycin
OR Clindamycin

Gram-negative coverage: Gentamicin
P
e
r
c
u
t
a
n
e
o
u
s

B
i
o
p
s
y

Transrectal percutaneous biopsy
Gentamicin 80 mg IV/IM and Ciprofloxacin 250 mg BID PO for five days OR
Ciprofloxacin 500 mg BID PO for four days (starting the day before the biopsy)
P
e
r
c
u
t
a
n
e
o
u
s

v
e
r
t
e
b
r
o
p
l
a
s
t
y

Cefazolin
Vancomycin +
Cefazolin
Vancomycin OR
Clindamycin
Vancomycin OR Clindamycin
P
u
l
m
o
n
a
r
y

A
r
t
e
r
i
o
v
e
n
o
u
s

M
a
l
f
o
r
m
a
t
i
o
n
s

Pulmonary arteriovenous malformation
embolization
Cefazolin
Vancomycin +
Cefazolin
Vancomycin OR
Clindamycin
Vancomycin OR Clindamycin

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20
Recommendations
1 Principles of antimicrobial surgical prophylaxis
3

1.1 The antimicrobial chosen for surgical prophylaxis should: (UW Health Strong
Recommendation, Low Quality of Evidence)
1.1.1 possess activity to likely surgical site pathogens;
1.1.2 be given at an appropriate dosage and time to achieve adequate concentrations
during the time period of potential contamination;
1.1.3 be safe;
1.1.4 be administered for the shortest period possible.
1.2 Antimicrobials should have the narrowest spectrum of activity to achieve efficacy (UW
Health Strong Recommendation, Low Quality of Evidence)
1.2.1 Cefazolin is the prophylactic antimicrobial of choice for most surgical procedures
(UW Health Strong Recommendation, Very Low Quality of Evidence)
1.2.1.1 Clindamycin is not recommended as the preferred alternative due to broad
anaerobic spectrum (increasing C. difficile infection risk) and lack of
efficacy in 35% or more of patients at UWHC (UW Health Strong
Recommendation, Low Quality of Evidence)
1.3 Routine use of vancomycin prophylaxis is not recommended for any procedure (UW
Health Strong Recommendation, Low Quality of Evidence)
1.3.1 Vancomycin may be considered for patients with known MRSA colonization or at
high risk for MRSA/MRSE colonization without surveillance data (e.g. recent
hospitalizations, nursing home residents, hemodialysis patients) or patients who
have received more than 48 hours of therapeutic beta-lactam antibiotics (UW
Health Weak/conditional Recommendation, Very Low Quality of Evidence)
1.3.2 Vancomycin is inferior to cefazolin in preventing SSIs caused by MSSA
5,6

1.3.2.1 Vancomycin is not recommended as monotherapy in patients who can
tolerate a cephalosporin (UW Health Strong Recommendation, Low Quality
of Evidence)
1.3.3 Vancomycin may be considered for monotherapy when the patient cannot tolerate
a beta-lactam due to IgE-mediated reaction or severe non-IgE-mediated reaction
(e.g. hemolysis, Stevens Johnson Syndrome, toxic epidermal necrolysis) (UW
Health Strong Recommendation, Very Low Quality of Evidence)
1.3.3.1 Vancomycin is preferred over clindamycin in these clinical situations (UW
Health Weak/conditional Recommendation, Very Low Quality of Evidence)
1.4 Antimicrobial intravenous administration is preferred for most procedures as this produces
rapid and predictable serum concentrations (UW Health Strong Recommendation, Very
Low Level of Evidence)
1.4.1 The first dose of antimicrobial should be given within 60 minutes of the first surgical
incision (UW Health Strong Recommendation, High Quality of Evidence)
1.4.2 The full dose of the antimicrobial should be infused prior to surgical incision. (UW
Health Weak/conditional Recommendation, Very Low Quality of Evidence)
1.4.3 Vancomycin and fluoroquinolones should be given within 120 minutes of the first
surgical incision (UW Health Strong Recommendation, Moderate Quality of
Evidence)
1.4.3.1 For vancomycin, it is not known whether starting the procedure (e.g. skin
incision) prior to completion of the vancomycin infusion results in
equivalent SSI reduction outcomes as infusing the entire dose prior to
incision. The best practice is to infuse the entire dose prior to incision.
However, based on pharmacokinetic evaluation, it may be acceptable to
start the procedure after a minimum of two-thirds of the vancomycin dose
has been infused in patients weighing fewer than 120 kg (the remainder of
the dose should continue infusing as the procedure is in progress). For
patients weighing 120 kg or more, the entire dose should be infused prior
to tourniquet inflation. For any procedure utilizing the application of a
tourniquet, the entire dose should be infused prior to incision. (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
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21
1.5 Patients receiving therapeutic antimicrobials for a remote infection prior to surgery should
also be given antimicrobial prophylaxis before surgery to ensure adequate serum and
tissue antimicrobial tissue levels with pathogen activity (UW Health Strong
Recommendation, Low Quality of Evidence)
1.5.1 If the therapeutic antimicrobial is appropriate for surgical prophylaxis, administering
an additional dose 60 minutes prior to incision is sufficient
1.6 Dosing adjustment in adult obesity
1.6.1 Patients weighing 120 kg or more should receive 3 g doses of cefazolin for
antimicrobial prophylaxis (UW Health Strong Recommendation, Moderate Quality
of Evidence)
1.6.2 Patients weighing 20% above ideal body weight who are receiving gentamicin,
should be dosed using an aminoglycoside dosing weight (ideal body weight plus
40% of the difference between the actual and ideal weights) (UW Health Strong
Recommendation, Low Quality of Evidence)
1.6.3 Perioperative antimicrobial dosing in obesity is poorly defined. As perioperative
antimicrobial prophylaxis is limited to fewer than 48 hours, risks of adverse drug
events associated with higher doses is low and while the benefit associated with
higher drug doses is not known, the suspected benefit likely outweighs risk of
adverse events. Higher antimicrobial doses may be reasonable in obese patients.
(UW Health Strong Recommendation, Very Low Quality of Evidence)
1.7 Pediatric patients should receive weight-based antimicrobial doses (UW Health Strong
Recommendation, Moderate Quality of Evidence)
1.7.1 Pediatric patients weighing more than 40 kg should receive weight-based doses
unless the dose exceeds the recommended adult dose
1.8 Surgical prophylaxis antimicrobials should be redosed if the procedure duration exceeds
two half-lives of the antimicrobial or there is excessive blood loss to ensure adequate
serum and tissue concentrations. (UW Health Strong Recommendation, High Quality of
Evidence)
1.8.1 The initial, intraoperative redosing interval is measured from the time of the
preoperative dose.
1.8.2 Redosing may be appropriate in clinical scenarios where the antimicrobial half-life
is shortened (e.g. extensive burns, blood loss). (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
1.8.3 Redosing may not be necessary in clinical scenarios where the antimicrobial half-
life is prolonged (e.g. renal insufficiency or failure). (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
1.8.4 Excessive blood loss is defined as the loss of 20% or more of estimated total blood
volume.
7
If this blood loss occurs in a time period of longer than halfway through
the redosing interval of the antimicrobial, the antimicrobial should be redosed at the
usual redosing interval. (UW Health Weak/conditional Recommendation, Moderate
Quality of Evidence)
1.8.5 Rapid, excessive blood loss is defined as the loss of 20% or more of estimated
total body blood volume in a time period shorter than one-half of the normal
intraoperative redosing interval for that antibiotic.
7
Antimicrobial redosing should
occur when rapid, excessive blood loss occurs. (UW Health Weak/conditional
Recommendation, Moderate Quality of Evidence)
1.8.6 Careful consideration is recommended for antimicrobials with higher toxicity risks
(e.g. vancomycin, aminoglycosides) to ensure safety with these agents when
requiring multiple doses. Consultation with the OR pharmacist may be advised in
these cases. (UW Health Weak/conditional Recommendation, Very Low Quality of
Evidence)
1.8.7 Antimicrobial redosing should not occur more than four times during a prolonged
operative case without excessive blood loss. If the case exceeds four redosing
intervals, additional dosing should follow recommendations outlined in the Renal
Function-based Dose Adjustments – Adult – Inpatient Clinical Practice Guidelines.
(UW Health Strong Recommendation, Low Quality of Evidence)
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22
1.9 Antimicrobial prophylaxis duration should be fewer than 24 hours for most procedures.
8,9

(UW Health Strong Recommendation, Moderate Quality of Evidence)
1.9.1 In clean and clean-contaminated procedures, it is reasonable to further limit
antimicrobial prophylaxis to no additional doses after the surgical incision is closed
in the operating room, even in the presence of a drain.
10
(UW Health
Weak/conditional Recommendation, Moderate Quality of Evidence)
1.9.2 Antimicrobial prophylaxis of up to 48 hours for cardiothoracic procedures (with
mediastinal tubes) effectiveness is unclear (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
1.10 Topical antimicrobial should not be used for surgical prophylaxis as safety and efficacy
has not been established (UW Health Strong Recommendation, Moderate Quality of
Evidence)

Surgical Antimicrobial Prophylaxis

2 Cardiac procedures
2.1 Patients undergoing cardiac procedures should receive antimicrobial prophylaxis
3,11
(UW
Health Strong Recommendation, High Quality of Evidence)
2.1.1 Includes CABG procedures, valve repairs, and placement of temporary or
permanent implantable cardiac devices (including ventricular assist devices)
3

2.2 Pathogens
3

2.2.1 Most common pathogens: S. aureus, coagulase-negative staphylococcus
2.2.2 Less common pathogens: Propionibacterium acnes, Enterobacter species,
Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Proteus
mirabilis, Acinetobacter species
2.3 Antimicrobial selection
2.3.1 Adults
2.3.1.1 First-line agents: cefazolin or cefuroxime
11-19
(UW Health Strong
Recommendation, High Quality of Evidence)
2.3.1.2 MRSA agents for documented MRSA or history of MRSA or risk for MRSE
with implanted prosthetic material: add vancomycin to the regimen
3,20,21

(UW Health Strong Recommendation, Moderate Quality of Evidence)
2.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin
3,20,21
(UW Health Strong
Recommendation, Moderate Quality of Evidence) and aztreonam (UW
Health Weak/conditional Recommendation, Very Low Quality of Evidence)
2.3.1.3.1 It is reasonable to consider aztreonam if risk for Gram-negative
infections.
2.3.2 Pediatrics
2.3.2.1 First-line agents: cefazolin or cefuroxime: cefazolin or cefuroxime
3
(UW
Health Strong Recommendation, Very Low Quality of Evidence)
2.3.2.2 MRSA agents for documented MRSA or history of MRSA or risk for MRSE
with implanted prosthetic material: add vancomycin to the regimen
3
(UW
Health Strong Recommendation, Very Low Quality of Evidence)
2.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin
3
(UW Health Strong
Recommendation, Very Low Quality of Evidence)
2.3.3 In patients who have received 48 hours or more of antibiotic therapy with
Staphylococcus or Streptococcus activity, it is reasonable to administer
vancomycin (in addition to other preoperative antibiotics) preoperatively for clean
and clean-contaminated procedures
22
(UW Health Strong Recommendation, Low
Quality of Evidence)
2.3.4 Prolonged antimicrobial prophylaxis may be considered for an open chest surgery
(UW Health Weak/conditional Recommendation, Very Low Quality of Evidence)

