Tools of the Trade
Surgical Wound Classification Examples
Clean - conventional angiography and venography
Clean contaminated - nephrostomy tube without UTI
Contaminated - biliary drain with infection or compromised sphincter of Oddi
Dirty - abscess drain
Timing - surgical literature suggests prophylactic antibiotics be given 60 minutes prior to the procedure and to consider redosing if 2 hours has lapsed from the initial dose
| Procedure | Potential Organisms Encountered | Procedure Classification | Routine Prophylaxis Recommended∗ | First-Choice Antibiotic | Suggested Antibiotic Regimens | Other Antibiotic Regimens | Comments∗ |
|---|---|---|---|---|---|---|---|
| Diagnostic angiography and angioplasty | Staphylococcus aureus, Staphylococcus epidermis | Clean | No | None | NA | NA | Special considerations: 1–2 g cefazolin IV in high-risk patients; vancomycin recommended in penicillin-allergic patients |
| Intravascular placement of bare metal stent | S. aureus, S. epidermis | Clean | No | None | NA | NA | Special considerations: 1–2 g cefazolin IV in high-risk patients; vancomycin recommended in penicillin-allergic patients |
| Arterial endografts | S. aureus, S. epidermis | Clean | Yes | 1–2 g cefazolin IV | NA | NA | Vancomycin recommended in penicillin-allergic patients |
| AV fistula and graft angioplasty, stent placement, thrombectomy. and coil embolization | S. aureus, S. epidermis | Clean | No | None | NA | NA | Special considerations: 1–2 g cefazolin IV in high-risk patients, especially those receiving covered stent; vancomycin recommended in penicillin-allergic patients |
| Closure devices | S. aureus, S. epidermis | Clean | No | None | NA | NA | Special considerations: 1–2 g cefazolin IV in high-risk patients; vancomycin recommended in penicillin-allergic patients |
| Uterine artery embolization | S. aureus, S. epidermis, Streptococcus spp., Escherichia coli, vaginal flora | Clean, clean contaminated | Yes | No consensus | 1–2 g cefazolin IV | (i) 900 mg clindamycin IV + 1.5 mg/kg gentamicin; (ii) 2 g ampicillin IV; (iii) 1.5–3 g ampicillin/sulbactam IV; (iv) 100 mg doxycycline twice daily for 7 d (in women with hydrosalpinx) | Vancomycin recommended in penicillin-allergic patients |
| Hepatic embolization and chemoembolization | S. aureus, S. epidermidis, enteric flora: anaerobes, eg, Bacteroides spp., Enterococcus spp., Enterobacteriaceae spp. (E. coli, Klebsiella spp., Lactobacillus spp.), Candida spp. | Clean, clean contaminated (if history of biliary colonization) | Yes | No consensus | With competent sphincter of Oddi: (i) 1.5–3 g ampicillin/sulbactam IV (hepatic chemoembolization); (ii) 1 g cefazolin + 500 mg metronidazole IV (hepatic chemoembolization); (iii) 2 g ampicillin IV + 1.5 mg/kg gentamicin (hepatic chemoembolization); (iv) 1 g ceftriaxone IV (hepatic chemoembolization or renal, splenic embolization) | With incompetent sphincter of Oddi: oral moxifloxacin 400 mg/d beginning 3 d before and continuing for 17 d postprocedure, (ii) levofloxacin 500 mg/d + metronidazole 500 mg twice daily beginning 2 wk after chemoembolization with bowel preparation of neomycin 1 g + erythromycin base 1 g orally at 1, 2, and 11 PM the day before chemoembolization and 1 g ceftriaxone IV preprocedure; (iii) 1.5–3 g ampicillin sulbactam IV; (iv) 1–2 g cefazolin IV with 500 mg metronidazole IV preprocedure followed by amoxicillin/clavulanic acid for 5 d postdischarge | Vancomycin or clindamycin/gentamycin recommended in penicillin-allergic patients |
