CMED_Ortho_VA 7/30/07 10:52 AM Page 1

Antibiotic Prophylaxis
in Orthopedic Surgery
Translated from the original French version published November 2005

This guide is provided for information purposes and is not a substitute for clinical judgment.

GENERAL
Most studies addressing antibiotic prophylaxis in orthopedic surgery have involved hip replacements or implantation
of internal fixation devices in hip fractures.
Antibiotic prophylaxis in other types of orthopedic surgery involving implantation of internal fixation devices (prosthesis,
plates, nails etc.) is considered a standard of practice however based on empiric data.

TREATMENT GUIDELINES
Antibiotic prophylaxis must be adapted to specific resistance patterns of each hospital environment.

Antibiotic prophylaxis
Prophylaxis NOT RECOMMENDED
Orthopedic surgery without implantation of internal fixation devices (e.g. arthroscopy, acromioplasty, soft tissue repair
with absorbable sutures)
Scientific evidence supporting antibiotic prophylaxis is insufficient to justify therapy.
Prophylaxis RECOMMENDED
Orthopedic surgery with implantation of internal fixation devices (prosthesis, nail, plate, screw, wire)
Recommended for all these types of orthopedic surgery because of the extensive morbidity associated with surgical
site infection.

First-line antibiotic prophylaxis

Cefazolin (Ancef )
Second-line antibiotic prophylaxis
Indications
Documented allergy to -lactams in patients:
having shown signs of anaphylaxis, urticaria or rash, within 72 hours of administering a -lactam antimicrobial

or having had a serious adverse drug reaction such as, drug fever or toxic epidermal necrolysis.
Patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) or with methicillin-resistant
coagulase-negative staphylococci.
REFERENCES
Vancomycin is considered an appropriate second-line choice by most authors because of its adequate coverage of pathogens American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Journal of Health-System Pharmacy 1999 ; 56 : 1839 - 88.
most likely to be encountered and because of its antibacterial effect. Vancomycin should be preferred unless clindamycin Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004 ; 38 : 1706 - 15.
offers better coverage against the pathogens encountered. Pickering LK (ed). Report of the Committee on Infectious Diseases, 26th edition, Red Book 2003. American Academy of Pediatrics, Elk Grove Village, 2003.
Scottish Intercollegiate Guidelines Network (SIGN). Antibiotic prophylaxis in surgery: a national clinical guideline. 2000 (45) : 1 - 36.
The Medical Letter. Antimicrobial prophylaxis for surgery. Treatment Guidelines from The Medical Letter 2004 ; 2(20) : 27- 32.

Antibiotic Prophylaxis in Orthopedic Surgery

This guide was developed in collaboration with professional corporations (CMQ, OPQ), the federations (FMOQ, FMSQ) and Qubec associations of pharmacists and physicians.
CMED_Ortho_VA 7/30/07 10:52 AM Page 2

THERAPY

ADULTS ANTIBIOTIC PROPHYLAXIS*

Timing of preoperative antibiotic administration
PROPHYLAXIS NOT RECOMMENDED FOR ORTHOPEDIC PROCEDURES WITHOUT IMPLANTATION OF FIXATION DEVICES

Type First-line therapy Second-line therapy

At induction of anesthesia of surgery Antibiotic Dosage Cost per dose Antibiotic Dosage Cost per dose
Variable depending on the recommended agent
Orthopedic Cefazolin (Ancef) 1 g IV at induction $1 Vancomycin 1 g IV infusion $7
If a proximal tourniquet is required: procedures with (Vancocin) over 60 min
The preoperative dose should be completely infused BEFORE applying the tourniquet. implantation of patient > 80 kg:
A minimum of 10 minutes is required before inflating the tourniquet. internal fixation 2 g IV at induction
devices (prosthesis,
nail, plate, screw, Repeat dose during
wire) procedure if it lasts
> 3 hours or if blood
loss exceeds 1500 mL

