Appendix: Antibioprophylaxis in Surgery and Interventional Medicine (Adult Patients). Update 2017
Neurosurgery Ophthalmology Cardiac surgery Vascular surgery Orthopaedic surgery Trauma Thoracic surgery ENT Maxillo-facial surgery Digestive surgery Urology Gynaecology obstetrics Interventional surgery Bariatric surgery Plastic and reconstructive surgery Prophylaxis of endocarditis These guidelines are based on guidelines released by the French Society of Anesthesia and Intensive Care Medicine (
Plastic and reconstructive surgery
These guidelines are based on guidelines released by the French Society of Anesthesia and Intensive Care Medicine (SFAR). Local practices may differ from these guidelines.
Table I: Neurosurgery
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| CSF shunt | Cefazolin If allergic: Vancomycina |
2g slow IVI 30mg/kg slowly IVI over 120min |
Single dose 1g IVI if surgery > 4h Single dose |
| External CSF shunt | No antibiotic prophylaxis | ||
| Craniotomy | Cefazolin If allergic: Vancomycin |
2g slow IVI 30mg/kg slowly IVI over 120min |
Single dose (if surgery > 4h re-inject 1g) Single dose |
| Neurosurgery transsphenoidal routes and trans-labyrinthine | Cefazolin If allergic: Vancomycin |
2g slow IVI 30mg/kg slowly IVI over 120min |
Single dose 1g IVI if surgery > 4h Single dose |
| Spine surgery with implantation of prosthetic material |
Cefazolin |
2g slow IVI 30mg/kg slowly IVI over 120min |
Single dose 1g IVI if surgery > 4h Single dose |
| Cranio-cerebral wounds | Peni A + IBb If allergic: Vancomycin |
2g slow IVI 30mg/kg slowly IVI over 120min |
2g every 8 hours 48h maximum Single dose |
| Base of skull fracture with rhinorrhoea | No antibiotic prophylaxis | ||
a: Indications of vancomycin: allergy to beta-lactams; suspected or proven colonisation by methicillin-resistant staphylococcus, re-operation in a patient hospitalised in a unit with an ecology including methicilline-resistant Staphylococcus aureus, previous antibiotic therapy. The injection lasts 120 minutes and must end at the latest at the beginning of the intervention and the best 30 minutes before.
b: Aminopenicillin + beta-lactamase inhibitor.
Table II: Ophthalmology
| SURGERY | PRODUCT | INITIAL DOSE | DOSAGE AND DURATION |
| Open eye surgery other than cataracts with risk factors | Levofloxacin oral dose | 500mg po | 1 tab po 12 hours pre-operative + 1 tab po 2–4 hours pre-operative |
| Cataracta | Intracameral injection cefuroximea | 1mg in 0.1ml | At the end of surgery |
| Open eye trauma | Levofloxacin | 500mg | 500mg IV on day 1 + 500mg orally on day 2 |
| Lacrimal duct wounds | Peni A + IBb | 2g | Re-injection of 1g if surgery > 2 hours |
| Puncture of anterior chamber Sub-retinal fluid puncture Closed globe surgery Intravitreal injections |
No antimicrobial prophylaxis | ||
a: For cataract surgery with and without risk factors, a single injection into the anterior chamber of cefuroxime (1 mg) has been approved since 2014.
b: Aminopenicillin + beta-lactamase inhibitor.
Table III: Cardiac surgery
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Cardiac surgery | Cefazolin Cefamandole or cefuroxime if allergic: Vancomycina |
2g IVI and 1g in priming 1.5g IV + 0.75g priming 30mg/kg/120 min |
1g at the 4th hour intraoperatively 1 re-injection 0.75g every 2 hours intraoperatively Single dose |
| Pacemaker Endovascular procedu |
See above heart surgery | Single dose | |
| Pericardial drainage Coronary dilatation/stent ECMO |
No antimicrobial prophylaxis | ||
a: Indications of vancomycin: allergy to beta-lactams; suspected or proven colonisation by methicillin-resistant staphylococcus, re-operation in a patient hospitalised in a unit with an ecology including methicilline-resistant Staphylococcus aureus, previous antibiotic therapy. The injection lasts 120 minutes and must end at the latest at the beginning of the intervention and the best 30 minutes before.