| Radioembolization | S. aureus, S. epidermidis, enteric flora: anaerobes, eg, Bacteroides spp., Enterococcus spp., Enterobacteriaceae spp. (E. coli, Klebsiella spp., Lactobacillus spp.), Candida spp. | Clean, clean contaminated (if history of biliary colonization) | No consensus | No consensus | With competent sphincter of Oddi: none | When infusing proximal to cystic artery: ciprofloxacin 500 mg twice per day for 5 d; with incompetent sphincter of Oddi, (i) oral moxifloxacin 400 mg/d beginning 2 d before radioembolization and continued for 10 d after, (ii) oral moxifloxacin 400 mg started 3 d before radioembolization and continued for 18 d after | Amoxicillin/clavulanic acid 875 mg twice daily for similar duration if allergic to moxifloxacin |
| Gastrointestinal embolization | Streptococcus, Staphylococcus; if evidence of hemobilia: enteric organisms, eg, E. coli, Enterococcus spp., anaerobes | Clean, clean contaminated (if history of biliary colonization) | Not in average-risk patients; antibiotics recommended for patients with hemobilia | No consensus | (i) 1 g ceftriaxone IV; (ii) 1.5–3g ampicillin/sulbactam IV; (iii) 1 g cefotetan IV + 4 g mezlocillin IV; (iv) 2 g ampicillin IV + 1.5 mg/kg gentamicin IV; (v) if penicillin-allergic, can use vancomycin or clindamycin and aminoglycoside | NA | NA |
| Partial splenic embolization for hypersplenism | Streptococcus, Staphylococcus | Clean | Antibiotics recommended if > 70% of spleen is expected to be embolized | No consensus | (i) Gentamicin 10 mg/kg/d, cefoxitin sodium 100 mg/kg/d beginning 2 h before and continuing for ≥ 5 d after; soaking of embolic spheres with 1,000,000 U penicillin and 40 mg gentamicin also recommended; (ii) 1 g cefoperazone every 12 h postprocedure for ≥ 5 d following; (iii) embolic particles suspended in gentamicin (16 mg) in combination with 5-d course of IV amoxicillin/clavulanate (3 g/d) and ofloxacin (400 mg/d) | NA | NA |
| Totally implanted central venous access ports | S. aureus, S. epidermidis | Clean | No | No consensus | 1–2 g cefazolin IV | NA | Vancomycin recommended in penicillin-allergic patients |
| Tunneled dialysis catheters | S. aureus, S. epidermidis | Clean | Yes | No consensus | 1–2 g cefazolin IV | NA | Vancomycin recommended in penicillin-allergic patients |
| Other central venous access catheters, including nontunneled hemodialysis catheters | S. aureus, S. epidermidis | Clean | No, except in high-risk patients, including immunocompromise | No consensus | 1–2 g cefazolin IV | NA | Vancomycin recommended in penicillin-allergic patients |
| Lower-extremity superficial venous insufficiency treatment | S. aureus, S. epidermidis | Clean | No | None | NA | NA | NA |
| IVC filter placement | S. aureus, S. epidermidis | Clean | No | None | NA | NA | NA |
| IVC filter retrieval | S. aureus, S. epidermidis, possibly polymicrobial colonic flora including anaerobes | Clean, clean contaminated | No except in cases of embedded IVC filters with known bowel penetration | No consensus | NA | NA | Special considerations: (i) piperacillin/tazobactam or (ii) ampicillin/sulbactam may be considered for prophylaxis for retrieval of embedded IVC filters with known bowel penetration |
| Thrombolysis | S. aureus, S. epidermis | Clean | No | None | NA | NA | Special considerations: 1–2 g cefazolin IV in high-risk patients; Vancomycin recommended in penicillin-allergic patients |
| Vascular malformation | S. aureus, S. epidermis | Clean, contaminated | Yes | None | (i) 1–2 g cefazolin for adults, (ii) cefazolin 25 mg/kg for pediatric patients, (iii) clindamycin 10 mg/kg for oral lesions | NA | Recommendations primarily for percutaneous sclerotherapy/ablation of slow flow venous or venolymphatic malformations. |