3 Cardiac device insertion procedures
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23
3.1 Patients undergoing cardiac implantable device insertion (e.g. permanent pacemaker,
implantable cardioverter defibrillator, cardiac resynchronization device) should receive
antimicrobial prophylaxis
3,23
(UW Health Strong Recommendation, High Quality of
Evidence)
3.1.1 Adults
3.1.1.1 First-line agents: cefazolin or cefuroxime
3
(UW Health Strong
Recommendation, High Quality of Evidence)
3.1.1.2 MRSA agents for documented MRSA or history of MRSA or risk for MRSE
with implanted prosthetic material: add vancomycin to the regimen
3
(UW
Health Strong Recommendation, Moderate Quality of Evidence)
3.1.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin
3
(UW Health Strong
Recommendation, Moderate Level of Evidence) or aztreonam (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
3.1.1.4 It is reasonable to consider aztreonam if risk for Gram-negative infections.
3.1.2 Pediatrics
3.1.2.1 First-line agents: cefazolin or cefuroxime
3
(UW Health Strong
Recommendation, Very Low Quality of Evidence)
3.1.2.2 MRSA agents for documented MRSA or history of MRSA or risk for MRSE
with implanted prosthetic material: add vancomycin to the regimen
3
(UW
Health Strong Recommendation, Very Low Quality of Evidence)
3.1.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin
3
(UW Health Strong
Recommendation, Very Low Quality of Evidence)
3.1.3 In patients who have received 48 hours or more of antibiotic therapy with
Staphylococcus or Streptococcus activity, it is reasonable to administer
vancomycin preoperatively (in addition to other preoperative antibiotics) for clean
and clean-contaminated procedures
22
(UW Health Strong Recommendation, Low
Quality of Evidence)
3.2 Patients undergoing cardiac catheterization or transesophageal echocardiogram should
not receive antimicrobial prophylaxis
3,24
(UW Health Strong Recommendation, Moderate
Quality of Evidence)

4 Thoracic procedures
4.1 Patient undergoing thoracic procedures should receive antimicrobial prophylaxis (UW
Health Strong Recommendation, Moderate Quality of Evidence)
21,25-28

4.1.1 Noncardiac thoracic procedures include lobectomy, pneumonectomy,
thoracoscopy, lung resection, thoracotomy, and video-assisted thoracoscopic
surgery
4.2 Pathogens
3

4.2.1 SSI: S. aureus, S. epidermidis
4.2.2 Postoperative pneumonia: Streptococcus species, Staphylococcus species, H.
influenzae, E. cloacae, K. pneumoniae, Acinetobacter species, P. aeruginosa, M.
catarrhalis, and Candida species
4.3 Antimicrobial selection
4.3.1 Adults
4.3.1.1 First-line agents: cefazolin or ampicillin-sulbactam
3
(UW Health Strong
Recommendation, Moderate Quality of Evidence)
4.3.1.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin
to the regimen
3
(UW Health Strong Recommendation, Moderate Quality of
Evidence)
4.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin
3
(UW Health Strong
Recommendation, Very Low Quality of Evidence)
4.3.2 Pediatrics
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4.3.2.1 First-line agents: cefazolin or ampicillin-sulbactam
3
(UW Health Strong
Recommendation, Very Low Quality of Evidence)
4.3.2.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin
to the regimen
3
(UW Health Strong Recommendation, Very Low Quality of
Evidence)
4.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin
3
(UW Health Strong
Recommendation, Very Low Quality of Evidence)

5 Gastroduodenal procedures
5.1 Patients undergoing gastroduodenal procedures who are at highest risk of postoperative
gastroduodenal should receive antimicrobial prophylaxis
3,29-32
(UW Health Strong
Recommendation, Low Quality of Evidence)
5.1.1 Includes resection with or without vagotomy for gastric or duodenal ulcers,
resection for gastric carcinoma, revision required to repair strictures of the gastric
outlet, PEG insertion, perforated ulcer procedures, pancreaticoduodenectomy, and
bariatric surgical procedures
5.1.2 Highest risk patients are those with increased gastric pH, gastroduodenal
perforation, decreased gastric motility, gastric outlet obstruction, gastric bleeding,
morbid obesity or cancer
5.1.3 Antimicrobial prophylaxis may not be required when the intestinal tract lumen is not
entered (UW Health Weak/conditional Recommendation, Very Low Quality of
Evidence)
5.2 Pathogens
3

5.2.1 Coliforms (E. coli, Proteus species, Klebsiella species), staphylococci, streptococci,
enterococci, and Bacteroides species
5.3 Antimicrobial selection
5.3.1 Adults
5.3.1.1 First-line agents: cefazolin
3
(UW Health Strong Recommendation,
Moderate Quality of Evidence)
5.3.1.1.1 Ceftriaxone or gentamicin may be considered for ERCP.
33,34

(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
5.3.1.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin
to the regimen
3
(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
5.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin plus gentamicin,
aztreonam, or ciprofloxacin
3
(UW Health Strong Recommendation,
Moderate Quality of Evidence) or moxifloxacin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
5.3.2 Pediatrics
5.3.2.1 First-line agents: cefazolin
3
(UW Health Strong Recommendation, Very
Low Quality of Evidence)
5.3.2.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin
to the regimen
3
(UW Health Strong Recommendation, Very Low Quality of
Evidence)
5.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin plus gentamicin,
aztreonam, or ciprofloxacin
3
(UW Health Strong Recommendation, Very
Low Quality of Evidence) (UW Health Weak/conditional Recommendation,
Very Low Quality of Evidence)
5.3.2.3.1 While the risk of tendon rupture or tendonitis secondary to
single-dose preoperative fluoroquinolone dose is quite small,
fluoroquinolones are not the first choice in pediatric patients.
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(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)

6 Biliary tract procedures
6.1 Patients undergoing open biliary tract and high-risk laparoscopic biliary tract procedures
should receive antimicrobial prophylaxis
3,35
(UW Health Strong Recommendation,
Moderate Quality of Evidence)
6.1.1 Antimicrobial prophylaxis is probably not needed for patients undergoing
laparoscopic cholecystectomy for biliary colic and low- or moderate-risk
cholecystitis.
36,37
(UW Health Strong Recommendation, High Quality of Evidence)
6.1.2 Includes cholecystectomy, exploration of common bile duct, and
choledochoenterostomy
6.1.3 Risk factors in laparoscopic biliary tract procedures include emergency procedure,
diabetes, anticipated duration longer than 120 minutes, risk of intraoperative gall
bladder rupture, age over 70 years, open cholecystectomy, risk of laparoscopic
conversion to open, episode of biliary colic within thirty days preceding the
procedure, reintervention in less than a month for noninfectious complications of
prior biliary operation, acute cholecystitis, anticipated bile spillage, jaundice,
pregnancy, nonfunctioning gall bladder, and immunosuppression
6.1.4 It may be reasonable to give antimicrobial prophylaxis to patients receiving low-risk
laparoscopic biliary tract procedures as all risk factors cannot be determined
preoperatively (UW Health Weak/conditional Recommendation, Very Low Quality
of Evidence)
6.2 Pathogens
3

6.2.1 Most common pathogens: E. coli, Klebsiella species
6.2.2 Less common pathogens: Gram-negative organisms, staphylococci, streptococci,
enterococci
6.3 Antimicrobial selection
6.3.1 Adults
6.3.1.1 First-line agents: cefazolin, cefoxitin, cefotetan, ceftriaxone, ampicillin-
sulbactam
3
(UW Health Strong Recommendation, Moderate Quality of
Evidence)
6.3.1.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin
to the regimen (UW Health Strong Recommendation, Very Low Quality of
Evidence)
6.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin plus gentamicin,
aztreonam, or ciprofloxacin; or metronidazole plus gentamicin or
ciprofloxacin
3
(UW Health Strong Recommendation, Moderate Quality of
Evidence)
6.3.2 Pediatrics
6.3.2.1 First-line agents: cefazolin, cefoxitin, cefotetan, ceftriaxone, ampicillin-
sulbactam
3
(UW Health Strong Recommendation, Very Low Quality of
Evidence)
6.3.2.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin
to the regimen (UW Health Strong Recommendation, Very Low Quality of
Evidence)
6.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin plus gentamicin,
aztreonam, or ciprofloxacin; or metronidazole plus gentamicin or
ciprofloxacin
3
(UW Health Strong Recommendation, Very Low Quality of
Evidence)
6.3.2.3.1 While the risk of tendon rupture or tendonitis secondary to
single-dose preoperative fluoroquinolone dose is quite small,
fluoroquinolones are not the first choice in pediatric patients.
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(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)

7 Appendectomy procedures
7.1 Patients undergoing appendectomy should receive antimicrobial prophylaxis
3,38-41
(UW
Health Strong Recommendation, High Quality of Evidence)
7.1.1 Includes complicated and uncomplicated appendicitis
7.2 Pathogens
3

7.2.1 Most common pathogens: anaerobic and aerobic Gram-negative enteric
organisms including B. fragilis and E. coli
7.2.2 Less common pathogens: aerobic and anaerobic streptococci, Staphylococcus
species, Enterococcus species. Infrequent: P. aeruginosa.
7.3 Antimicrobial selection
7.3.1 Adults
7.3.1.1 First-line agents: Cefoxitin or cefotetan or cefazolin and metronidazole
3

(UW Health Strong Recommendation, High Quality of Evidence)
7.3.1.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin
to the regimen (UW Health Strong Recommendation, Very Low Quality of
Evidence)
7.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: clindamycin plus gentamicin or aztreonam or
ciprofloxacin; or metronidazole plus gentamicin or ciprofloxacin
3
(UW
Health Strong Recommendation, Moderate Quality of Evidence)
7.3.2 Pediatrics
7.3.2.1 First-line agents: Cefoxitin or cefotetan or cefazolin and metronidazole
3,39

(UW Health Strong Recommendation, High Quality of Evidence)
7.3.2.1.1 Ceftriaxone 50 mg/kg/day daily, and metronidazole 30
mg/kg/day daily are reasonable for pediatric patients
7.3.2.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin
to the regimen (UW Health Strong Recommendation, Very Low Quality of
Evidence)
7.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: clindamycin plus gentamicin or aztreonam or
ciprofloxacin; or metronidazole plus gentamicin or ciprofloxacin
(ciprofloxacin or levofloxacin)
3,39
(UW Health Strong Recommendation,
Moderate Quality of Evidence)
7.3.2.3.1 While the risk of tendon rupture or tendonitis secondary to
single-dose preoperative fluoroquinolone dose is quite small,
fluoroquinolones are not the first choice in pediatric patients.
(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)

8 Small intestine procedures
8.1 Patients undergoing small intestine procedures (or small bowel surgery) should receive
antimicrobial prophylaxis
3
(UW Health Strong Recommendation, Very Low Quality of
Evidence)
8.1.1 Includes incision or resection of the small intestine, enterectomy with or without
intestinal anastomosis or enterostomy, intestinal bypass, and stricturoplasty
8.1.2 Does not include small-to-large bowel anastomosis
8.2 Pathogens
3

8.2.1 Most common pathogens: aerobic Gram-negative enteric organisms (particularly
E. coli)
8.2.2 Additional pathogens: Streptococci, Staphylococcus species, Enterococcus
species
8.3 Antimicrobial selection for patients without obstruction
3

