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
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