| Varicocele embolization (transcatheter) | S. aureus, S. epidermis | Clean | No | None | None | NA | – |
| TIPS | S. aureus, Enterococcus faecalis, E. coli, Klebsiella spp., Lactobacillus acidophilus, Gemella morbillorum, Acinetobacter spp., Streptococcus sanguinis, Streptococcus gallolyticus, and Candida albicans | Clean, clean contaminated | Yes | No consensus | (i) 1 g ceftriaxone IV; (ii) 1.5–3 g ampicillin/sulbactam | NA | Vancomycin or clindamycin/gentamycin recommended for penicillin-allergic patients |
| Percutaneous transhepatic biliary drain and cholecystostomy | Enterococcus spp., Candida spp., Gram-negative aerobic bacilli, Streptococcus viridans, E. coli, and Clostridium spp.; Klebsiella, Pseudomonas, and Bacteroides spp., particularly in cases of advanced biliary disease, including hepatolithiasis | Contaminated, dirty | Yes for new placement and routine exchanges | No consensus | (i) 1 g ceftriaxone IV; (ii) 1.5–3 g ampicillin/sulbactam IV; (iii) 1 g cefotetan IV plus 4 g mezlocillin IV; (iv) 2 g ampicillin IV plus 1.5 mg/kg gentamicin IV | NA | Vancomycin or clindamycin-gentamycin recommended for penicillin-allergic patients |
| Percutaneous nephrostomy tubes | E. coli, Proteus, Klebsiella, and Enterococcus spp. | Clean contaminated, contaminated, or dirty | Yes except in routine catheter exchange for low-risk patients | No consensus | (i) 1–2 g ceftriaxone IV single dose; (ii) 1.5–3 g ampicillin/sulbactam IV every 6 h + 5 mg/kg gentamycin IV single dose | NA | Patients with indwelling ureteral catheters, ureteroileal anastomosis should be considered high-risk; vancomycin recommended in penicillin-allergic patients |
| Gastrostomy tube placement | Push type, S. aureus, S. epidermis, pull type, S. aureus, S. epidermidis, and oropharyngeal flora (eg, S. viridans (α-hemolytic), Lactobacillus spp., non-diphtheroid Corynebacterium spp., anaerobes Bacteroides spp., Actinobacillus spp.) | Clean contaminated | Yes for push and pull type | Push type, cefazolin single dose; pull type, cefazolin/cefalexin for 6 d | Push type, 1–2 g cefazolin or clindamycin (if penicillin-allergic); pull type, (i) 1–2 g cefazolin preprocedure followed by 500 mg cephalexin oral/gastrostomy-inserted twice daily for 5 d; (ii) 600 mg clindamycin IV at time of procedure followed by 600 mg oral clindamycin twice daily for 5 d | NA | Special consideration: 1–2 g cefazolin IV pre-procedure for push-type gastrostomies in patients with head and neck cancer; Vancomycin or clindamycin-gentamycin is recommended for penicillin-allergic patients |
| Liver tumor ablation | S. aureus, S. epidermidis, E. coli, Clostridium perfringens, Enterococcus spp. | Clean contaminated, contaminated if sphincter of Oddi dysfunction | Yes, especially in high-risk patients (eg history of biliary–enteric anastomosis, cirrhosis, diabetes) | No consensus | In low-risk patients, 1–2 g cefazolin IV | In high risk patients, (i) oral levofloxacin 500 mg/d + oral metronidazole 500 mg twice daily beginning 2 d before and continuing for 14 d after ablation + neomycin 1 g and erythromycin base 1 g orally at 1, 2, and 11 PM on the day before ablation; (ii) 1.5 g ampicillin/sulbactam IV; (iii) vancomycin or clindamycin can be given for Gram-positive coverage and gentamicin for Gram-negative coverage | NA |
| Renal tumor ablation | E. coli, Proteus, Klebsiella spp. | Clean contaminated, contaminated if urothelial colonization | No, except in patients with colonized urothelium | No consensus | 1 g ceftriaxone IV | Clindamycin/gentamycin recommended for penicillin-allergic patients | |
