Antimicrobial prophylaxis for orthopedic surgery in adults

IV: intravenous; N/A: not applicable; MRSA: methicillin-resistant Staphylococcus aureus.
* 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 one to two times the half-life of the drug for the duration of the procedure in patients with normal renal function.
Δ If a tourniquet is to be used in the procedure, the entire dose of antibiotic must be infused prior to its inflation.
◊ Use of vancomycin is appropriate in hospitals in which MRSA and Staphylococcus 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. Some experts would give 15 mg/kg of vancomycin to patients weighing more than 75 kg, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g).
​§ The role of antimicrobial prophylaxis prior to removal of orthopedic hardware used for treatment of lower extremity factures is controversial. According to the guidelines issued by the United States Centers for Disease Control and Prevention, this is considered a "clean" surgical procedure (ie, without skin contamination or local infection), for which preoperative antibiotic prophylaxis is not routinely recommended. However, relatively high rates of surgical site infection have been reported for this procedure; therefore, we favor administration of preoperative antimicrobial prophylaxis. Refer to the text for further discussion.