Cefazolin 2g IV followed by 2g IV q8h

If MRSA colonized:

Cefazolin 2g IV STAT

PLUS

Vancomycin 15-20mg/kg IV STAT

Followed by:

Cefazolin 2g IV q8h

PLUS

Vancomycin 15mg/kg IV q12h

Severe penicillin allergy:

Vancomycin 15-20mg/kg IV STAT followed by 15mg/kg IV q12h

IV vancomycin dose of 20mg/kg pre-operatively may be preferred to achieve sufficient tissue concentrations at the time of surgery.

At onset of bypass: May consider additional 1-2g of IV cefazolin via cardiopulmonary bypass circuit. 

Cefazolin 2g IV

Cefuroxime 1.5g IV 

Single dose 

Duration: 24-48 hours

Cefazolin 2g IV

Cefuroxime 1.5g IV

Single dose

Cefazolin 2g IV 

MRSA colonized:

Vancomycin 15-20mg/kg IV

Severe penicillin allergy:

Clindamycin 600-900mg IV 

OR

Vancomycin 15-20mg/kg IV

Single dose

Cefazolin 2g IV followed by 2g IV q8h

MRSA colonized:

Cefazolin 2g IV

PLUS

Vancomycin 15-20mg/kg IV

Followed by:

Cefazolin 2g IV q8h

PLUS

Vancomycin 15mg/kg IV q12h

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV STAT followed by 600mg IV q8h

OR

Vancomycin 15-20mg/kg IV STAT followed by 15mg/kg IV q12h

Single dose

Ampicillin/Sulbactam 3g IV

Amoxicillin/Clavulanate 1.2g IV

Single dose

Cefazolin 2g IV

Cefuroxime 1.5g IV

Severe penicillin allergy:

Gentamicin 5mg/kg IV; MAY ADD Clindamycin 600-900mg IV 

Single dose

Cefazolin 2g

PLUS

Metronidazole 500mg IV

Cefuroxime 1.5g IV  

PLUS

Metronidazole 500mg IV

OR

Amoxicillin-clavulanate 1.2g IV

Severe penicillin allergy:

Gentamicin 5mg/kg IV; MAY ADD Clindamycin 600-900mg IV 

Single dose

Clindamycin resistance has been increasing in Bacteroides species. 

Metronidazole may be preferred if the procedure transverses the lower gastrointestinal tract.

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Cefuroxime 1.5g IV  

PLUS

Metronidazole 500mg IV

Severe penicillin allergy:

Gentamicin 5mg/kg IV; MAY ADD Clindamycin 600-900mg IV 

Single dose

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV 

*To be used only in conjunction with Mechanical Bowel Preparation (MBP) (if given):

Neomycin sulfate 1g PO 

PLUS

Erythromycin base 1g PO

OR

Neomycin sulfate 1g PO 

PLUS

Metronidazole 1g PO

Cefoperazone 2g IV

OR

Ceftriaxone 2g IV

PLUS

Metronidazole 500mg IV

Severe penicillin allergy:

Gentamicin 5mg/kg IV; 

MAY ADD Metronidazole 500mg IV OR Clindamycin 600-900mg IV

Single dose

Clindamycin resistance has been increasing in Bacteroides species.

Metronidazole may be preferred if the procedure transverses the lower gastrointestinal tract.

*3 doses in conjunction with MBP over 10 hours the day before surgery (between 1pm – 11pm). The need for MBP + PO prophylaxis to be decided by individual institution.

Cefazolin 2g IV

Severe penicillin allergy:

Vancomycin 15-20mg/kg IV

Single dose.

Includes laparoscopic repair.

Antibiotic not required for hernia repair with no mesh placement. 

Surgical antibiotic prophylaxis not recommended.

*For patients with risk factors: 

Cefazolin 2g IV

Surgical antibiotic prophylaxis not recommended.

*Severe penicillin allergy for patients with risk factors: 

Clindamycin 600-900mg IV

OR 

Vancomycin 15-20mg/kg IV

Single dose.