| Other tumor ablation (lung, adrenal, bone) | Skin and respiratory flora | Clean, clean contaminated (lung) | No consensus | No consensus | 1–2 g cefazolin IV | NA | Special consideration: for patients with single lung, ablation/amoxicillin clavulanate 2 g or ofloxacin 400 mg/d continued for 3–7 d postablation |
| Percutaneous abscess drainage | Polymicrobial | Dirty | Yes if not already on antibiotics | Location of abscess influences organisms encountered | Single-agent regimens for intraabdominal infections: meropenem, imipenem/cilastatin, doripenem, piperacillin/tazobactam | Metronidazole in combination with ciprofloxacin, levofloxacin, ceftazidime, ampicillin, sulbactam, or cefepime | Antibiotics should cover anticipated organisms for empiric treatment and then be adjusted for final culture results |
| Paracentesis and thoracentesis | S. aureus, S. epidermidis, S. viridans | Clean | No | NA | NA | NA | Special considerations: 1–2 g cefazolin IV can be considered for tunneled pleural or peritoneal catheters; vancomycin can be considered in patients with penicillin allergy |
| Percutaneous biopsy | Transrectal Gram-negative bacteria Enterococcus spp., E. coli, Bacteroides spp., other anaerobes | Clean, transrectal biopsies, contaminated | No, except for transrectal prostate biopsy | No consensus | For transrectal prostate biopsy: (i) 500 mg ciprofloxacin + 1.5 mg/kg gentamycin | (i) 1 g ceftriaxone + 1.5 g/kg gentamycin, (ii) 160 mg trimethoprim/800 mg sulfamethoxazole orally as single dose 1 h before biopsy | NA |
| Percutaneous vertebral body augmentation | S. aureus, S. epidermis | Clean | Yes | 1–2 g cefazolin IV | NA | NA | Vancomycin recommended in penicillin-allergic patients |
| Salivary gland Botox injections | S. aureus, S. epidermis | Clean | No | NA | NA | NA | NA |
| Percutaneous cecostomy insertion | Polymicrobial-including anaerobes from colonic flora, S. aureus, S. epidermidis | Clean contaminated | Yes | No consensus | (i) Cefoxitin 30 mg/kg single prophylactic dose; addition of triple antibiotic regimen only in complicated insertions using gentamycin 2.5 mg/kg IV, metronidazole 10 mg/kg IV, and ampicillin 20 mg/kg IV administered before and for 2 d after procedure with continuation of metronidazole 10 mg/kg orally for total of 5 d; (ii) prophylactic gentamycin 2.5 mg/kg IV, metronidazole 10 mg/kg IV, and ampicillin 20 mg/kg IV administered before and for 2 d after procedure with continuation of metronidazole 10 mg/kg orally for total of 5 d; (iii) prophylactic gentamycin 2.5 mg/kg IV and metronidazole 10 mg/kg IV before and 2 d after procedure | NA | NA |
| Bone interventions (osteoid osteoma ablation, sclerotherapy) | S. aureus, S. epidermis | Clean | No | NA | NA | NA | NA |
Low bleeding risk procedures: breast needle localization, superficial abscess drain or biopsy, transjugular liver biopsy, bone marrow biopsy, joint aspiration/injection, paracentesis, thoracentesis, tunneled drain/line placement or removal (including ports), chest tube, diagnostic venography, drain exchanges, arterial interventions with <7 Fr access (e.g., UFE, TARE), IVC filter placement or non-complex removal, peripheral nerve blocks, dialysis access interventions.
Pre-procedure lab testing not routinely recommended for otherwise healthy outpatients. Otherwise, INR should be corrected to <2-3 and platelets to >20K.
Most anticoagulants and antiplatelet agents DO NOT need to be held except as follows.
