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OR cefazolin Δ <80 kg: 1 g IV ≥80 kg: 2 g IV PLUS metronidazole 500 mg IV * Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure. For prolonged procedures (>3 hours) or those with major blood loss, or in patients with extensive burns, additional intraoperative doses should be given at intervals one to two times the half-life of the drug (ampicillin-sulbactam every 2 hours, cefazolin every 4 hours, cefuroxime every 4 hours, cefoxitin every 2 hours, clindamycin every 6 hours, vancomycin every 12 hours) for the duration of the procedure in patients with normal renal function. If vancomycin or a fluoroquinolone is used, the infusion should be started within 60 to 120 minutes before the initial incision to have adequate tissue levels at the time of incision and to minimize the possibility of an infusion reaction close to the time of induction of anesthesia. • Morbid obesity, gastrointestinal (GI) obstruction, decreased gastric acidity or GI motility, gastric bleeding, malignancy or perforation, or immunosuppression. Δ For patients allergic to penicillins and cephalosporins, clindamycin or vancomycin with either gentamicin, ciprofloxacin, levofloxacin, or aztreonam is a reasonable alternative. ◊ Age >70 years, acute cholecystitis, non-functioning gall bladder, obstructive jaundice, or common bile duct stones. § Cefotetan, cefoxitin, and ampicillin-sulbactam are reasonable alternatives. ¥ In addition to mechanical bowel preparation, 1 g of neomycin plus 1 g of erythromycin at 1 PM, 2 PM, and 11 PM, or 2 g of neomycin plus 2 g of metronidazole at 7 PM and 11 PM the day before an 8 AM operation. ‡ Due to increasing resistance of E. coli to fluoroquinolones and ampicillin-sulbactam, local sensitivity profiles should be reviewed prior to use. † For a ruptured viscus, therapy is often continued for about five days. Reprinted with special permission from: Treatment Guidelines from The Medical Letter, October 2012; Vol. 10 (122):73. www.medicalletter.org .