*Risk factors: 

• Post neo-adjuvant chemotherapy 

• Immunocompromised individuals

Cefazolin 2g IV

Amoxicillin/Clavulanate 1.2g IV

OR

Ceftriaxone 2g IV

Severe Penicillin Allergy:

Vancomycin 15-20mg/kg IV

OR

Clindamycin 600-900mg IV

PLUS

Gentamicin 5mg/kg IV

Single Dose

It is reasonable to give single dose prophylaxis for patients undergoing laparoscopic cholecystectomy although evidence showed that antibiotic not required in low risk patients. This is because some of these risk factors cannot be determined before surgery.

Cefazolin 2g IV

Amoxicillin/Clavulanate 1.2g IV

OR

Ceftriaxone 2g IV

Severe penicillin allergy:

Vancomycin 15-20mg/kg IV

OR

Clindamycin 600-900mg IV

PLUS

Gentamicin 5mg/kg IV

Single dose

Duration: Up to 24 hours

If procedure is expected to involve lower GI tract, consider adding anaerobic coverage. 

Cefazolin 2g IV

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

Vancomycin 15-20mg/kg IV

Single Dose

There is no need to extend duration for patients who are not immunized. Administer appropriate immunizations.

Phenoxymethylpenicillin (Penicillin V) 250mg PO q12h

Amoxicillin 250mg PO q24h

Severe penicillin allergy:

Cephalexin 250mg PO q12h

OR 

Azithromycin 250mg PO q24h

Duration of chemoprophylaxis:

At least 1 year following splenectomy. 

Risk of sepsis remains lifelong and is highest in immunocompromised patients.

Duration of chemoprophylaxis should be individualized based on patient’s risk factors:

• Severely immunosuppressed patient

• Patient with hematological malignancy

• Patient who has survived severe sepsis

Post-splenectomy counselling with regards to need for repeated vaccinations and appropriate health-seeking behavior in the event of fever.

• Pamphlet

• Post splenectomy card

Initial - Single dose only

• Pneumococcal PCV13 0.5ml IM/SC stat, 

followed by PPV23 0.5ml IM/SC stat (8 weeks interval)

• Meningococcal A,C,Y,W 135 0.5ml IM stat

• Haemophilus influenzae Type B conjugate 0.5ml IM/SC stat

Revaccination - Every 5 years

• *Pneumococcal PPV23 0.5ml IM/SC stat

• Meningococcal A,C,Y,W 135 0.5ml IM stat

--

Elective splenectomy:

Administer vaccines at least 2 weeks before procedure

Emergency splenectomy:

Give vaccine at least 7 days postoperatively or on the day of discharge, whichever comes first

It is safe to give all the initial vaccinations at the same time using different administration sites.

*A third dose is recommended at the age of 60 years OR a minimum of 5 years after the second dose, whichever is later. You can have a maximum of 3 doses of Pneumovax 23(23vPPV) as an adult (> 18 years). If you have your spleen removed after 60 years of age, only a single booster dose is recommended (i.e. the third and final dose is not given). 

Cefazolin 2g IV

Amoxicillin/clavulanate 1.2g IV

OR

Ceftriaxone 2g IV

Severe penicillin allergy:

Vancomycin 15-20mg/kg IV

OR

Clindamycin 600-900mg IV

PLUS

Gentamicin 5mg/kg IV

Single dose

Duration: Up to 24 hours

For patients with recent biliary interventions/stenting, there is a higher incidence of bacteria with ESBL-producers. 

Antibiotic should be tailored to in-house antibiogram or recent bile/blood culture from the patients

Cefazolin 2g IV

Cefuroxime 1.5g IV

Single dose

Antibiotics are ONLY recommended when there is:

• Incomplete biliary drainage

• Obstructive biliary tract disease

Cefazolin 2g IV

Cefuroxime 1.5g IV

Severe penicillin allergy:

*Vancomycin 15-20mg/kg IV

OR

Clindamycin 600mg-900mg IV 

Single dose

*Situation where the use of vancomycin is appropriate: 

• In patients previously colonized with MRSA 

• Those who are allergic to penicillins or cephalosporins

• In hospitals in which MRSA or MRCoNS are frequent causes of postoperative wound infection

Rapid IV administration of vancomycin may cause vancomycin infusion reaction AND/OR hypotension.