Abciximab (ReoPro) - hold 24 hrs prior pending discussion with cardiology if recent PCI
Eptifibatide (Integrilin) and tirofiban (Aggrastat) - hold 4-8 hrs prior
Cangrelor (Kengreal) - defer procedure until off medication if possible, otherwise hold 1 hr prior
Anagrelide (Agrylin) and Ibrutinib (Imbruvica) - hold 5 days prior
Vorapaxar (Zontivity) and bevacizumab (Avastin) - discuss with referring clinician given increased bleeding risk
High bleeding risk procedures: thermal ablation, deep or solid organ biopsy, deep abscess drain, biliary interventions, TIPS, catheter directed thrombolysis, enteric tube placement, arterial intervention with >7 Fr access, GU interventions (e.g. PCN), complex IVC filter removal, intrathoracic or CNS venous interventions, most spine interventions (e.g. vertebral augmentation, epidural injections)
Pre-procedure lab testing recommended with PT/INR, platelets, and hemoglobin as well as aPTT or anti-Xa if on heparin or DOAC
Correct INR to <1.5-1.8
Correct platelets to >50K
Thromboelastography (TEG) may more accurately characterize coagulopathy and bleeding risk for patients with cirrhosis. It also guides the ideal means of correcting the coagulopathy (e.g. giving FFP vs platelets).
Anticoagulants
Warfarin - Adjust to meet INR goal above
Heparin - SubQ hold 6 hrs, IV hold 4-6 hrs prior
LWMH - Prophylactic dosing hold 1 dose, therapeutic dosing hold 2 doses or 24 hrs
Fondaparinux (Arixstra) - Hold 2-3 days (CrCl≥ 50mL/min) or 3-5 days (CrCl ≤ 50 mL/min)
Rivaroxaban (Xarelto) - Hold 2 doses; hold 3 doses if CrCl <15-30 mL/min
Apixaban (Eliquis) - Hold 4 doses; hold 6 doses if CrCl <30-50mL/min
Edoxaban (Savaysa) - Hold 2 doses
Argatroban - Hold 2-4 hrs
Bivalirudin (Angiomax) - Hold 2-4 hrs
Dabigatran (Pradaxa) - Hold 4 doses; hold 6-8 doses if CrCl <30-50 mL/min
Antiplatelets agents
Cilostazol (Pletal) - No need to hold
Diclofenac (Voltaren), Etodolac (Lodine), Ibuprofen (Advil), Indomethacin (Indocin), Ketoprofen - Hold 24 hrs
Celecoxib (Celebrex), Diflunisal (Dolobid), Ketorolac (Toradol), Sulindac (Clinoril) - Hold 2 days
Naproxen (Aleve/Naprosyn) - Hold for 2 days for CrCl > 50 mL/min; Hold 3 days for CrCl < 50 mL/min
Aspirin, Clopidogrel (Plavix), Ticlopidine(Ticlid), Ticagrelor (Brilinta) - Hold 5 days
Oxaprozin (Daypro) - Hold 6 days
Prasugrel (Effient) - Hold 7 days
Meloxicam (Mobic), Nabumetone (Relafen), Piroxicam (Feldene) - Hold 10 days
Glycoprotein IIb/IIIa inhibitors
Abciximab (ReoPro) - Hold 24 hrs prior and discuss with cardiology if recent PCI
Eptifibatide (Integrilin) or Tirofiban (Aggrastat) - Hold 4-8 hrs prior
Other medications
Cangrelor (Kengreal) - defer procedure until off medication if possible
Dalteparin (Fragmin) - Hold 1 dose prior
Betrixaban (Bevyxxa) - Hold 3 doses prior
Anagrelide (Agrylin) - Hold 7 days
Pentoxigylline (Trental) - Hold 4 hrs prior
Vorapaxar (Zontivity) and Bevacizumab (Avastin) - Discuss holding period with referring clinician given increased bleeding risk
Ibrutinib (Imbruvica) - Hold 5 days