8.3.1 Adults and pediatrics
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8.3.1.1 First-line agent: cefazolin (UW Health Strong Recommendation, Very Low
Quality of Evidence)
8.3.1.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin
to the regimen (UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
8.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: metronidazole plus gentamicin or ciprofloxacin or
aztreonam (UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
8.4 Antimicrobial selection for patients with obstruction
3

8.4.1 Adults and pediatrics
8.4.1.1 First-line agents: Cefoxitin or cefotetan or cefazolin and metronidazole (UW
Health Strong Recommendation, Very Low Quality of Evidence)
8.4.1.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin
to the regimen (UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
8.4.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: metronidazole plus gentamicin or ciprofloxacin (UW
Health Strong Recommendation, Very Low Quality of Evidence)
8.4.1.3.1 While the risk of tendon rupture or tendonitis secondary to
single-dose preoperative fluoroquinolone dose is quite small,
fluoroquinolones are not the first choice in pediatric patients
(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)

9 Hernia repair
9.1 Patients undergoing hernia repair should receive antimicrobial prophylaxis
3,42,43
(UW
Health Strong Recommendation, High Quality of Evidence)
9.1.1 Includes hernioplasty and herniorrhaphy
9.2 Pathogens
3

9.2.1 Streptococci, Staphylococcus species, Enterococcus species, MRSA
9.3 Antimicrobial selection
9.3.1 Adults
3

9.3.1.1 First-line agent: cefazolin (UW Health Strong Recommendation, High
Quality of Evidence)
9.3.1.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin
to the regimen (UW Health Strong Recommendation, High Quality of
Evidence)
9.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin (UW Health Strong
Recommendation, High Quality of Evidence)
9.3.2 Pediatrics
3

9.3.2.1 First-line agent: cefazolin (UW Health Strong Recommendation, Very Low
Quality of Evidence)
9.3.2.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin
to the regimen (UW Health Strong Recommendation, Very Low Quality of
Evidence)
9.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin (UW Health Strong
Recommendation, Very Low Quality of Evidence)

10 Colorectal procedures
10.1 Patients undergoing colorectal procedures should receive antimicrobial prophylaxis
3,44-46

(UW Health Strong Recommendation, High Quality of Evidence)
10.1.1 Prophylaxis should be parental (UW Health Strong Recommendation, High Quality
of Evidence)
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10.1.2 Prophylaxis should be oral if mechanical bowel preparation is also performed
preoperatively (UW Health Strong Recommendation, High Quality of Evidence)
10.2 Pathogens
3

10.2.1 Organisms of the bowel lumen: B. fragilis, other obligate anaerobes, E.coli
10.3 Antimicrobial selection
3

10.3.1 Adults
10.3.1.1 First-line agents: Cefazolin and metronidazole, , , ampicillin-sulbactam,
ceftriaxone and metronidazole (UW Health Strong Recommendation, High
Quality of Evidence)
10.3.1.1.1 Cefazolin and metronidazole may provide better aerobic and
anaerobic coverage compared to cefoxitin, cefotetan, or
ampicillin/sulbactam.
47-49

10.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Strong Recommendation, Low
Quality of Evidence)
10.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: clindamycin and gentamicin, aztreonam
and levofloxacin, or metronidazole and gentamicin or levofloxacin; add
vancomycin for Gram-positive coverage (UW Health Strong
Recommendation, Very Low Quality of Evidence)
10.3.1.4 Oral regimens: neomycin and metronidazole or erythromycin;
given as three doses over approximately ten hours the
afternoon and evening before the procedure and after
mechanical bowel preparation (UW Health Strong
Recommendation, High Level of Evidence)
10.3.1.4.1 Combination oral and intravenous prophylaxis may be
considered (UW Health Weak/conditional Recommendation,
Very Low Quality of Evidence)
10.3.2 Pediatrics
10.3.2.1 First-line agents: Cefazolin and metronidazole, cefoxitin, cefotetan,
ampicillin-sulbactam, ceftriaxone and metronidazole, or ertapenem (UW
Health Strong Recommendation, Very Low Quality of Evidence)
10.3.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Strong Recommendation, Very
Low Quality of Evidence)
10.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: clindamycin and gentamicin, aztreonam
and levofloxacin, or metronidazole and gentamicin or levofloxacin; add
vancomycin for Gram-positive coverage (UW Health Strong
Recommendation, Very Low Quality of Evidence)
10.3.2.3.1 While the risk of tendon rupture or tendonitis secondary to
single-dose preoperative fluoroquinolone dose is quite small,
fluoroquinolones are not the first choice in pediatric patients
(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
10.3.2.4 Oral regimens: neomycin and metronidazole or erythromycin; given as
three doses over approximately ten hours the afternoon and evening
before the procedure and after mechanical bowel preparation (UW Health
Strong Recommendation, Very Low Level of Evidence)
10.3.2.4.1 Combination oral and intravenous prophylaxis may be
considered (UW Health Weak/conditional Recommendation,
Very Low Quality of Evidence)
10.3.3 Metronidazole plus aztreonam is not recommended as this combination provides
no aerobic Gram-positive activity
50
(UW Health Strong Recommendation, Moderate
Quality of Evidence)

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29
11 Head and neck procedures
11.1 Patients undergoing clean surgical procedures of the head and neck should not receive
antimicrobial prophylaxis
3,51
(UW Health Strong Recommendation, Moderate Quality of
Evidence)
11.1.1 Includes thyroidectomy and lymph node excisions
11.2 Patients undergoing clean surgical procedures of the head and neck with placement of
prosthetic material should receive preoperative antimicrobial prophylaxis
3
(UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
11.3 Antimicrobial prophylaxis may be considered for patients undergoing clean-contaminated
procedures of the head and neck.
3,52
(UW Health Weak/conditional Recommendation,
Low Quality of Evidence)
11.3.1 Includes procedures involving incision through the oral or pharyngeal mucosa (e.g.
parotidectomy, submandibular gland excision, rhinoplasty, complicated tumor
debulking, mandibular fracture repair)
11.3.2 Patients undergoing tonsil or adenoid surgery or functional endoscopic sinus
procedures should not receive antimicrobial prophylaxis
53-55
(UW Health Strong
Recommendation, Moderate Quality of Evidence)
11.4 Pathogens
3

11.4.1 Normal flora of mouth and oropharynx: Streptococci species, oral anaerobes
(Bacteroides species excepting B. fragilis), Peptostreptococcus species, Prevotella
species, Fusobacterium species, Veillonella species, Enterobacteriaceae,
staphylococci
11.4.2 Normal nasal flora: Staphylococcus species and Streptococcus species
11.5 Antimicrobial selection for patients throat or oral cavity procedures
3

11.5.1 Adults and pediatrics
11.5.1.1 First-line agents: ampicillin-sulbactam (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
11.5.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
11.5.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: clindamycin or moxifloxacin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
11.5.1.3.1 While the risk of tendon rupture or tendonitis secondary to
single-dose preoperative fluoroquinolone dose is quite small,
fluoroquinolones are not the first choice in pediatric patients.
(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
11.6 Antimicrobial selection for patients undergoing procedures needing skin flora coverage
only (not entering throat or oral cavity
3

11.6.1 Adults and pediatrics
11.6.1.1 First-line agents: Cefuroxime (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
11.6.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
11.6.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)

12 Neurosurgery procedures
12.1 Patients undergoing elective craniotomy and cerebrospinal fluid-shunting procedures
should receive antimicrobial prophylaxis
3,56-59
(UW Health Strong Recommendation, High
Quality of Evidence)
12.2 Patients undergoing intrathecal pump placement should receive antimicrobial prophylaxis
3

(UW Health Strong Recommendation, Very Low Quality of Evidence)
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30
12.3 Pathogens
3

12.3.1 Most common: Gram-positive bacteria, S. aureus, coagulase-negative
staphylococci
12.3.2 Less common: P. acnes, Gram-negative bacteria
12.4 Antimicrobial selection
12.4.1 Adults
3

12.4.1.1 First-line agents: cefazolin (UW Health Strong Recommendation, High
Quality of Evidence) or cefuroxime (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
12.4.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
12.4.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin with or without levofloxacin
(UW Health Strong Recommendation, Very Low Quality of Evidence) or
levofloxacin (UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
12.4.2 Pediatrics
3

12.4.2.1 First-line agents: cefazolin (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence) or cefuroxime (UW
Health Weak/conditional Recommendation, Very Low Quality of Evidence)
12.4.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
12.4.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence) and
levofloxacin (UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
12.4.2.3.1 While the risk of tendon rupture or tendonitis secondary to
single-dose preoperative fluoroquinolone dose is quite small,
fluoroquinolones are not the first choice in pediatric patients.
(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
12.4.3 It is reasonable to administer vancomycin to patients who have received 48 hours
or more of antimicrobial therapy with Staphylococcus or Streptococcus species
activity preoperatively
22
(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)

13 Cesarean delivery
13.1 Patients undergoing cesarean delivery should receive antimicrobial prophylaxis
3,60,61
(UW
Health Strong Recommendation, High Quality of Evidence)
13.2 Pathogens
3

13.2.1 Polymicrobial and include aerobic streptococcus, Gram-negative aerobes
(particularly E. coli), Gram-negative anaerobic bacilli (particularly B. bivus),
anaerobic cocci (Peptostreptococcus species, Peptococcus species), Ureaplasma
urealyticum, Staphylococcus species, enterococci
13.3 Antimicrobial selection
3,62

13.3.1 First-line agent: cefazolin (UW Health Strong Recommendation, High Quality of
Evidence)
13.3.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin to the
regimen (UW Health Weak/conditional Recommendation, Very Low Quality of
Evidence)
13.3.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: clindamycin and gentamicin (UW Health Strong
Recommendation, Very Low Quality of Evidence)
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14 Hysterectomy
14.1 Patients undergoing hysterectomy should receive antimicrobial prophylaxis
3,63-65
(UW
Health Strong Recommendation, Moderate Quality of Evidence)
14.1.1 Includes vaginal and abdominal (open and laparoscopic) hysterectomies
14.2 Pathogens
3

14.2.1 Usually polymicrobial: enterococci, aerobic Gram-negative bacilli, Bacteroides
species
14.3 Antimicrobial selection
14.3.1 Adults
3

14.3.1.1 First-line agents: cefazolin, cefoxitin, cefotetan, or ampicillin-sulbactam
(UW Health Strong Recommendation, Moderate Quality of Evidence)
14.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
14.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin and
gentamicin or aztreonam or ciprofloxacin; or metronidazole and
gentamicin or ciprofloxacin (UW Health Strong Recommendation, Low
Quality of Evidence)

15 Gynecologic procedures
15.1 Patients with a history of pelvic infection or findings of dilated fallopian tubes undergoing
hysterosalpingography (HSG) or chromotubation should receive antimicrobial
prophylaxis
66,67
(UW Health Strong Recommendation, Very Low Quality of Evidence)
15.1.1 Patients with without a history of pelvic infection or dilated fallopian tubes who are
undergoing HSG or chromotubation should not receive preoperative antimicrobial
prophylaxis
66,67
(UW Health Strong Recommendation, Moderate Quality of
Evidence)
15.2 Patients undergoing surgical abortion should receive antimicrobial prophylaxis
66,68
(UW
Health Strong Recommendation, High Quality of Evidence)
15.3 Patients undergoing urogynecologic procedures, including those involving mesh should
receive antimicrobial prophylaxis (UW Health Strong Recommendation, Very Low Quality
of Evidence)
15.4 Patients undergoing the following procedures should not receive should not receive
antimicrobial prophylaxis: non-vaginal, non-intestinal laparoscopy or laparotomy including
tubal sterilization; sonohysterography; hysteroscopic surgery; IUD insertion; or
endometrial biopsy
66,69-74
(laparoscopy and laparotomy, sonohysterography, hysteroscopy,
endometrial ablation: UW Health Strong Recommendation, Moderate Quality of Evidence;
IUD insertion: UW Health Strong Recommendation, High Quality of Evidence;
endometrial biopsy: UW Health Strong Recommendation, Low Quality of Evidence)
15.5 Mechanical bowel preparation is not recommended in patients undergoing gynecologic
procedures
66,75
(UW Health Strong Recommendation, Moderate Quality of Evidence)
15.6 Pathogens
66

