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OR vancomycin Δ 1 g 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. • Due to increasing resistance of E. coli to fluoroquinolones and ampicillin-sulbactam, local sensitivity profiles should be reviewed prior to use. Δ Vancomycin can be used in hospitals in which methicillin-resistant S. aureus and S. epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with diphenhydramine and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of vancomycin to patients weighing more than 75 kg, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g). For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an aminoglycoside (gentamicin, tobramycin, or amikacin), aztreonam, or a fluoroquinolone. Reprinted with special permission from: Treatment Guidelines from The Medical Letter, October 2012; Vol. 10 (122):73. www.medicalletter.org .