Duration of antibiotic prophylaxis * Only one brand name product is listed although several manufacturers may market other brand names.
Two additional doses of 1 g IV every 8 hours may be required.
Approximate cost negotiated for the healthcare facilities of the region of Qubec (June 2005). Cost may vary with the region.
A single preoperative dose is sufficient for most orthopedic surgeries.
For practical purposes, a 24-hour prophylaxis may be justified because surgical site infections following contamination
during orthopedic surgery are a major source of morbidity.
The half-life of cefazolin may warrant the administration of a preoperative dose followed by two postoperative doses.
A single dose of Vancomycin is sufficient because of its longer half-life.
Characteristics of pediatric antibiotic prophylaxis
Pediatric dose: calculated in mg/kg with a maximum dose equivalent to the adult dose.
Few studies have evaluated the efficacy of antibiotic prophylaxis in children undergoing orthopedic surgery.
Antibiotic prophylaxis for over 24 hours is not warranted, even in the presence of a drain or urinary catheter.
Recommendations are based on adult population trials and may be adapted to local experience.
www.cdm.gouv.qc.ca

CHILDREN ANTIBIOTIC PROPHYLAXIS*

PROPHYLAXIS NOT RECOMMENDED FOR ORTHOPEDIC PROCEDURES WITHOUT IMPLANTATION OF FIXATION DEVICES
Antibiotic administration
Type First-line therapy Second-line therapy
of surgery Antibiotic Dosage Cost per dose
Antibiotic Dosage Cost per dose
Cefazolin direct IV over 3-5 minutes OR IV infusion over 1530 minutes
Orthopedic Cefazolin (Ancef) 25 mg/kg IV at induction $1 Vancomycin 10 mg/kg IV infusion $1
procedures with Dose range: 20 - 30 mg/kg (Vancocin) over 60 min
Vancomycin IV infusion over 60 minutes. Start infusion 60-90 minutes before incision implantation of Maximal dose: 1 g Maximal dose: 1 g
internal fixation
devices (prosthesis,
nail, plate, screw,
wire)

* Only one brand name product is listed although several manufacturers may market other brand names.
Two additional doses of 25 mg/kg IV every 8 hours may be required.
Approximate cost negotiated for the healthcare facilities of the region of Qubec (June 2005). Cost may vary with the region.
Approximate cost for lowest dosage in a 20 kg-child.

Antibiotic Prophylaxis in Orthopedic Surgery

CMED_Ortho_VA 7/30/07 10:52 AM Page 2

THERAPY

ADULTS ANTIBIOTIC PROPHYLAXIS*

Timing of preoperative antibiotic administration
PROPHYLAXIS NOT RECOMMENDED FOR ORTHOPEDIC PROCEDURES WITHOUT IMPLANTATION OF FIXATION DEVICES

Type First-line therapy Second-line therapy

At induction of anesthesia of surgery Antibiotic Dosage Cost per dose Antibiotic Dosage Cost per dose
Variable depending on the recommended agent
Orthopedic Cefazolin (Ancef) 1 g IV at induction $1 Vancomycin 1 g IV infusion $7
If a proximal tourniquet is required: procedures with (Vancocin) over 60 min
The preoperative dose should be completely infused BEFORE applying the tourniquet. implantation of patient > 80 kg:
A minimum of 10 minutes is required before inflating the tourniquet. internal fixation 2 g IV at induction
devices (prosthesis,
nail, plate, screw, Repeat dose during
wire) procedure if it lasts
> 3 hours or if blood
loss exceeds 1500 mL

Duration of antibiotic prophylaxis * Only one brand name product is listed although several manufacturers may market other brand names.
Two additional doses of 1 g IV every 8 hours may be required.
Approximate cost negotiated for the healthcare facilities of the region of Qubec (June 2005). Cost may vary with the region.
A single preoperative dose is sufficient for most orthopedic surgeries.
For practical purposes, a 24-hour prophylaxis may be justified because surgical site infections following contamination
during orthopedic surgery are a major source of morbidity.
The half-life of cefazolin may warrant the administration of a preoperative dose followed by two postoperative doses.
A single dose of Vancomycin is sufficient because of its longer half-life.
Characteristics of pediatric antibiotic prophylaxis
Pediatric dose: calculated in mg/kg with a maximum dose equivalent to the adult dose.
Few studies have evaluated the efficacy of antibiotic prophylaxis in children undergoing orthopedic surgery.
Antibiotic prophylaxis for over 24 hours is not warranted, even in the presence of a drain or urinary catheter.
Recommendations are based on adult population trials and may be adapted to local experience.
www.cdm.gouv.qc.ca