15.6.1 Endogenous flora of skin or vagina including Gram-positive cocci, possibly fecal
flora (anaerobic bacteria and Gram-negative aerobes) if incisions are near
perineum or groin
15.7 Antimicrobial selection for HSG or chromotubation in patients with a history of pelvic
infection or dilated fallopian tubes
66
(UW Health Strong Recommendation, Low Quality of
Evidence)
15.7.1 Patients with a history of pelvic infection: preoperative doxycycline
15.7.2 Patients with dilated fallopian tubes: doxycycline 100 mg PO BID for 5 days
postoperatively
15.8 Antimicrobial selection in patients undergoing surgical abortion
66
(UW Health Strong
Recommendation, Moderate Quality of Evidence)
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32
15.8.1 Doxycycline (100 mg PO one hour before procedure and 200 mg PO after surgery)
or metronidazole 500 mg PO BID for 5 days
15.9 Antimicrobial selection in patients undergoing urogynecologic procedures
66
(UW Health
Strong Recommendation, Very Low Quality of Evidence)
15.9.1 First-line agents: cefoxitin, ampicillin-sulbactam, or cefazolin
15.9.2 MRSA agents for documented MRSA or history of MRSA: vancomycin
15.9.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: metronidazole and gentamicin or fluoroquinolone
clindamycin and gentamicin or fluoroquinolone or aztreonam
15.10 Antimicrobial selection in patients undergoing vaginal or urethral sling procedures
76
(UW
Health Strong Recommendation, Moderate Quality of Evidence)
15.10.1 First line agents: Cefoxitin or cefazolin plus metronidazole
15.10.2 MRSA agents for documented MRSA or history of MRSA: vancomycin
15.10.3 Agents for patients with IgE-mediated reaction or severe non-IgE mediated
reaction to β-lactam: gentamicin or ciprofloxacin plus metronidazole

16 Ophthalmic procedures
16.1 Antimicrobial prophylaxis may be reasonable in patients undergoing ophthalmic
procedures given the consequences of postoperative bacterial endophthalmitis despite the
lack of well-controlled trials evaluating preoperative antimicrobial prophylaxis
3,77-80

16.1.1 Includes cataract extractions, vitrectomies, keratoplasties, intraocular lens
implantation, glaucoma procedures, strabismus procedures, retinal detachment
repair, laser in situ keratomileusis, and laser-assisted subepithelial keratectomy
16.2 Pathogens
3

16.2.1 Most common: Staphylococcus species, primarily S. epidermidis
16.2.2 Less common: S. aureus, Streptococcus species, Enterococcus species, P.
acnes, Corynebacterium species, Serratia species, Klebsiella species, P. mirabilis,
P. aeruginosa
16.3 Antimicrobial selection
3

16.3.1 Adults and pediatrics
16.3.1.1 First-line agents
16.3.1.1.1 Topical neomycin-polymixin B-gramicidin or fourth-generation
topical fluoroquinolone (gatifloxacin or moxifloxacin) given as
one drop every 5-15 minutes for five doses
81-84
(UW Health
Weak/conditional Recommendation, Very Low Quality of
Evidence)
16.3.1.1.2 Optional at end of procedure cefazolin 100 mg by
subconjunctival injection or intracameral cefazolin 1-2.5 mg or
intracameral cefuroxime 1 mg
77,78,85-90
(UW Health
Weak/conditional Recommendation, Very Low Quality of
Evidence)
16.3.1.2 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam:
16.3.1.2.1 Topical neomycin-polymixin B-gramicidin or fourth-generation
topical fluoroquinolone (gatifloxacin or moxifloxacin) given as
one drop every 5-15 minutes for five doses
81-84
(UW Health
Weak/conditional Recommendation, Very Low Quality of
Evidence)
16.3.1.2.2 Topical vancomycin (20 mcg/mL) given as irrigating fluid
91,92

(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)

17 Orthopedic procedures
17.1 Patients undergoing clean orthopedic without instrumentation or implantation of foreign
materials should not receive antimicrobial prophylaxis
3,93-97
(UW Health Strong
Recommendation, Moderate Quality of Evidence)
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33
17.1.1 Includes knee, hand, and foot procedures, arthroscopy, and other procedures
without instrumentation or implantation of foreign materials
17.2 Patients undergoing spinal procedures (with or without instrumentation) should receive
antimicrobial prophylaxis
3,98-101
(UW Health Strong Recommendation, High Quality of
Evidence)
17.2.1 Includes fusions, laminectomies, minimally invasive disk procedures
17.3 Patients undergoing hip fracture repair should receive antimicrobial prophylaxis
3,102,103

(UW Health Strong Recommendation, High Quality of Evidence)
17.3.1 Includes internal fixation procedures
17.4 Patients undergoing total joint replacement should receive antimicrobial prophylaxis
3,104

(UW Health Strong Recommendation, Low Quality of Evidence)
17.4.1 Includes total hip, elbow, knee, ankle, or shoulder replacement
17.5 Preoperative mupirocin decolonization protocols decrease overall SSI and should be given
to MRSA- or MSSA-colonized patients
3,105-107
(UW Health Strong Recommendation, Low
Quality of Evidence)
17.6 Pathogens
3

17.6.1 Skin flora including S. aureus, Gram-negative bacilli, coagulase-negative
staphylococci, β-hemolytic streptococci
17.7 Antimicrobial selection for patients undergoing spinal procedures (with or without
instrumentation)
17.7.1 Adults
3

17.7.1.1 First-line agent: cefazolin (UW Health Strong Recommendation, High
Quality of Evidence) or cefuroxime (UW Health Strong Recommendation,
Very Low Quality of Evidence)
17.7.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin or clindamycin to the regimen
100
(UW Health Strong
Recommendation, Moderate Quality of Evidence)
17.7.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin
100
(UW Health
Strong Recommendation, Moderate Quality of Evidence)
17.7.2 Pediatrics
3,108,109

17.7.2.1 First-line agent: cefazolin (UW Health Strong Recommendation, Very
Low Quality of Evidence) or cefuroxime (UW Health Strong
Recommendation, Very Low Quality of Evidence)
17.7.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin or clindamycin to the regimen (UW Health Strong
Recommendation, Very Low Quality of Evidence)
17.7.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Very Low Quality of Evidence)
17.7.3 Pediatric spinal fusions: upper thoracic and cervical
17.7.3.1 Frist-line agent: cefazolin or cefuroxime (UW Health Strong
Recommendation, Very Low Quality of Evidence)
17.7.3.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin or clindamycin to the regimen (UW Health Strong
Recommendation, Very Low Quality of Evidence)
17.7.3.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Very Low Quality of Evidence)
17.7.4 Pediatric spinal fusions: lower thoracic and lumbar
17.7.4.1 Frist-line agent: cefepime and vancomycin for 24 hours, followed by
cefuroxime until drains removed (UW Health Strong Recommendation,
Very Low Quality of Evidence)
17.7.4.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin or clindamycin to the regimen (UW Health Strong
Recommendation, Very Low Quality of Evidence)
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34
17.7.4.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin with
gentamicin(UW Health Strong Recommendation, Very Low Quality of
Evidence)
17.7.5 It is reasonable to administer vancomycin to patients who are undergoing repeat
spinal fusions
17.7.6 It is reasonable to administer vancomycin to patients who have received 48 hours
or more of antimicrobial therapy with Staphylococcus or Streptococcus species
activity preoperatively
22
(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
17.8 Antibiotic selection for patients undergoing hip fracture repair
17.8.1 Adults
3

17.8.1.1 First-line agent: cefazolin (UW Health Strong Recommendation, High
Quality of Evidence) or cefuroxime (UW Health Strong Recommendation,
Very Low Quality of Evidence)
17.8.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin or clindamycin to the regimen (UW Health Strong
Recommendation, Low Quality of Evidence)
17.8.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Low Quality of Evidence)
17.8.2 Pediatrics
3

17.8.2.1 First-line agent: cefazolin (UW Health Strong Recommendation, Very
Low Quality of Evidence) or cefuroxime (UW Health Strong
Recommendation, Very Low Quality of Evidence)
17.8.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin or clindamycin to the regimen (UW Health Strong
Recommendation, Very Low Quality of Evidence)
17.8.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Very Low Quality of Evidence)
17.9 Antibiotic selection for patients undergoing total joint replacement
17.9.1 Adults
3

17.9.1.1 First-line agent: cefazolin (UW Health Strong Recommendation, Low
Quality of Evidence) or cefuroxime
110
(UW Health Strong
Recommendation, Very Low Quality of Evidence)
17.9.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin or clindamycin to the regimen
111
(UW Health Strong
Recommendation, Low Quality of Evidence)
17.9.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Low Quality of Evidence)
17.9.2 Pediatrics
3

17.9.2.1 First-line agent: cefazolin (UW Health Strong Recommendation, Very
Low Quality of Evidence) or cefuroxime (UW Health Strong
Recommendation, Very Low Quality of Evidence)
17.9.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin or clindamycin to the regimen (UW Health Strong
Recommendation, Low Quality of Evidence)
17.9.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Very Low Quality of Evidence)

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35
18 Urologic procedures
18.1 Patients undergoing clean urologic procedures without risk factors should receive no
antimicrobial prophylaxis
3
(UW Health Strong Recommendation, Very Low Quality of
Evidence)
18.2 Patients undergoing lower urinary tract instrumentation with risk factors for infection
should receive antimicrobial prophylaxis
3,112-114
(UW Health Strong Recommendation,
Moderate Quality of Evidence)
18.2.1 Urologic-specific preoperative risk factors: anatomic anomalies of the urinary tract,
urinary obstruction, urinary stone, preoperative UTI, and indwelling or externalized
catheters
18.2.2 Urologic operation-specific risk factors: length of post-operative catheterization,
mode of irrigation (open versus closed), and postoperative pyuria
18.3 Patients undergoing clean urologic procedures without entry into the urinary tract should
receive antimicrobial prophylaxis
3
(UW Health Weak/conditional Recommendation, Very
Low Quality of Evidence)
18.4 Patients undergoing clean urologic procedures with entry into the urinary tract should
receive antimicrobial prophylaxis
3
(UW Health Weak/conditional Recommendation, Very
Low Quality of Evidence)
18.5 Patients undergoing clean-contaminated procedures of the urinary tract should receive
antimicrobial prophylaxis as recommended for elective colorectal surgery
3,115-121
(UW
Health Strong Recommendation, Very Low Quality of Evidence)
18.6 Pathogens
3

18.6.1 Most common: E. coli
18.6.2 Less common: other Gram-negative bacilli, enterococci, S. aureus, coagulase-
negative Staphylococcus species, Group A Streptococcus species
18.7 Antimicrobial selection for patients undergoing lower urinary tract instrumentation with risk
factors for infection without breach or incision of skin
3