Table IV: Vascular surgery
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Surgery of the aorta, arteries of the lower limbs, supra-aortic trunks Arterial endoprosthesis Carotid surgery with patch |
Cefazolin Cefuroxime if allergic: Vancomycina |
2g slow IVI 1.5g slow IVI 30mg/kg/120 min |
Single dose (if time > 4h, re-inject 1g) Single dose (if duration > 2h, re-inject 0.75g) Single dose |
| Carotid surgery without a patch | No antimicrobial prophylaxis | ||
| Expansion with or without stent | See above aortic surgery | Single dose | |
| Limb amputation | Peni A + IBb | 2g IV slow | 1g/6 hours for a period of 48 hours |
| Vein surgery | No antimicrobial prophylaxis | ||
a: Indications of vancomycin: allergy to beta-lactams; suspected or proven colonisation by methicillin-resistant staphylococcus, re-operation in a patient hospitalised in a unit with an ecology including methicilline-resistant Staphylococcus aureus, previous antibiotic therapy. The injection lasts 120 minutes and must end at the latest at the beginning of the intervention and the best 30 minutes before.
b: Aminopenicillin + beta-lactamase inhibitor.
Table V: Orthopaedic surgery
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Joint prosthesis (upper limb, lower limb) | Cefazolin Cefuroxime If allergic: Clindamycin If allergic: Vancomycina |
2g slow IVI 1.5g IV slow 900mg IV slow 30mg/kg/120min |
1g if duration > 4h Limited to the operative period (24 hours max) 0.75g if duration > 2h Limited to the operative period (24 hours max) Limited to the operative period (24 hours max) Single dose |
| Foreign material (resorbable or not, cement, bone graft) and whatever the technique (percutaneous, videoscopy) Joint surgery arthrotomy | Cefazolin If allergic: Clindamycin or Vancomycina |
2g slow IVI 900mg slow IVI 30mg/kg/120min |
1g if duration > 4h Single dose Single dose |
| Arthroscopy without implant (with or without meniscectomy) extra-articular soft tissue surgery without implant | No antimicrobial prophylaxis | ||
| Spine surgery with implantation of prosthetic material | Cefazolin If allergic: Vancomycina |
2g slow IVI 30mg/kg/120min |
Single dose (if duration > 4h re-inject 1g) Single dose |
a: Indications of vancomycin: allergy to beta-lactams, suspected or proven colonisation by methicillin-resistant staphylococcus, re-operation in a patient hospitalised in a unit with an ecology including methicilline-resistant Staphylococcus aureus, previous antibiotic therapy. The injection lasts 120 minutes and must end at the latest at the beginning of the intervention and the best 30 minutes before.
Table VI: Trauma
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Closed fracture requiring isolated extrafocal osteosynthesis | No antimicrobial prophylaxis | ||
| Closed fracture requiring intrafocal osteosynthesis Open fracture stage I Cauchoix Soft tissue wound non-contused, with or without lesion of artery, nerve, tendon Articular wound | Cefazolin Cefuroxime If allergic: Clindamycin and Gentamycin |
2g slow IVI 1.5g slow IVI 900mg slow IVI 5mg/kg/day |
1 g if duration > 4h Limited to the operative period (24 hours max) 0.75g if duration > 2h Limited to the operative period (24 hours max) 600mg if duration > 4h |
| Open fracture stage II and III Cauchoix Large wound soft tissue contused with or without lesion of artery, nerve, tendon | Peni A + IBa If allergic: Clindamycin and Gentamycin |
2g slow IVI 900mg slow IVI 5mg/kg/day |
1g if duration > 2h 48h maximum 600mg if duration > 4h 48h maximum Max 48 hours |
a: Aminopenicillin + beta-lactamase inhibitor.