Cefazolin 2g IV

Cefuroxime 1.5g IV

Severe penicillin allergy:

*Vancomycin 15-20mg/kg IV

OR

Clindamycin 600mg-900mg IV 

Single dose 

*Situation where the use of vancomycin is appropriate: 

• In patients previously colonized with MRSA 

• Those who are allergic to penicillins or cephalosporins

• In hospitals in which MRSA or MRCoNS are frequent causes of postoperative wound infection

Rapid IV administration of vancomycin may cause Vancomycin infusion reaction AND/OR hypotension.

Cefuroxime 1.5g IV

PLUS

Metronidazole 500mg IV

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

*Vancomycin 15-20mg/kg IV

PLUS 

Gentamicin 5mg/kg IV

PLUS

Metronidazole 500mg IV

Single dose

Consider escalation to ceftriaxone 2g IV if there is dura breach or CSF leak.

*Situation where the use of vancomycin is appropriate: 

• In patients previously colonized with MRSA 

• Those who are allergic to penicillins or cephalosporins

• In hospitals in which MRSA or MRCoNS are frequent causes of postoperative wound infection

Rapid IV administration of vancomycin may cause Vancomycin infusion reaction AND/OR hypotension.

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Cefuroxime 1.5g IV

PLUS

Metronidazole 500mg IV

OR

Ampicillin/Sulbactam 3g IV

OR

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV

Single dose after delivery

Please refer to Obstetrics & Gynaecology Infections section for:

• Group B Streptococcus (GBS)

• Preterm premature rupture of membranes (PPROM) prophylaxis

Cefazolin 2g IV q8h

PLUS

Metronidazole 500mg IV q8h

Ampicillin/Sulbactam 3g IV q6h

OR

Amoxicillin/Clavulanate 1.2g IV q8h

Severe penicillin allergy:

Clindamycin 600-900mg IV q6-8h

Duration: 5-7 days

Cefazolin 2g IV

Ampicillin/Sulbactam 3g IV

Severe penicillin allergy:

Clindamycin 900mg IV

Single dose

Continuation of antimicrobial prophylaxis (max up to 2 days) may be considered for patients with major risk factors for surgical infections. E.g.:

• Obesity

• Complicated cesarean

• Immunocompromised

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Ampicillin 2g IV

PLUS

Metronidazole 500mg IV

OR

Amoxicillin/Clavulanate 1.2g IV

Single dose

1st trimester:

Doxycyline 400mg PO as a single dose 

(1-2 hours prior to procedure)

2nd trimester:

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

1st trimester:

Azithromycin 1g PO (1-2 hours prior to procedure)

2nd trimester:

Ampicillin 2g IV

PLUS

Metronidazole 500mg IV

OR

Amoxicillin/Clavulanate 1.2g IV

Single dose

Doxycyline 400mg PO as a single dose 

(1-2 hours prior to procedure)

Azithromycin 1g PO (1-2 hours prior to procedure)

Single dose

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Cefuroxime 1.5g IV

PLUS

Metronidazole 500mg IV

OR

Ampicillin/Sulbactam 3g IV

OR

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV

PLUS
Gentamicin 5mg/kg IV

Single dose

Povidone Iodine 10% to the periorbital skin

Povidone Iodine 5% into the conjunctival sac

--

--

Intracameral Injection of Cefuroxime 1mg / 0.1ml

*Intracameral Injection Moxifloxacin 0.5mg / 0.1ml (0.5%)

*Alternative in patients with penicillin allergy (OFF-LABEL)

● Guidelines on Off Label Drugs applies

● Informed consent required

Intracameral Injection of Cefuroxime 1mg / 0.1ml

*Intracameral Injection Moxifloxacin 0.5mg / 0.1ml (0.5%)

*Alternative in patients with penicillin allergy (OFF-LABEL)

● Guidelines on Off Label Drugs applies

● Informed consent required

Topical Antibiotics

--

--

Benzylpenicillin 2MU IV

Oral (PO) prophylaxis options

Amoxicillin 2g PO

OR

Amoxicillin/Clavulanate 1.25g PO

OR

Cephalexin 2g PO

PLUS

Metronidazole 400mg PO

Intravenous (IV) prophylaxis options

Ampicillin 2gm IV 

OR

Amoxicillin/clavulanate 1.2gm IV

OR

Cefazolin 2g IV 

PLUS

Metronidazole 500mg IV

Severe penicillin allergy:

Clindamycin 600-900mg PO/IV

Single dose

*Additional of metronidazole only if choice of prophylaxis is cephalosporin.