18.7.1 Adults
18.7.1.1 First-line agent: ciprofloxacin (oral or IV), gentamicin, cefazolin, or
trimethoprim-sulfamethoxazole with or without ampicillin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
18.7.1.2 MRSA agents for documented MRSA or history of MRSA in the urine:
add vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
18.7.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin with or without ciprofloxacin,
gentamicin, or trimethoprim-sulfamethoxazole (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
18.7.2 Pediatrics
18.7.2.1 First-line agent: gentamicin, cefazolin, or trimethoprim-sulfamethoxazole
with or without ampicillin or ciprofloxacin (oral or IV). (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
18.7.2.1.1 While the risk of tendon rupture or tendonitis secondary to
single-dose preoperative fluoroquinolone dose is quite small,
fluoroquinolones are not the first choice in pediatric patients.
(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
18.7.2.2 MRSA agents for documented MRSA or history of MRSA in the urine:
add vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
18.7.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin with or without ciprofloxacin,
gentamicin, or trimethoprim-sulfamethoxazole (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
18.8 Antimicrobial selection for patients undergoing clean urologic procedures without entry
into the urinary tract
3

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36
18.8.1 Adults
18.8.1.1 First-line agent: cefazolin (UW Health Strong Recommendation, Very
Low Quality of Evidence)
18.8.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
18.8.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Very Low Quality of Evidence)
18.8.2 Pediatrics
18.8.2.1 First-line agent: cefazolin (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
18.8.2.2 MRSA agents for documented MRSA or history of MRSA: vancomycin
(UW Health Weak/conditional Recommendation, Very Low Quality of
Evidence)
18.8.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
18.9 Antimicrobial selection for patients undergoing clean urologic procedures with entry into
the urinary tract and breach of the skin
3

18.9.1 Adults
18.9.1.1 First-line agent: cefazolin (UW Health Strong Recommendation, Very
Low Quality of Evidence)
18.9.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Strong Recommendation, Very
Low Quality of Evidence)
18.9.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: ciprofloxacin or gentamicin with or without
clindamycin (UW Health Strong Recommendation, Very Low Quality of
Evidence)
18.9.2 Pediatrics
18.9.2.1 First-line agent: cefazolin (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
18.9.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
18.9.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: gentamicin or ciprofloxacin with or without
clindamycin (UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
18.9.2.3.1 While the risk of tendon rupture or tendonitis secondary to
single-dose preoperative fluoroquinolone dose is quite small,
fluoroquinolones are not the first choice in pediatric patients.
(UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
18.10 Antimicrobial selection for patients undergoing clean-contaminated urologic procedures
with entry into the urinary tract and breach of the skin
3

18.10.1 Adults
18.10.1.1 First-line agent: cefazolin and metronidazole or cefoxitin (UW Health
Strong Recommendation, High Quality of Evidence)
18.10.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Strong Recommendation, Low
Quality of Evidence)
18.10.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: ciprofloxacin or gentamicin with
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37
metronidazole or clindamycin (UW Health Strong Recommendation,
Low Quality of Evidence)
18.10.2 Pediatrics
18.10.2.1 First-line agent: cefazolin and metronidazole or cefoxitin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
18.10.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
18.10.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: gentamicin or ciprofloxacin with
metronidazole or clindamycin (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
18.10.2.3.1 While the risk of tendon rupture or tendonitis secondary to
single-dose preoperative fluoroquinolone dose is quite
small, fluoroquinolones are not the first choice in pediatric
patients. (UW Health Weak/conditional Recommendation,
Very Low Quality of Evidence)
18.11 In patients with a history of urinary tract infections caused by Enterococcus species, it
may be reasonable to add to add ampicillin to the prophylactic regimen (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
18.12 Clindamycin poorly penetrates the urinary tract and use in urologic procedures is to
cover for skin flora

19 Vascular procedures
19.1 Patients undergoing brachiocephalic procedures without implantation of prosthetic graft
material should receive no antimicrobial prophylaxis
3,122
(UW Health Strong
Recommendation, Moderate Quality of Evidence)
19.1.1 Includes carotid endarterectomy, brachial artery repair
19.2 Patients undergoing vascular procedures that involve implantation of prosthetic material
and procedures with a higher risk of infection should receive antimicrobial prophylaxis
3,123-
126
(UW Health Strong Recommendation, Low Quality of Evidence)
19.2.1 Includes aneurysm repair, thromboendarterectomy, vein bypass
19.3 Pathogens
3

19.3.1 S. aureus, S. epidermidis, enteric Gram-negative bacilli
19.4 Antimicrobial selection
3

19.4.1 Adults
19.4.1.1 First-line agent: cefazolin (UW Health Strong Recommendation, Low
Quality of Evidence)
19.4.1.2 MRSA agents for documented MRSA or history of MRSA or risk for MRSE
with implanted prosthetic material: add vancomycin to the regimen (UW
Health Weak/conditional Recommendation, Very Low Level of Evidence)
19.4.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Very Low Quality of Evidence)
19.4.2 Pediatrics
19.4.2.1 First-line agent: cefazolin (UW Health Strong Recommendation, Very
Low Quality of Evidence)
19.4.2.2 MRSA agents for documented MRSA or history of MRSA or risk for MRSE
with implanted prosthetic material: add vancomycin to the regimen (UW
Health Weak/conditional Recommendation, Very Low Quality of Evidence)
19.4.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Low Quality of Evidence)
19.4.3 Rifampin may be considered for soaking vascular stents for placement in dirty,
contaminated tissue.
127
If rifampin soak is utilized, use should be limited to one vial.
(UW Health Weak/conditional Recommendation, Very Low Quality of Evidence)
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38

20 Heart transplantation
20.1 Patients receiving heart transplantation should receive antimicrobial prophylaxis
3,128-130

20.2 Pathogens
3

20.2.1 Most common: Staphylococcus species
20.2.2 Less common: Enterococcus faecalis, coagulase-negative staphylococci,
Enterococcus species, Enterobacteriaceae species, P. aeruginosa, S. maltophilia
20.3 Antimicrobial selection
3

20.3.1 Adults
20.3.1.1 First-line agent: cefazolin (UW Health Strong Recommendation, Very
Low Quality of Evidence)
20.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
20.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Very Low Quality of Evidence) and ciprofloxacin
(UW Health Weak/conditional Recommendation, Very Low Quality of
Evidence)
20.3.2 Pediatrics
20.3.2.1 First-line agent: cefazolin (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
20.3.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
20.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)

21 Lung and heart-lung transplantation
21.1 Patients receiving lung or heart-lung transplantation should receive antimicrobial
prophylaxis
3,128,129,131
(UW Health Strong Recommendation, Very Low Quality of Evidence)
21.1.1 Antimicrobial prophylaxis regimens should be adjusted to include coverage for
potential bacterial or fungal pathogens isolated by pre-operative culture from either
the recipient’s airway or donor lung
132-134

21.1.2 End-stage cystic fibrosis patients should receive antimicrobials based on pre-
transplant culture and sensitivity
21.2 Pathogens
3

21.2.1 P. aeruginosa, Candida species, S. aureus, enterococci, coagulase-negative
staphylococci, B. cepacia, E. coli, Klebsiella species
21.3 Antimicrobial selection
21.3.1 Adults
21.3.1.1 Heart first-line agent: cefuroxime and vancomycin (UW Health Weak
Recommendation, Very Low Quality of Evidence)
21.3.1.2 Lung first-line agent: ceftriaxone (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
21.3.1.3 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
21.3.1.4 Lung transplant agents for patients with IgE-mediated reaction or severe
non-IgE-mediated reaction to β-lactam: moxifloxacin (UW Health Strong
Recommendation, Very Low Quality of Evidence)
21.3.2 Pediatrics
21.3.2.1 First-line agent: cefazolin (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
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39
21.3.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
21.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
21.3.3 It may be reasonable to extend the duration of antimicrobial prophylaxis beyond 48
hours (UW Health Weak/conditional Recommendation, Very Low Level of
Evidence)

22 Liver transplantation
22.1 Patients receiving liver transplant should receive antimicrobial prophylaxis
3,135-137
(UW
Health Strong Recommendation, Low Quality of Evidence)
22.1.1 Routine selective bowel decontamination is not recommended
138
(UW Health
Strong Recommendation, High Quality of Evidence)
22.1.2 It is reasonable to provide postoperative antifungal prophylaxis to patient according
to the UWHealth Antifungal Prophylaxis in Liver Transplant Recipients Clinical
Practice Guideline.
139

22.2 Pathogens
3

22.2.1 Aerobic Gram-negative bacilli (E. coli, Klebsiella species, Enterobacter species, A.
baumannii, Citrobacter species), S. aureus, coagulase-negative staphylococci,
Candida species
22.3 Antimicrobial selection
3

22.3.1 Adults
140-142

22.3.1.1 First-line agent: Piperacillin-tazobactam or ceftriaxone and ampicillin (UW
Health Strong Recommendation, Low Quality of Evidence)
22.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Low Quality of Evidence)
22.3.1.3 Documented history of vancomycin-resistant Enterococcus (VRE):
ceftriaxone and daptomycin (UW Health Weak/conditional
Recommendation, Low Quality of Evidence)
22.3.1.4 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam and no history of VRE: gentamicin or
aztreonam and vancomycin (UW Health Weak/conditional
Recommendation, Low Quality of Evidence)
22.3.1.5 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam and VRE history: gentamicin or aztreonam
and daptomycin. (UW Health Strong Recommendation, Low Quality of
Evidence)
22.3.1.6 High risk for Candida infection: fluconazole (UW Health Strong
Recommendation, Low Quality of Evidence)
22.3.2 Pediatrics
143,144

22.3.2.1 First-line agent: Piperacillin-tazobactam or cefotaxime and ampicillin (UW
Health Strong Recommendation, Low Quality of Evidence)
22.3.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
22.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin: vancomycin
or clindamycin and gentamicin or aztreonam or ciprofloxacin (UW Health
Strong Recommendation, Very Low Quality of Evidence)
22.3.2.3.1 While the risk of tendon rupture or tendonitis secondary to
single-dose preoperative ciprofloxacin is quite small,
ciprofloxacin is not the first choice in pediatric patients (UW
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40
Health Weak/conditional Recommendation, Very Low Quality
of Evidence)

23 Kidney transplantation
23.1 Patients receiving kidney transplant should receive antimicrobial prophylaxis
3,145
(UW
Health Strong Recommendation, Moderate Quality of Evidence)
23.2 Pathogens
3

23.2.1 Staphylococcus species, Enterococcus species, E. coli, Enterobacter species,
Klebsiella species, P. aeruginosa, Candida species
23.3 Antimicrobial selection
23.3.1 Adults
3,146-149

23.3.1.1 First-line agent: cefazolin (UW Health Strong Recommendation,
Moderate Quality of Evidence)
23.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
23.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin and
gentamicin or aztreonam or ciprofloxacin (UW Health Strong
Recommendation, Very Low Quality of Evidence)
23.3.2 Pediatrics
23.3.2.1 First-line agent: cefazolin (UW Health Strong Recommendation, Very
Low Quality of Evidence)
23.3.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen(UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
23.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin and
gentamicin or aztreonam or ciprofloxacin (UW Health Strong
Recommendation, Very Low Quality of Evidence)
23.3.2.4 High risk for Candida infection: fluconazole (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
24 Pancreas transplantation
24.1 Patients receiving pancreas transplant (alone or in combination with kidney) should
receive antimicrobial prophylaxis.
3
(UW Health Strong Recommendation, Low Quality of
Evidence)
24.2 Selective bowel decontamination is recommended prior to pancreas transplant (UW
Health Weak/conditional Recommendation, Very Low Quality of Evidence)
24.3 It is reasonable to provide antifungal prophylaxis to patient perioperatively at time of
pancreas transplant due to enteric anastomosis (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
24.4 Pathogens
3

