Antibiotic Prophylaxis In Cardiac Surgery, Part II: Antibiotic Choice

Publication Date: March 31, 2007
Last Updated: March 14, 2022


Choice of Primary Prophylactic Antibiotic

Cephalosporin or Glycopeptide

A β-lactam antibiotic is indicated as a single antibiotic of choice for standard cardiac surgical prophylaxis in populations that do not have a high incidence of methicillin-resistant Staphylococcus aureus. (Level A, Class I (benefit > > >risk))

Distinguishing Between Cephalosporins

Based on availability and cost, it is reasonable to use cefazolin (a first-generation agent) as the cephalosporin for standard cardiac surgical prophylaxis in view of the fact that most randomized trials could not discriminate between cephalosporins. (Level B, Class IIa (benefit > > risk))

Issues Surrounding Staphylococcal Infection

Potential (Nonallergic) Indications for Primary or Adjuvant Glycopeptide (Vancomycin) Prophylaxis

In the setting of either a presumed or known staphylococcal colonization, the institutional presence of a “high incidence” of MRSA, patients susceptible to colonization (hospitalized longer than 3 days, transfer from other inpatient facility, already receiving antibiotics), or an operation for a patient having prosthetic valve or vascular graft insertion, it would be reasonable to combine the β-lactam (cefazolin) with a glycopeptide (vancomycin) for prophylaxis, with the restriction to limit vancomycin to only one or two doses. (Level C, Class IIb (benefit > >risk))

Vancomycin as the Sole Prophylactic Antibiotic

Because vancomycin is an agent that has no effect on gram-negative flora, its usefulness as an exclusive agent in cardiac surgical prophylaxis is not recommended. (Level C, Class IIb (benefit > >risk))

Mupirocin for Preoperative Therapy to Eliminate Staphylococcal Nasal Colonization

Routine mupirocin administration is recommended for all patients undergoing cardiac surgical procedures in the absence of a documented negative testing for staphylococcal colonization. (Level A, Class I (benefit > > >risk))

Guidelines for Appropriate Dosing of Prophylactic Antibiotics

In patients for whom cefazolin is the appropriate prophylactic antibiotic for cardiac surgery, administration within 60 minutes of the skin incision is indicated (Class I, Level of Evidence A). The preoperative prophylactic dose of cefazolin for a patient of greater than 60 kg body weight is recommended to be 2 g. (Level B, Class I (benefit > > >risk))
When the surgical incision remains open in the operating room, to patients with normal renal function, a second dose of 1 g should be administered every 3 to 4 hours. If it is apparent that cardiopulmonary bypass will be discontinued within 4 hours, it is appropriate to delay until perfusion is complete to maximize effective blood levels. (Level B, Class I (benefit > > >risk))
In patients for whom vancomycin is an appropriate prophylactic antibiotic for cardiac surgery, a dose of 1 to 1.5 g or a weight-adjusted dose of 15 mg/kg administered intravenously slowly over 1 hour, with completion within 1 hour of the skin incision, is recommended (Class I, Level of Evidence A). A second dose of vancomycin of 7.5 mg/kg may be considered during cardiopulmonary bypass, although its usefulness is not well established. (Level C, Class IIb (benefit > >risk))
For patients who receive an aminoglycoside (usually gentamicin, 4 mg/kg) in addition to vancomycin before cardiac surgery, the initial dose should be administered within 1 hour of the skin incision (Class I, Level of Evidence C). Redosing an aminoglycoside during cardiopulmonary bypass is not indicated and may be harmful. (Level C, Class III (harm))

Guidelines for Prophylactic Antibiotics in Special Circumstances

Allergy to Penicillin

In patients with a history of an immunoglobulin-E (IgE)–mediated reaction to penicillin or cephalosporin (anaphylaxis, hives, or angioedema), vancomycin should be given preoperatively and for no more than 48 hours. Alternatively, skin testing may be performed in these patients and, if negative, a cephalosporin regimen administered. (Level A, Class I (benefit > > >risk))
For patients with a history of a non-IgE mediated reaction to penicillin (such as a simple rash) or an unclear history either vancomycin or a cephalosporin is recommended for prophylaxis with the understanding that these patients have a low incidence of significant allergic reactions to cephalosporins. (Level B, Class I (benefit > > >risk))
The addition of an aminoglycoside or other gramnegative bacterial coverage to a vancomycin antibiotic regimen may be reasonable, but its efficacy is not well established. (Level C, Class IIb (benefit > >risk))

Specific Issues Regarding Gram-Negative Infections

For institutions with an outbreak of gram-negative deep wound infections due to a specific pathogen, it is reasonable to employ a first-generation cephalosporin for routine prophylaxis (48 hours) supplemented with an appropriate antibiotic to which the offending organisms are sensitive. (Level C, Class IIa (benefit > > risk))
In patients with renal dysfunction requiring gramnegative prophylaxis to supplement a cephalosporin or vancomycin as the primary antibiotic, it is reasonable to use either one dose of an aminoglycoside or an antibiotic such as levofloxacin with a low incidence of renal toxicity. (Level C, Class IIa (benefit > > risk))

Topical Application of Antibiotics

Topical antibiotics may be considered for antibiotic prophylaxis in cardiac surgery. (Level B, Class IIb (benefit > >risk))

Recommendation Grading



Antibiotic Prophylaxis In Cardiac Surgery, Part II: Antibiotic Choice

Authoring Organization

Publication Month/Year

March 31, 2007

Last Updated Month/Year

January 4, 2024

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

This Guideline defines the choice of antibiotic to be recommended, its dose, or frequency of administration of prophylactic antibiotics for cardiac surgery.

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Assessment and screening, Prevention

Diseases/Conditions (MeSH)

D019918 - Heart Valve Prosthesis Implantation, D006348 - Cardiac Surgical Procedures


cardiac surgery, Antibiotic prophylaxis, surgical site infection, sternal wound infection

Source Citation

The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic Prophylaxis in Cardiac Surgery, Part II: Antibiotic Choicelow asterisk

Engelman, Richard et al.
The Annals of Thoracic Surgery, Volume 83, Issue 4, 1569 - 1576