Antimicrobial prophylaxis for cardiac surgery in adults

* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure. If vancomycin is used, the infusion should be started within 60 to 120 minutes before the initial incision to have adequate tissue levels at the time of incision and to minimize the possibility of an infusion reaction close to the time of induction of anesthesia.
¶ For prolonged procedures (>3 hours) or those with major blood loss or in patients with extensive burns, additional intraoperative doses should be given at intervals 1 to 2 times the half-life of the drug for the duration of the procedure in patients with normal renal function.
Δ Cefazolin is preferred over cefuroxime, given increasing resistance to second-generation cephalosporins. Indications for vancomycin are summarized in footnote §. Clindamycin may be used for patients unable to tolerate the other agents listed.
◊ Some experts recommend an additional dose when patients are removed from bypass during open-heart surgery.
§ Use of vancomycin is appropriate in hospitals in which methicillin-resistant S. aureus (MRSA) and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with diphenhydramine and further slowing of the infusion rate may be helpful. For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (gentamicin 5 mg/kg IV), aztreonam (2 g IV), or a fluoroquinolone (ciprofloxacin 400 mg IV or levofloxacin 500 mg IV).