24.4.1 Staphylococcus species, Enterococcus species, E. coli, Enterobacter species,
Klebsiella species, P. aeruginosa, Candida species
24.5 Antimicrobial Selection
24.5.1 Adults
3,129,139,150,151

24.5.1.1 First-line agent: Ceftriaxone, ampicillin, and fluconazole (UW Health
Strong Recommendation, Low Quality of Evidence)
24.5.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Low Quality of Evidence)
24.5.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: gentamicin, vancomycin, and fluconazole
(UW Health Weak/conditional Recommendation, Low Quality of Evidence)

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25 Plastic surgery
25.1 Antimicrobial prophylaxis is not recommended for patients undergoing clean procedures
without additional postoperative infection risk factors
152-159
(UW Health Strong
Recommendation, Moderate Quality of Evidence)
25.2 It may be reasonable to provide antimicrobial prophylaxis to patients undergoing clean
procedures with risk factors (UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
25.2.1 Risk factors include: age extremes, nutritional status, obesity, diabetes, tobacco
use, coexistent remote body-site infection, altered immune response, corticosteroid
therapy, recent surgical procedure, length of preoperative hospitalization,
colonization
25.3 Patients undergoing clean-contaminated or breast cancer procedures should receive
antimicrobial prophylaxis
160-162
(UW Health Strong Recommendation, Moderate Quality of
Evidence)
25.4 Pathogens
3

25.4.1 Most common: S. aureus, staphylococci, streptococci
25.4.2 Procedures involving macerated and moist environments, below the waist, or in
diabetic patients have higher rates of Gram-negative organisms: P. aeruginosa, S.
marcescens, E. coli, Klebsiella species, P. mirabilis
25.5 Antimicrobial selection undergoing clean procedures with risk factors, clean-contaminated
procedures, or breast cancer procedures
3

25.5.1 Adults
25.5.1.1 First-line agent: cefazolin (UW Health Strong Recommendation, Very
Low Quality of Evidence)
25.5.1.1.1 For mastectomy or breast tissue expander procedure add
vancomycin (UW Health Strong Recommendation, Very Low
Quality of Evidence)
25.5.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
25.5.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Very Low Quality of Evidence)
25.5.2 Pediatrics
25.5.2.1 First-line agent: cefazolin (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
25.5.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
25.5.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)

26 Open fractures
26.1 Patients with open fractures should receive preoperative antibiotics
163,164
(UW Health
Strong Recommendation, Moderate Quality of Evidence)
26.2 Pathogens
163,164

26.2.1 All open fractures: Gram-positive organisms
26.2.2 Type III fractures: Gram-positive and Gram-negative organisms
26.2.3 Fecal or farm-related injuries: clostridial species
26.3 Antimicrobial selection
163,164

26.3.1 Adults and pediatrics
26.3.1.1 First-line agents:
26.3.1.1.1 Type I and II fractures: cefazolin (UW Health Strong
Recommendation, Low Quality of Evidence)
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26.3.1.1.2 Type III fractures: ceftriaxone with or without gentamicin (UW
Health Strong Recommendation, Low Quality of Evidence)
26.3.1.1.3 Fecal or farm-related injuries: Add metronidazole for
Clostridium species and other anaerobic coverage (UW Health
Weak/conditional Recommendation, Very Low Level of
Evidence)
26.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Strong Recommendation, Very
Low Quality of Evidence)
26.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin (UW Health Strong
Recommendation, Very Low Quality of Evidence)

27 Penetrating abdominal wounds
27.1 Patients with penetrating abdominal trauma should receive preoperative antibiotics
165,166

(UW Health Strong Recommendation, Moderate Quality of Evidence)
27.2 Pathogens
165,166

27.2.1 Aerobes and anaerobes
27.3 Antimicrobial selection
165-170

27.3.1 First-line agents: cefoxitin (UW Health Strong Recommendation, Moderate Level
of Evidence) or cefuroxime and metronidazole (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
27.3.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin to the
regimen (UW Health Weak/conditional Recommendation, Very Low Quality of
Evidence)
27.3.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin and ciprofloxacin and metronidazole (UW
Health Weak/conditional Recommendation, Very Low Quality of Evidence)
27.3.4 Aminoglycosides should not be utilized due to altered pharmacokinetics including
subtherapeutic aminoglycoside levels in patients with increased volume of
distribution secondary to aggressive fluid resuscitation
171,172
(UW Health Strong
Recommendation, Moderate Quality of Evidence)
27.3.5 In patients with hemorrhagic shock, it may be reasonable to increase antimicrobial
dose two- to three-fold and to repeat dosing after transfusion of every ten units of
blood
165,166,172
(UW Health Weak/conditional Recommendation, Low Quality of
Evidence)

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43
Interventional Radiology Prophylaxis

28 Vascular interventions
28.1 Antimicrobial prophylaxis is not recommended for patients undergoing diagnostic
angiography, routine angioplasty, thrombolysis, arterial closure device placement, or
arterial stent placement
173-175
(UW Health Strong Recommendation, Moderate Quality of
Evidence)
28.2 Antimicrobial prophylaxis may be considered for patients at high risk of infection
undergoing arterial stent placement
175-177
(UW Health Weak/conditional Recommendation,
Low Quality of Evidence)
28.2.1 High risk includes: cases or repeat intervention within seven days, prolonged
indwelling arterial sheath, prolonged duration of procedure
28.3 Pathogens
173

28.3.1 S. aureus, S. epidermidis
28.4 Antimicrobial selection for patients at high risk of infection undergoing arterial stent
placement
173

28.4.1 Adults
28.4.1.1 First-line agent: cefazolin (UW Health Strong Recommendation, Very
Low Quality of Evidence)
28.4.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
28.4.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Very Low Quality of Evidence)
28.4.2 Pediatrics
28.4.2.1 First-line agent: cefazolin (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
28.4.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
28.4.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)

29 Endograft placement
29.1 Antimicrobial prophylaxis is probably recommended in patients undergoing endograft
placement
173,178,179
(UW Health Strong Recommendation, Low Quality of Evidence)
29.1.1 Includes aortic and peripheral placement
29.2 Pathogens
173

29.2.1 S. aureus, S. epidermidis
29.3 Antimicrobial selection
173

29.3.1 Adults and pediatrics
29.3.1.1 First-line agent: cefazolin (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
29.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
29.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)

30 Superficial venous insufficiency treatment
30.1 Antimicrobial prophylaxis is not recommended for patients undergoing lower-extremity
superficial venous insufficiency treatment (includes endovascular thermal ablation,
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44
sclerotherapy, and ambulatory phlebectomy).
173,180,181
(UW Health Strong
Recommendation, Moderate Quality of Evidence)
30.2 Antimicrobial prophylaxis is recommended for patients undergoing sclerotherapy of upper
extremity.
182,183
(UW Health Weak/conditional Recommendation, Low Quality of Evidence)
30.3 Pathogens: S. aureus, S. epidermidis
30.4 Antimicrobial selection (UW Health Weak/conditional Recommendation, Very Low Quality
of Evidence)
30.4.1 First-line agent: cefazolin
30.4.2 MRSA agents for documented MRSA or history of MRSA: add vancomycin to the
regimen or use clindamycin as single agent
30.4.3 Agents for patients with IgE-mediated reaction or severe non-IgE-mediated
reaction to β-lactam: vancomycin or clindamycin

31 Inferior vena cava (IVC) filter placement
31.1 Antimicrobial prophylaxis is not recommended for patients undergoing IVC filter
placement
173,184
(UW Health Strong Recommendation, Moderate Quality of Evidence)

32 Central venous catheter placement
32.1 Antimicrobial prophylaxis is not recommended for patients undergoing central venous
catheter placement including PICC line, tunneled and cuffed lines, non-tunneled and
temporary lines, or hemodialysis or pheresis lines.
173,176
(UW Health Strong
Recommendation, Low Quality of Evidence)
32.2 Antimicrobial prophylaxis may be considered in patients undergoing venous catheter
placement at high risk of infection including port placement.
173,185
(UW Health
Weak/conditional Recommendation, Low Quality of Evidence)
32.2.1 Includes immunocompromised patients who require catheter placement before
chemotherapy or patients with a history of catheter infection
32.3 Pathogens
173

32.3.1 S. aureus, S. epidermidis
32.4 Antimicrobial selection for patients undergoing central venous catheter placement at high
risk of infection including port placement.
173

32.4.1 Adults and pediatrics
32.4.1.1 First-line agent: cefazolin (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
32.4.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
32.4.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)

33 Embolization and chemoembolization
33.1 Patients undergoing tumor and/or solid organ embolization with the intent to create an
infarct or there is a high likelihood of infarct should receive antimicrobial
prophylaxis
173,186,187
(UW Health Strong Recommendation, Moderate Quality of Evidence)
33.2 It is reasonable to provide antimicrobial prophylaxis to patients undergoing
chemoembolization
173,188,189
(UW Health Strong Recommendation, Very Low Level of
Evidence)
33.3 Pathogens
173

33.3.1 S. aureus, Streptococcus species, Corynebacterium species, enteric flora
33.4 Antimicrobial selction
173

33.4.1 Adults and pediatrics
33.4.1.1 First-line agent choice (UW Health Weak/conditional Recommendation,
Very Low Quality of Evidence)
33.4.1.1.1 Hepatic artery embolization (HAE), bland embolization, portal
vein embolization (PVE): ampicillin/sulbactam or cefazolin and
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metronidazole or cefoxitin or ampicillin and gentamicin or
ceftriaxone
33.4.1.1.2 Renal or splenic embolization: ceftriaxone
33.4.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
33.4.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin with
gentamicin plus metronidazole (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
33.4.2 It may be reasonable to administer extended oral antibiotic prophylaxis based on
tissue necrosis (UW Health Weak/conditional Recommendation, Very Low Quality
of Evidence)

34 Uterine artery embolization
34.1 It may be reasonable to provide antimicrobial prophylaxis to patients undergoing uterine
artery embolization
173,190-192
(UW Health Weak/conditional Recommendation, Low Quality
of Evidence)
34.2 Pathogens
173

34.2.1 S. aureus, S. epidermidis, Streptococcus species, E. coli
34.3 Antimicrobial selection
173

34.3.1 Adults and pediatrics
34.3.1.1 First-line agent: cefazolin, cefoxitin, clindamycin and gentamicin, or
ampicillin-sulbactam (UW Health Weak/conditional Recommendation,
Very Low Quality of Evidence)
34.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen or clindamycin and gentamicin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
34.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin and gentamicin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)

35 Transjugular Intrahepatic Portosystemic Shunt (TIPS) creation
35.1 It is reasonable to provide antimicrobial prophylaxis to patients undergoing TIPS
creation
173,193,194
(UW Health Strong Recommendation, Very Low Quality of Evidence)
35.2 Pathogens
173

35.2.1 S. aureus, S. epidermidis, Corynebacterium species, biliary pathogens, enteric
Gram-negative rods, anaerobes, Enterococcus species
35.3 Antimicrobial selection
173