Table VII: Thoracic surgery
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Pulmonary resection (including video-assisted surgery) | Peni A + IBa or Cefuroxime or Cefazolin If allergic: Clindamycin and Gentamycin |
2g slow IVI 1.5g slow IVI 2g slow IVI 900mg slow IVI 5mg/kg/day |
Single dose (if duration > 2h re-inject 1g) Single dose (if duration > 2h re-inject 0.75g) Single dose (if surgery > 4 hours, re-inject 1g) Single dose (if surgery > 4 hours, re-inject 600mg Single dose |
| Mediastinal surgery Surgery for pneumothorax Decortication (uninfected patient) Isolated parietal resection | Cefuroxime or Cefazolin If allergic: Clindamycin and Gentamycin |
1.5g slow IVI 2g slow IVI 900mg slow IVI 5mg/kg/day |
Single dose (if duration > 2h re-inject 0.75g) Single dose (if surgery > 4 hours, reinject 1g) Single dose (if surgery > 4 hours, re-inject 600mg) Single dose |
| Mediastinotomy, videothoracoscopy, tracheostomy, thoracic drainage | No antimicrobial prophylaxis | ||
a: Aminopenicillin + inhibitor of beta-lactamases.
Table VIII: ENT
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Rhinologic surgery with placement of a graft or re-operation | Cefazolin Peni A + IBa |
2g slow IVI 2g slow IVI |
Single dose Single dose |
| Neck surgery with oropharyngeal opening. Surgery of the salivary glands with access through the oropharyngeal cavity | Peni A + IBa If allergic: Clindamycin and Gentamycin |
2g slow IVI 900mg slow IVI |
Re-injection of 1g every 2h during intraoperative then 1g every 6 hours for 24 hours Re-injection of 600mg if duration > 4h and then 600mg/6 hours for 24 hours Single dose |
| Alveolar surgery | Prevention of endocarditis (see endocarditis prophylaxis) | ||
| Stapes surgery, middle ear surgery Salivary surgery without access through the oropharyngeal cavity Cervicotomy Lymphadenectomy Velopalatin surgery Tonsillectomy |
No antimicrobial prophylaxis | ||
a: Aminopenicillin + inhibitor of beta-lactamases.
Table IX: Maxillo-facial surgery
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Maxillofacial surgery with oropharyngeal opening. Surgery of the salivary glands with access through the oropharyngeal cavity | Peni A + IBa If allergic: Clindamycin and Gentamycin |
2g slow IVI 900mg slow IVI 5mg/kg/day |
Re-injection of 1g every 2h during intraoperative then 1g every 6 hours for 24 hours Re-injection of 600mg if duration > 4h and then 600mg/6 hours for 24 hours Single dose |
| Alveolar surgery | Prevention of endocarditis (see endocarditis prophylaxis) | ||
| Salivary surgery without access through the oropharyngeal cavity Cervicotomy; Lymphadenectomy Velopalatin surgery |
No antimicrobial prophylaxis | ||
| Tooth extraction in a non-septic environment | Prevention of endocarditis (see endocarditis prophylaxis) | ||
a: Aminopenicillin + inhibitor of beta-lactamases.