In patients with cardiac conditions with increased risk of Infective Endocarditis, chemoprophylaxis is indicated. Please refer to Chemoprophylaxis Non-Surgical section.

Benzylpenicillin 2MU IV

Amoxicillin/clavulanate 1.2g IV

OR

Cefuroxime 1.5g IV 

PLUS 

Metronidazole 500mg IV

Single dose

For oral & maxillofacial fractures, antibiotics is recommended for the immediate post trauma period and should be discontinued once open reduction and internal fixation is completed.

Additional of metronidazole only if choice of prophylaxis is cephalosporin 

In patients with cardiac conditions with increased risk of Infective Endocarditis, chemoprophylaxis is indicated. Please refer to Chemoprophylaxis Non-Surgical section.

Cefazolin 2g IV

Cefuroxime 1.5g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV

Single dose

The benefits of routine postoperative antibiotic are uncertain. If used, postoperative prophylaxis should not exceed 24 hours.

Cefazolin 2g IV 

PLUS 

Metronidazole 500mg IV

Cefuroxime 1.5g IV

PLUS 

Metronidazole 500mg IV

OR 

Ampicillin/Sulbactam 3g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV; MAY ADD *Gentamicin 5mg/kg IV

Single dose

Duration: Up to 24 hours

Prolonged course of oral antibiotics has not been shown to reduce post-operative infections and may increase risk of complications.

*Addition of gentamicin may be appropriate when there is an increase likelihood of gram-negative contamination of surgical site.

Cefazolin 2g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV; MAY ADD *Gentamicin 5mg/kg IV

Single dose

*Addition of gentamicin may be appropriate when there is an increase likelihood of gram-negative contamination of surgical site

Cefazolin 2g IV 

PLUS 

Metronidazole 500mg IV

Cefuroxime 1.5g IV

PLUS 

Metronidazole 500mg IV

OR 

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV; MAY ADD *Gentamicin 5mg/kg IV

Single dose

Duration: Up to 24 hours

*Addition of gentamicin may be appropriate when there is an increase likelihood of gram-negative contamination of surgical site.

Simple septorhinoplasty:

Surgical antibiotic prophylaxis not recommended. Infection rates are very low, especially when nasal packing/splint use ≤ 48 hours.

Complex septorhinoplasty:

Cefazolin 2g IV 

PLUS 

Metronidazole 500mg IV

Complex septorhinoplasty:

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV; MAY ADD *Gentamicin 5mg/kg IV

Single dose

Complex septorhinoplasty:

Duration: Up to 24 hours

*Addition of gentamicin may be appropriate when there is an increase likelihood of gram-negative contamination of surgical site.

Cefazolin 2g IV 

PLUS 

Metronidazole 500mg IV

Amoxicillin/Clavulanate 1.2g IV

Severe Penicillin Allergy

Clindamycin 600-900mg IV; MAY ADD *Gentamicin 5mg/kg IV

Single Dose

*Addition of gentamicin may be appropriate when there is an increase likelihood of gram-negative contamination of surgical site.

Post-operative antibiotics should not be given if there is no mucous seen intra-operatively.

Cefazolin 2 g IV

Amoxicillin/clavulanate 1.2g IV

Single dose

Duration: Up to 24 hours

Amoxicillin/clavulanate 1.2gm IV q8h

Ampicillin/sulbactam 3g IV q8h

Duration: 3-5 days

There is no consensus on the use of post-operative prophylaxis antibiotics. However, studies have shown that postoperative pre-emptive antibiotics may reduce postoperative complications such as palatal fistula.