35.3.1 Adults
35.3.1.1 First-line agent: ceftriaxone, ampicillin-sulbactam (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
35.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to regimen (UW Health Weak/conditional Recommendation,
Very Low Quality of Evidence)
35.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin with
gentamicin (UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)

36 Fluoroscopically guided gastrostomy and gastrojejunostomy tube placement
36.1 No antimicrobial prophylaxis is recommended for patients undergoing gastrostomy or
gastrojejunostomy placement.
33,34,173,195,196
(UW Health Strong Recommendation, Low
Quality of Evidence)
36.2 It is reasonable to provide antimicrobial prophylaxis to patients undergoing decompressive
gastrostomy tube placement or percutaneous endoscopic gastrostomy (PEG) tube
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placement by “pull” technique.
33,34,173,197
(UW Health Strong Recommendation, Moderate
Level of Evidence)
36.3 Pathogens
173

36.3.1 S. epidermidis, S. aureus, Corynebacterium species
36.4 Antimicrobial selection
173

36.4.1 Adults and pediatrics
36.4.1.1 First-line agent: cefazolin (UW Health Weak/conditional
Recommendation, Low Quality of Evidence)
36.4.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to regimen (UW Health Weak/conditional Recommendation,
Very Low Quality of Evidence)
36.4.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin and
gentamicin or ciprofloxacin; moxifloxacin. (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)

37 Liver and biliary interventions
37.1 Patients undergoing liver and biliary interventions should receive antimicrobial
prophylaxis
173,176,198
(UW Health Strong Recommendation, Moderate Quality of Evidence)
37.2 Pathogens
173

37.2.1 More common: Enterococcus species, Candida species, Gram-negative aerobic
bacilli, S. viridans, E. coli, Clostridium species
37.2.2 Advanced biliary disease including hepatolithiasis: Klebsiella species,
Pseudomonas species, Bacteroides species
37.3 Antimicrobial selection
37.3.1 It is reasonable to select antimicrobial based on culture information, if known (UW
Health Weak/conditional Recommendation, Very Low Quality of Evidence)
37.3.2 Adults
173,176,198

37.3.2.1 First-line agent: ceftriaxone, ampicillin-sulbactam, cefoxitin, ampicillin,
gentamicin, or ciprofloxacin (UW Health Strong Recommendation, Low
Quality of Evidence)
37.3.2.1.1 Ciprofloxacin, gentamicin, or ceftriaxone may be considered
for ERCP.
33,34
(UW Health Weak/conditional Recommendation,
Very Low Quality of Evidence)
37.3.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
37.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin with
gentamicin (UW Health Strong Recommendation, Very Low Quality of
Evidence)
37.3.3 Pediatrics
173

37.3.3.1 First-line agent: ceftriaxone, ampicillin-sulbactam, cefoxitin, ampicillin and
gentamicin (UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)
37.3.3.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
37.3.3.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin with
gentamicin (UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)

38 Genitourinary procedures
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38.1 Antimicrobial prophylaxis is not indicated for patients undergoing routine tube change who
are neither obstructed nor infected
173,199
(UW Health Strong Recommendation, Low
Quality of Evidence)
38.2 It is reasonable to provide antimicrobial prophylaxis to patients undergoing genitourinary
procedures
173,200
(UW Health Strong Recommendation, Very Low Quality of Evidence)
38.2.1 Includes percutaneous nephrostomy tube placement, tube exchange, ureteral
stents
38.3 Pathogens
199

38.3.1 E. coli. Proteus species, Klebsiella species, Enterococcus species
38.4 Antimicrobial selection
173

38.4.1 It is reasonable to select antimicrobial based on culture information, if known (UW
Health Weak/conditional Recommendation, Very Low Quality of Evidence)
38.4.2 Adults and pediatrics
38.4.2.1 First-line agent: cefazolin, ceftriaxone, ampicillin-sulbactam, ampicillin
and gentamicin (UW Health Strong Recommendation, Very Low Quality of
Evidence)
38.4.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to regimen(UW Health Weak/conditional Recommendation,
Very Low Quality of Evidence)
38.4.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin and gentamicin (UW Health
Strong Recommendation, Very Low Quality of Evidence)

39 Tumor Ablation
39.1 Antimicrobial prophylaxis may be reasonable in patients undergoing percutaneous tumor
ablation
173,201
(UW Health Strong Recommendation, Low Quality of Evidence)
39.2 Pathogens
173

39.2.1 S. aureus, S. epidermidis, Streptococcus species, E. coli
39.2.2 Previous bilioenteric anastomosis: E. coli, Proteus species, Klebsiella species,
Enterococcus species
39.3 Antimicrobial selection
173

39.3.1 Adults and pediatrics
39.3.1.1 First-line agents (UW Health Strong Recommendation, Very Low Quality
of Evidence)
39.3.1.1.1 Liver: ampicillin-sulbactam
39.3.1.1.2 Bone: cefazolin
39.3.1.1.3 Renal: ceftriaxone
39.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Strong Recommendation, Low
Quality of Evidence)
39.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin (UW Health Strong
Recommendation, Very Low Quality of Evidence)
39.3.2 It may be reasonable to administer extended oral antibiotic prophylaxis based on
tissue necrosis (UW Health Weak/conditional Recommendation, Very Low
Quality of Evidence)

40 Percutaneous abscess drainage
40.1 Patients undergoing percutaneous abscess drainage should receive antimicrobial
prophylaxis
173,199
(UW Health Strong Recommendation, Low Level of Evidence)
40.1.1 Patients undergoing these procedures typically are receiving therapeutic
antimicrobial treatment prior to procedure
40.2 Pathogens
173

40.2.1 Skin flora: S. epidermidis, S. aureus, Corynebacterium species
40.2.2 Intracavitary: Gram-negative bacteria, Enterococcus species, E. coli, B. fragilis,
other anaerobes
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40.3 Antimicrobial selection
173

40.3.1 Adults and pediatrics
40.3.1.1 First-line agents: cefoxitin, ampicillin-sulbactam, ceftriaxone (UW Health
Strong Recommendation, Very Low Quality of Evidence)
40.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
40.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam (UW Health Strong Recommendation,
Very Low Quality of Evidence)
40.3.1.3.1 Gram-positive coverage: vancomycin or clindamycin
40.3.1.3.2 Gram-negative coverage: aminoglycoside

41 Percutaneous biopsy
41.1 Patients undergoing nontransrectal percutaneous biopsy should not receive antimicrobial
prophylaxis
173,199
(UW Health Strong Recommendation, Low Quality of Evidence)
41.2 Patients undergoing transrectal percutaneous biopsy should receive antimicrobial
prophylaxis
173,202,203
(UW Health Strong Recommendation, High Quality of Evidence)
41.3 Pathogens
173

41.3.1 Gram-negative bacteria, Enterococcus species, E. coli, B. fragilis, other anaerobes
41.4 Antimicrobial selection
173,199,202

41.4.1 Adults
41.4.1.1 First-line agents: 80 mg gentamicin IV/IM AND ciprofloxacin PO twice
daily for 5 days or ciprofloxacin PO twice daily for 4 days starting the day
before the biopsy (UW Health Strong Recommendation, Low Quality of
Evidence)

42 Percutaneous vertebroplasty
42.1 It is reasonable to provide antimicrobial prophylaxis to patients undergoing percutaneous
vertebroplasty
173,201,204
(UW Health Strong Recommendation, Very Low Quality of
Evidence)
42.2 Pathogens
173

42.2.1 Skin flora: S. epidermidis, S. aureus, Corynebacterium species
42.3 Antimicrobial selection
173,201

42.3.1 Adults
42.3.1.1 First-line agents: cefazolin (UW Health Strong Recommendation, Very
Low Quality of Evidence)
42.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
42.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Strong Recommendation, Very Low Quality of Evidence)
42.3.2 Pediatrics
42.3.2.1 First-line agents: cefazolin (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
42.3.2.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
42.3.2.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
43 Pulmonary Arteriovenous Malformations
43.1 It is reasonable to provide antimicrobial prophylaxis to patients undergoing pulmonary
arteriovenous malformation embolization.
205
(UW Health Strong Recommendation, Very
Low Quality of Evidence)
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43.2 Pathogens
43.2.1 S. aureus, S. epidermidis
43.3 Antimicrobial selection
43.3.1 Adults and pediatrics
43.3.1.1 First-line agent: cefazolin (UW Health Weak/conditional
Recommendation, Low Quality of Evidence)
43.3.1.2 MRSA agents for documented MRSA or history of MRSA: add
vancomycin to the regimen (UW Health Weak/conditional
Recommendation, Very Low Quality of Evidence)
43.3.1.3 Agents for patients with IgE-mediated reaction or severe non-IgE-
mediated reaction to β-lactam: vancomycin or clindamycin (UW Health
Weak/conditional Recommendation, Very Low Quality of Evidence)
UW Health Implementation
Potential Benefits and Harms of Implementation
• Identification and standardization of appropriate antimicrobial prophylaxis for surgeries and
procedures.
• Administration of antimicrobials with potential side effects with specific antimicrobials.
• No antimicrobial administration with potential infection associated with a surgery or procedure.

Pertinent UWHealth Policies and Procedures
None identified.

Patient Resources
None identified.

Guideline Metrics
• Proportion of patients receiving appropriate antimicrobials with correct time frame as defined by
SCIP measures
• Proportion of surgical site infection

Implementation Plan/Clinical Tools
1. Guideline will be posted on U-Connect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the guideline
recommendations will be reviewed for consistency and modified as appropriate.

Order Set
All preoperative order sets reference this guideline.

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood
that some patients will not fit the clinical condition contemplated by a guideline and that a guideline
will rarely establish the only appropriate approach to a problem.
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Appendix A. Antimicrobial selection in patients with reported β-lactam allergy or intolerance (from Treatment of Patients with Reported Allergies to
Beta-Lactam Antibiotics – Adult – Inpatient – Clinical Practice Guideline)

Indication for beta lactam antibiotic
and history of beta lactam allergy
or adverse reaction?
No
Has the patient received
antibiotic in the same class in
the past without reaction?
Yes
Type of reaction?
Adverse reaction or
side effect
(examples: GI
intolerance or
headache)
Order, process, and/or
administer beta-lactam antibiotic
No
Unable to ascertain
type of reaction from
patient, family, or
medical record
Non-severe, Non-IgE
mediated reaction
occurring AFTER 72
hours (delayed
macular papular
rash)
Possible IgE
mediated reaction
occurring WITHIN 72
hours (rash ± hives)
IgE mediated
reaction
occurring WITHIN 24
hours (immediate
urticaria,
angioedema,
anaphylaxis)
Severe, Non-IgE
mediated reaction
(hemolysis, Stevens-
Johnson Syndrome,
toxic epidermal
nerolysis, etc.)
Use non-beta lactam antibiotic
C,D
First Line: Use non-beta lactam antibiotic
C,D
Second Line and beta lactam needed:
• If penicillin antibiotic planned: consult Allergy for
penicillin skin testing and/or desensitization
• If cephalosporin or carbapenem planned: consult
Allergy for desensitization
Penicillin Allergy
- First Line: Cephalosporin
- Second Line: Carbapenem
Cephalosporin Allergy
- First Line: Penicillin
- Second Line: Carbapenem
Carbapenem Allergy
- First Line: Penicillin or Cephalosporin
Aztreonam Allergy
- First Line: Penicillin or Cephalosporin
- Second Line: Carbapenem
** Use beta lactam with different side chain (See Table 1)
** If use of beta lactam from same class is desired, consult Allergy
Prescribe beta
lactam antibiotic
from different class
based on class of
beta lactam allergy
A
Prescribe beta
lactam antibiotic
from different class
via GRADED
CHALLENGE
B
based
on class of beta
lactam allergy
Yes
Footnotes
A
May give via graded challenge if reaction history was recent
B
Graded challenge: use oral challenge if oral therapy is desired; use IV challenge if IV therapy is desired
• Graded challenges are intended for patients with low probability of an immediate allergic reaction.
Patients must be able to report symptoms and use a call light
• Patients do not need to increase their level of care during a graded challenge
• Use Acudose cabinet and Crash Cart stock, if needed, for anaphylaxis medications (epinephrine,
diphenhydramine, albuterol nebs) during graded challenges
• Patients should be monitored for immediate hypersensitivity reactions (hives, clearing of throat,
coughing, dyspnea, abdominal pain, uneasiness) for up to 60 minutes after the full dose is
administered
C
Do not use aztreonam in ceftazidime-allergic or ceftolozane-allergic patients
D
If no alternatives are available, aztreonam may be considered for Gram-negative infections
From: Treatment of Patients with Reported Allergies to
Beta-Lactam Antibiotics; Revision Date 9/2016; Guideline
Contact Philip Trapskin, PharmD, 608-263-1328,
PTrapskin@uwhealth.org
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51