Table X: Digestive surgery
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Oesophageal surgery (without coloplasty) Gastroduodenal surgery (including endoscopic gastrostomy and duodenopancreatectomy) Pancreatic surgery Liver surgery |
Cefazolin Cefuroxime If allergic: Clindamycin and Gentamycin |
2g slow IVI 1.5g slow IVI 900mg slow IVI 5mg/kg/day |
Single dose (if duration > 4h re-inject 1g) Single dose (if duration > 2h re-inject 0.75g) Single dose (if duration > for 4h, inject 600mg) Single dose |
| Biliary tract surgery (the biliary prosthesis patients are excluded from recommendations) | Cefazolin Cefuroxime If allergic: Clindamycin and Gentamycin |
2g slow IVI 1.5g slow IVI 900mg slow IVI 5mg/kg/day |
Single dose (if duration > 4h re-inject 1g) Single dose (if duration > 2h re-inject 0.75g) Single dose (if duration > for 4h, inject 600mg) Single dose |
| Gallbladder surgery laparoscopically without risk factorsa | No antimicrobial prophylaxis | ||
| Colonic and intestinal surgery | Cefoxitin and Metronidazole If allergic: Imidazole and Gentamycin |
2g slow IVI Slow 1g infusion 1g infusion 5mg/kg/day |
Single dose (if duration > 2h re-inject 1g) Single dose Single dose Single dose |
| Anal surgery | Imidazole | 1g infusion | Single dose |
| Hernia without prosthetic plate | No antimicrobial prophylaxis | ||
| Hernia with establishment of a prosthetic plate | Cefazolin Cefuroxime If allergic: Clindamycin and Gentamycin |
2g slow IVI 1.5g slow IVI 900mg slow IVI 5mg/kg/day |
Single dose (if duration > 4h re-inject 1g) Single dose (if duration > 4h re-inject 1g) Single dose (if duration > for 4h, inject 600mg) Single dose |
| Eventration | Cefazolin Cefuroxime If allergic: Clindamycin and Gentamycin |
2g slow IVI 1.5g slow IVI 900mg slow IVI 5mg/kg/day |
Single dose (if duration > 4h re-inject 1g) Single dose (if duration > 2h re-inject 0.75g) Single dose (if duration > for 4h, inject 600mg) Single dose |
| Abdominal wounds | See colorectal surgery | ||
| Prolaps (any surgical approach) | Peni A + IBb If allergic: Gentamycin and Metronidazole |
2g slow IV 5mg/kg/day Slow 1g infusion |
Single dose 1g if duration > 2h Single dose Single dose |
a: Laparoscopic cholecystectomy without risk factors: absence of recent cholecystitis, no conversion to laparotomy (on the event of conversion to ABP), no pregnancy, no immune suppression, no exploration of bile duct intraoperatively. If risk factors, refer to the “biliary tract surgery”.
b: Aminopenicillin + beta-lactamase inhibitor.
Table XI: Urology
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Prostate surgery | |||
| Endoscopic resection of the prostate, cervical-prostatic incision prostatectomy | Cefazolin Cefuroxime If allergic: Gentamycin |
2g slow IVI 1.5mg slow IVI 5mg/kg |
Single dose (if duration > 4h re-inject 1g) Single dose (if duration > 2h, re-inject 0.75g) Single dose |
| Radical prostatectomy | No antimicrobial prophylaxis | ||
| Prostate biopsy | Ofloxazin If allergic: Ceftriaxone |
400mg 1 hour before the biopsy 1g |
Single dose Single dose |
| Kidney surgery, adrenal and urinary tract | |||
| Endoscopic treatment of the renal and ureteral ithiases, ureteroscopy, percutaneous nephrolithotomy, nephrostomy, JJ probe mounted or ureteral | Cefazolin Cefuroxime If allergic: Gentamycin |
2g slow IVI 1.5mg slow IVI 5mg/kg |
Single dose (if duration > 4h re-inject 1g) Single dose (if duration > 2h, re-inject 0.75g) Single dose |
| Transurethral resection of the prostate | Cefazolin Cefuroxime If allergic: Gentamycin |
2g slow IVI 1.5mg slow IVI 5mg/kg |