Cefazolin 2g IV followed by 2g IV q8h

--

Duration: Up to 24 hour

However, as suggested by SICPRE guidelines, prophylaxis can be prolonged up to 72 hours in case of high risk index such as:

• Microsurgical transplantation

• Major skin cancer surgery

• Large flap harvest

Cefazolin 2g IV followed by 2g IV q8h

Amoxicillin/clavulanate 1.2g IV followed by 1.2g IV q8h

Severe penicillin allergy

Clindamycin 600-900mg IV STAT followed by 600mg IV q8h

OR

Vancomycin 15-20mg/kg IV STAT followed by 15mg/kg IV q12h

Duration: Up to 24 hour

Unless a drain is present, antibiotics should be discontinued within 24 hours of the completion of the procedure. If a drain is present, the role of antibiotics is less clear and should be left to physician judgment.

Ampicillin/Sulbactam 3g IV

OR

Amoxicillin/Clavulanate 1.2g IV

PLUS

Gentamicin 3mg/kg IV

Fosfomycin trometamol 3g PO 3 hours before procedure, followed by 3g PO 24 hours after procedure

Single dose

Rectal wash out (rectal povidone-iodine preparation) to further decrease infection risk.

Consider pre-operative rectal swab followed by targeted antibiotic prophylaxis

Surgical antibiotic prophylaxis not recommended

Prophylaxis may be recommended in *high risk cases:

Cefuroxime 500mg PO

--

Single dose

*High-risk cases:

• Immunocompromised patients 

• Debilitated patients on long term catheters

• Patient with prosthesis/ heart valves**

• Diabetics

• Transplant recipients

**Follow recommendation for subacute bacterial endocarditis (SBE) prophylaxis.

Surgical antibiotic prophylaxis not recommended

*Prophylaxis may be recommended in patients with risk factors:

Ampicillin/Sulbactam 3g IV

--

Single dose

*Risk factors:

• Chronic steroid use

• Immunocompromising condition

• Recent systemic chemotherapy

• Poorly controlled diabetes mellitus

• Prior severe urosepsis

• Post-biopsy infection

Amoxicillin/clavulanate 1.2g IV

OR

Ampicillin/Sulbactam 3g IV

Cefuroxime 1.5g IV

Single dose

Antibiotics choices for urine culture negative cases.

Consider tailor antibiotic prophylaxis based on pre-procedural latest urine cultures.

Amoxicillin/clavulanate 1.2g IV

OR

Ampicillin/sulbactam 3g IV

Cefazolin 2g IV

OR

Ceftriaxone 2g IV

PLUS

Gentamicin 3-5mg/kg IV/IM

Single dose

Antibiotics choices for urine culture negative cases.

Consider tailor antibiotic prophylaxis based on pre-procedural latest urine cultures.

Cefuroxime 1.5g IV

PLUS
Metronidazole 500mg IV

Amoxicillin/clavulanate 1.2g IV

OR

Cefoperazone 2g IV

PLUS
Metronidazole 500mg IV

Severe penicillin allergy:
Gentamicin 3-5mg/kg IV

PLUS

Metronidazole 500mg IV

Single dose

Amoxicillin/clavulanate 1.2g IV

OR

Ampicillin/sulbactam 3g IV

Ceftriaxone 2g IV

MRSA coloniser:

Vancomycin 15-20mg/kg IV

Severe penicillin allergy:
Clindamycin 600-900mg IV

PLUS

Gentamicin 3-5mg/kg IV

Single dose

Amoxicillin 2g PO single dose 30 to 60 minutes before procedure

OR

Ampicillin 2g IV single dose 30 to 60 minutes before procedure 

*Antibiotic allergy:

For non-severe hypersensitivity to penicillin:

Cephalexin 2g PO

OR

Cefazolin 1g IV single dose 30 to 60 minutes before procedure

For severe hypersensitivity to penicillin:

Doxycycline 100mg PO

OR

Azithromycin 500mg PO single dose 30 to 60 minutes before procedure

See above for antibiotic prophylaxis in patients undergoing invasive surgical procedure to treat an established infection.

*Refer to Appendix 3 for antibiotic allergy. 

Benzathine Penicillin 1.2MU IM every 4 weeks (*consider every 3 weeks for high-risk group)

OR

Phenoxymethylpenicillin (Penicillin V) 250mg PO q12h

Antibiotic allergy:

Erythromycin ethylsuccinate 800mg PO q12h

Refer to Appendix 3 for antibiotic allergy.

*High risk group:

• Breakthrough ARF despite complete adherence to a 28-day regimen, OR

• Severe RHD, or a history of heart valve surgery