Appendix B. UW Health Anesthesia Table for OR Antibiotics: Preparation and consideration for IV push administration
From: Surgical and Interventional Radiology Antimicrobial Prophylaxis Clinical Practice Guideline
Last reviewed: 11/2017
Contact information: Philip Trapskin, PharmD; (608)-263-1328, PTrapskin@uwhealth.org

All antibiotics should be prepared prior to case, labeled appropriately, and discarded if unused.

Appropriate labeling consists of:
(1) Name and concentration (strength) of the medication or solution;
(2) Volume/amount (if not apparent from the container);
(3) Diluent name and volume (if not apparent from the container);
(4) Expiration date (if it is not to be used within 24 hours); and
(5) Time of expiration (if it is fewer than 24 hours)

Do not use 0.9% sodium chloride flushes for drug dilution and product preparation.
1


Drug Reconstitution Intravenous (IV) Push Time
Ampicillin 1 g
2,3
Reconstitute each vial with 7.4 mL sterile water for injection
• Administer doses less than 500 mg over 3 to 5 minutes
• Administer doses of 1-2 g over 10-15 minutes
• More rapid administration may result in seizures
Ampicillin 2 g
2,3
Reconstitute each vial with 14.8 mL sterile water for injection
• Administer doses less than 500 mg over 3 to 5 minutes
• Administer doses of 1-2 g over 10-15 minutes
• More rapid administration may result in seizures
Ampicillin/
sulbactam 1.5 g
(Unasyn)
2,3

Reconstitute each vial with 3.2 mL of sterile water for injection.
Reconstituted solution should be diluted further in 0.9% sodium chloride
(normal saline) to yield a concentration between 3 and 45 mg/mL
(ampicillin sodium 2 to 30 mg/mL and sulbactam sodium 1 to 15
mg/mL).
Administer by slow IV push over 10 to 15 minutes
Ampicillin/
sulbactam 3 g
(Unasyn)
2,3

Reconstitute each vial with 6.4 mL of sterile water for injection.
Reconstituted solution should be diluted further in 0.9% sodium chloride
(normal saline) to yield a concentration between 3 and 45 mg/mL
(ampicillin sodium 2 to 30 mg/mL and sulbactam sodium 1 to 15
mg/mL).
Administer by slow IV push over 10 to 15 minutes
Cefazolin 1 g
2,3
Reconstitute each 1 g vial with 7.5 mL sterile water for injection
• Administer by slow IV push over 3 to 5 minutes
• Thrombophlebitis can occur
• Diluted solution should be translucent and yellow
Cefazolin 2 g
2,3

• Cefazolin 2 gram DUPLEX
®
bag system: directions to reconstitute
• Or use two 1 gram vials: instructions above
• Duplex bag: administer over 30 to 60 minutes
• Vials: administer each 1 g dose by slow IV push over 3 to 5
minutes
Cefazolin 3 g
2,3
Use three 1 gram vials; instructions above Administer each 1 g dose by slow IV push over 3 to 5 minutes
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52

Drug Reconstitution Intravenous (IV) Push Time
Cefepime 1 g
2-4

Reconstitute each 1 g vial with 10 mL sterile water for injection or 0.9%
sodium chloride (normal saline).
Reconstituted solution should be diluted further in 0.9% sodium chloride
(normal saline) to yield a concentration between 1 and 40 mg/mL.
• Administer by slow IV push over 5 minutes.
• Localized phlebitis can occur

Cefepime 2 g
2-4

Reconstitute each 2 g vial with 10 mL sterile water for injection or 0.9%
sodium chloride (normal saline)
Reconstituted solution should be diluted further in 0.9% sodium chloride
(normal saline) to yield a concentration between 1 and 40 mg/mL.
• Administer by slow IV push over 5 minutes.
• Localized phlebitis can occur
Ceftriaxone 1
g
2,3,5-7

Reconstitute each vial with 9.6 mL sterile water for injection or 0.9%
sodium chloride (normal saline)

• Administer by slow IV push over 3 to 5 minutes in adult patients
or
• IV push only in patients 12 years of age and older
• Do not administer simultaneously with calcium-containing
solutions (e.g. Lactated Ringer’s or Hartmann solution),
products, or continuous calcium-containing infusions (e.g.
parenteral nutrition) in the same IV line or Y-site due to risk of
precipitate formation

Ceftriaxone 2
g
2,3,5,6

Reconstitute each vial with 19.2 mL sterile water for injection or 0.9%
sodium chloride (normal saline)


• Administer by slow IV push over 5 minutes in adult patients
• IV push only in patients 12 years of age and older
• Do not administer simultaneously with calcium-containing
solutions (e.g. Lactated Ringer’s or Hartmann solution),
products, or continuous calcium-containing infusions (e.g.
parenteral nutrition) in the same IV line or Y-site due to risk of
precipitate formation
Cefoxitin 1 g
2,3
Reconstitute each 1 g vial with 10 mL sterile water for injection Administer by slow IV push over 3 to 5 minutes
Cefoxitin 2 g
2,3
Reconstitute each 2 g vial with 10 mL sterile water for injection Administer by slow IV push over 3 to 5 minutes
Cefoxitin 3 g
2,3

Reconstitute a 1 g vial and a 2 g vial each with 10 mL of sterile water for
injection
• Administer each 1 g dose by slow IV push over 3 to 5 minutes.
• Administer each 2 g dose by slow IV push over 3 to 5 minutes.
Cefuroxime 1.5
g and 3 g
2,3

Reconstitute each 1.5 gram vial with 16 mL of sterile water for injection.
Shake gently.
• Administer each 1.5 g dose by slow IV push over 3 to 5
minutes.
• Local thrombophlebitis can occur.
Clindamycin 600
mg, 900 mg or
1200 mg bag
2,3,8

Provided as a premade bag in the OR pharmacies
Cannot be administered by IV push. Administer no faster than
30 mg/min. Do not exceed 1,200 mg/hour.
Doxycycline 100
mg
2,3,8

Either use 100 mL minibag plus bag or, if unavailable, reconstitute vial
with 10 mL sterile water for injection or 0.9% sodium chloride and
further dilute to 100 mL.
Cannot be administered by IV push. Must be given over 1 hour.
If 100 mL bag is not available, obtain from pharmacy.
Gentamicin 40
mg/mL vials
2,3,8

Dilute dose in 50 mL to 100 mL of 0.9% normal saline. Obtain product
from pharmacy if bags unavailable. Maximum concentration < 10
mg/mL.
Cannot be administered by IV push. Doses less than 250 mg
may be given over 30 minutes, doses greater than 250 mg
administer over 60 minutes.
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53

Drug Reconstitution Intravenous (IV) Push Time
Piperacillin/
Tazobactam
3.375 g
(Zosyn)
2,3,8

Either use 100 mL minibag plus bag, advantage vial with advantage
bag, or contact pharmacy for product. Reconstitute vial with 15 mL
sterile water for injection or 0.9% sodium chloride and further dilute to
50 to150 mL. Maximum recommended volume per dose of sterile water
for injection is 50 mL.
Cannot be administered by IV push. Administer over at least 30
minutes.
Piperacillin/
Tazobactam 4.5
g
(Zosyn)
2,3,8

Either use 100 mL minibag plus bag, if unavailable contact pharmacy
for product. Reconstitute vial with 20 mL sterile water for injection or
0.9% sodium chloride and further dilute to 50-150 mL. Maximum
recommended volume per dose of sterile water for injection is 50 mL.
Cannot be administered by IV push. Administer over at least 30
minutes.
Vancomycin
2,3,8
Use bags provided by pharmacy.
Cannot be administered by IV push. Must use infusion pump to
prevent systematic histamine release and hypotension. Administer
500 mg to 1 gram doses over 60 minutes, 1.5 gram doses over 90
minutes, and 2 gram doses over 120 minutes.

References
1. Institute for Safe Medication Practices (ISMP). ISMP Safe Practice Guidelines for Adult IV Push Medications. Institute for Safe Medication Practices (ISMP) website.
https://www.ismp.org/Tools/guidelines/IVSummitPush/IVPushMedGuidelines.pdf. 2015. Accessed November 8, 2017.
2. LexiComp Online, Hudson, Ohio: Wolters Kluwer Clinical Drug Information, Inc.; 2017; Accessed November 8, 2017.
3. Trissel's™ 2 Clinical Pharmaceutics Database Online, Hudson, Ohio: Wolters Kluwer Clinical Drug Information, Inc.; 2017; Accessed November 8, 2017.
4. Garrelts JC, Wagner DJ. The pharmacokinetics, safety, and tolerance of cefepime administered as an intravenous bolus or as a rapid infusion. Ann Pharmacother. Dec
1999;33(12):1258-1261.
5. Baumgartner JD, Glauser MP. Single daily dose treatment of severe refractory infections with ceftriaxone. Cost savings and possible parenteral outpatient treatment. Arch
Intern Med. Oct 1983;143(10):1868-1873.
6. Poole SM, Nowobilski-Vasilios A, Free F. Intravenous push medications in the home. J Intraven Nurs. Jul-Aug 1999;22(4):209-215.
7. Garrelts JC, Ast D, LaRocca J, Smith DF, Peterie JD. Postinfusion phlebitis after intravenous push versus intravenous piggyback administration of antimicrobial agents. Clin
Pharm. Oct 1988;7(10):760-765.
8. Bouchard CA. Intravenous Administration of Formulary Medications – Adult– Inpatient/Ambulatory – Clinical Practice Guideline. UW Health website.
https://www.uwhealth.org/cckm/?path=/cckm/cpg/medications/name-97579-en.html. November 2017. Accessed November 8, 2017.

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54

Appendix C. Evidence Grading Scheme
Figure 1. GRADE Methodology adapted by UWHealth
1








GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate
We are quite confident that the effect in the study is close to the true effect, but it is also
possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong
The net benefit of the treatment is clear, patient values and circumstances are
unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and preferences, the
resources available, or the setting in which the intervention will be implemented.
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55

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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org