Single dose (if duration > 4h re-inject 1g) Single dose (if duration > 2h, re-inject 0.75g) Single dose |
| Nephrectomy and other upper tract surgery Extracorporeal lithotripsy Adrenalectomy |
No antimicrobial prophylaxis | ||
| Bladder surgery | |||
| Transurethral resection of the prostate | Cefazolin Cefuroxime If allergic: Gentamycin |
2g slow IVI 1.5mg slow IVI 5mg/kg |
Single dose (if duration > 4h re-inject 1g) Single dose (if duration > 2h, re-inject 0.75g) Single dose |
| Cystectomy (Bricker, bladder replacement) | PENI A + IBa If allergic: Gentamycin and Metronidazole |
2g slow IVI 5mg/kg Slow 1g infusion |
Single dose (if duration > 2h re-inject 1g) Single dose Single dose |
| Surgery of the urethra | |||
| Urethroplasty, urethrotomy | Cefazolin Cefuroxime If allergic: Gentamycin |
2g slow IVI 1.5mg slow IVI 5mg/kg |
Single dose (if duration > 4h re-inject 1g) Single dose (if duration > 2h, re-inject 0.75g) Single dose |
| Artificial sphincter | Cefoxitin or Amoxicillin + Clavulanic acid If allergic: Gentamycin and Metronidazole |
2g slow IVI 5mg/kg 1g infusion |
Single dose Single dose |
| Urethral support (TOT, TVT) | PENI A + IBa If allergic: Gentamycin and Metronidazole |
2g slow IVI 5mg/kg 1g infusion |
Single dose |
| Male genital system | |||
| Scrotal surgery or rod (not replacement) | No antimicrobial prophylaxis | ||
| Penile prosthesis or testicular | Cefazolin | 2g slow IVI | Single dose (if surgery > 2 hours, re-inject 1g) |
| Female genital system | |||
| Treatment of prolapse (any surgical approach) | PENI A + IBa If allergic: Metronidazole and Gentamycin |
2g slow IVI 1g infusion 5mg/kg/day |
Single dose (if surgery > 2h, re-inject 1g) Single dose Single dose |
| Diagnostic investigations Bladder fibroscopy Urodynamic evaluation Ureteroscopic diagnostic |
No antimicrobial prophylaxis | ||
a: Aminopenicillin + beta-lactamase inhibitor.
Table XII: Gynaecology obstetrics
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Hysterectomy (high or low road) | Cefazolin | 2g slow IVI | Single dose (if surgery > 4 hours, re-inject 1g) |
| Coelio surgery (Laparoscopic surgery) | Cefuroxime If allergic: Clindamycin and Gentamycin |
1.5 g slow IVI 900 mg slow IVI 5 mg/kg/day |
Single dose (if surgery > 2 hours, re-inject 0.75g) Single dose Single dose |
| Laparoscopy diagnostic or exploratory without vaginal incision or digestive | No antimicrobial prophylaxis | ||
| Hysteroscopy hysterosalpingography | No antimicrobial prophylaxis | ||
| Endometrial biopsy | No antimicrobial prophylaxis | ||
| In vitro fertilisation | No antimicrobial prophylaxis | ||
| Insertion of intra-uterine device | No antimicrobial prophylaxis | ||
| Abortion | No antimicrobial prophylaxis | ||
| Caesarean section | Cefazolin Cefuroxine If allergic: Clindamycin |
2g slow IV 1.5g slow IVI 900mg slow IVI |
Single dose Single dose Single dose |
| Mastectomy Reconstruction and/or mammoplasty |
Cefazolin Cefuroxine If allergic: Clindamycin and Gentamycin |
2 g slow IV 1.5 g slow IVI 900mg slow IVI 5mg/kg |
Single dose (1g if duration > 4 hours) Single dose (0.75g if surgery > 2 hours) 600mg if surgery > 4 hours Single dose |
| Simple breast lumpectomy | No antimicrobial prophylaxis | ||
| Prolapse (all surgical approaches; only in case of implementation of prosthetic material: promontofixation, implant placement or strip) | Peni A + IBa If allergic: Gentamycin and Metronidazole |
2g slow IVI 5mg/kg 1g infusion |
Single dose (1g if surgery > 4 hours) Single dose Single dose |
a: Aminopenicillin + beta-lactamase inhibitor.