CHILDREN ANTIBIOTIC PROPHYLAXIS*

PROPHYLAXIS NOT RECOMMENDED FOR ORTHOPEDIC PROCEDURES WITHOUT IMPLANTATION OF FIXATION DEVICES
Antibiotic administration
Type First-line therapy Second-line therapy
of surgery Antibiotic Dosage Cost per dose
Antibiotic Dosage Cost per dose
Cefazolin direct IV over 3-5 minutes OR IV infusion over 1530 minutes
Orthopedic Cefazolin (Ancef) 25 mg/kg IV at induction $1 Vancomycin 10 mg/kg IV infusion $1
procedures with Dose range: 20 - 30 mg/kg (Vancocin) over 60 min
Vancomycin IV infusion over 60 minutes. Start infusion 60-90 minutes before incision implantation of Maximal dose: 1 g Maximal dose: 1 g
internal fixation
devices (prosthesis,
nail, plate, screw,
wire)

* Only one brand name product is listed although several manufacturers may market other brand names.
Two additional doses of 25 mg/kg IV every 8 hours may be required.
Approximate cost negotiated for the healthcare facilities of the region of Qubec (June 2005). Cost may vary with the region.
Approximate cost for lowest dosage in a 20 kg-child.

Antibiotic Prophylaxis in Orthopedic Surgery

CMED_Ortho_VA 7/30/07 10:52 AM Page 1

Antibiotic Prophylaxis
in Orthopedic Surgery
Translated from the original French version published November 2005

This guide is provided for information purposes and is not a substitute for clinical judgment.

GENERAL
Most studies addressing antibiotic prophylaxis in orthopedic surgery have involved hip replacements or implantation
of internal fixation devices in hip fractures.
Antibiotic prophylaxis in other types of orthopedic surgery involving implantation of internal fixation devices (prosthesis,
plates, nails etc.) is considered a standard of practice however based on empiric data.

TREATMENT GUIDELINES
Antibiotic prophylaxis must be adapted to specific resistance patterns of each hospital environment.

Antibiotic prophylaxis
Prophylaxis NOT RECOMMENDED
Orthopedic surgery without implantation of internal fixation devices (e.g. arthroscopy, acromioplasty, soft tissue repair
with absorbable sutures)
Scientific evidence supporting antibiotic prophylaxis is insufficient to justify therapy.
Prophylaxis RECOMMENDED
Orthopedic surgery with implantation of internal fixation devices (prosthesis, nail, plate, screw, wire)
Recommended for all these types of orthopedic surgery because of the extensive morbidity associated with surgical
site infection.

First-line antibiotic prophylaxis

Cefazolin (Ancef )
Second-line antibiotic prophylaxis
Indications
Documented allergy to -lactams in patients:
having shown signs of anaphylaxis, urticaria or rash, within 72 hours of administering a -lactam antimicrobial

or having had a serious adverse drug reaction such as, drug fever or toxic epidermal necrolysis.
Patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) or with methicillin-resistant
coagulase-negative staphylococci.
REFERENCES
Vancomycin is considered an appropriate second-line choice by most authors because of its adequate coverage of pathogens American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Journal of Health-System Pharmacy 1999 ; 56 : 1839 - 88.
most likely to be encountered and because of its antibacterial effect. Vancomycin should be preferred unless clindamycin Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004 ; 38 : 1706 - 15.
offers better coverage against the pathogens encountered. Pickering LK (ed). Report of the Committee on Infectious Diseases, 26th edition, Red Book 2003. American Academy of Pediatrics, Elk Grove Village, 2003.
Scottish Intercollegiate Guidelines Network (SIGN). Antibiotic prophylaxis in surgery: a national clinical guideline. 2000 (45) : 1 - 36.
The Medical Letter. Antimicrobial prophylaxis for surgery. Treatment Guidelines from The Medical Letter 2004 ; 2(20) : 27- 32.

Antibiotic Prophylaxis in Orthopedic Surgery

This guide was developed in collaboration with professional corporations (CMQ, OPQ), the federations (FMOQ, FMSQ) and Qubec associations of pharmacists and physicians.