Table XIII: Interventional surgery
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Embolisation of uterine fibroids | No antimicrobial prophylaxis | ||
| Nephrostomy | No antimicrobial prophylaxis | ||
| Transjugular intrahepatic portosystemic shunt | No antimicrobial prophylaxis | ||
| Endoscopic gastrostomy, sclerosis of oesophageal varicose veins | Peni A +1Ba If allergic: Clindamycin and Gentamycin |
2g slow IVI 900mg slow IVI 5mg/kg |
Single dose Single dose Single dose |
| Puncture under endoscopic ultrasonography (except trans-colorectal puncture) | No antimicrobial prophylaxis | ||
| Endoscopic dilatation, digestive prosthesis, laser, argon, plasma coagulation | No antimicrobial prophylaxis | ||
| Chemo-embolisation | No antimicrobial prophylaxis | ||
| Radio frequency | No antimicrobial prophylaxis | ||
| Catheter or implantable chamber | No antimicrobial prophylaxis | ||
| Angiography/angioplasty | No antimicrobial prophylaxis | ||
| Stent (excluding intra-coronary) | Cefazolin Cefuroxine If allergic: Vancomycinb |
2g slow IV 1.5g slow IVI 30 mg/kg/120 min |
Single dose (1g if duration > 4 hours) Single dose (0.75g if surgery > 2 hours) Single dose |
a: Aminopenicillin + beta-lactamase inhibitor.
b: Indications of vancomycin: allergy to beta-lactams; suspected or proven colonisation by methicillin-resistant staphylococcus, re-operation in a patient hospitalised in a unit with an ecology including methicillin-resistant Staphylococcus aureus, previous antibiotic therapy. The injection lasts 120 minutes and must end at the latest at the beginning of the intervention and the best 30 minutes before.
Table XIV: Bariatric surgery
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Gastric band | Cefazolin Cefuroxine If allergic: Vancomycina |
4g as an infusion over 30min 3g as an infusion over 30min 30mg/kg/120 min |
Single dose (if duration > 4 hours, inject 2g) Single dose (if duration > 2 hours, inject 1.5g) Single dose |
| Performing a gastric bypass or “sleeve” gastrectomy |
Cefoxitin If allergic: Clindamycin |
4g (30 min infusion)b 2 100mg slow IVI 5mg/kg |
Single dose (if duration > 2 hours, reinject 2g) Single dose Single dose |
| Abdominoplasty (dermolipectomy | Cefazolin Cefuroxine If allergic: Clindamycin and Gentamycin |
4g (30 min infusion)b 3g (30 min infusion)b 2 100mg slow IVI 5mg/kg (dose based on actual weight) |
Single dose (if duration > 4 hours, inject 2g) Single dose (if duration >2 hours, inject 1.5g) Single dose Single dose |
a: Indications of vancomycin: allergy to beta-lactams, suspected or proven colonisation by methicillin-resistant staphylococcus, re-operation in a patient hospitalised in a unit with an ecology including methicillin-resistant Staphylococcus aureus, previous antibiotic therapy. The injection is done at 1 000 mg/hour maximum and must end at the latest at the beginning of the intervention and at best 30 minutes before. Maximum dose is 4 g.
b: Dose calculated on the actual weight.
Table XV: Plastic and reconstructive surgery
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| Plastic and reconstructive surgery: class 1 Altemeier |
No antimicrobial prophylaxis in the absence of implant Cefazolin |
2g slow IVI 900mg slow IVI |
Single dose (if duration > 4 hours, re-inject 1g) Single dose (if duration > 4 hour, re-inject 600mg) |
| Plastic and reconstructive surgery: class 2 Altemeier |
Cefazolin If allergic: Clindamycin |
2g slow IVI 900mg slow IVI |
Single dose (if duration > 2 hours, re-inject 1g) Single dose (if duration > 4 hour, re-inject 600mg |
Table XVI: Prophylaxis of endocarditis
Antibiotics 30–60min prior to the procedure
| SURGERY | PRODUCT | INITIAL DOSE | RE-INJECTION DOSE AND DURATION |
| No allergy to beta-lactams Allergy to beta-lactams |
Amoxicillin or ampicillin Clindamycin |
2g oral or IVI 600mg orally or IVI |
50mg/kg orally or IV 20mg/kg orally or IV |
South African Society of Anaesthesiologists (SASA) Guidelines for Infection Control and Prevention in Anaesthesia in South Africa 2021