Intervențional — Profilaxie antibiotică în intervențional (SIR 2018) (MCB)

Volume ▪▪Number ▪▪Month ▪2018 5 continued Vancomycin or clindamycin/ gentamycin recommended in penicillin-allergic patients Vancomycin recommended in penicillin-allergic patients 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 þ metronidazole 500 mg twice daily beginning 2 wk after chemoembolization with bowel First-Choice Antibiotic Suggested Anti- biotic Regimens Other Antibiotic Regimens Comments Yes No consensus With competent sphincter of Oddi: (i) 1.5–3 g ampicillin/ sulbactam IV (hepatic chemoembolization); (ii) 1 g cefazolin þ 500 mg metronidazole IV (hepatic chemoembolization); (iii) 2 g ampicillin IV þ 1.5 mg/kg gentamicin (hepatic chemoembolization); Clean, clean contaminated (if history of biliary colonization) Clean, clean contaminated Yes No consensus 1–2 g cefazolin IV (i) 900 mg clindamycin IV þ 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) III B-NR Staphylococcus aureus, Staphylococcus epidermis IIb B-NR, C-LD S. aureus, S. epidermidis, enteric flora: anaerobes, eg, Bacteroides spp., Enterococcus spp., Enterobacteriaceae spp. (E. coli, Klebsiella spp., Lactobacillus spp.), Candida spp. Table 2. Suggested Antibiotic Regiments for Vascular and Interventional Radiology Procedures Diagnostic angiography and angioplasty Procedure Class of Recommendation Level of Evidence Potential Organ- isms Encountered Procedure Classification Routine Prophy- laxis Recommended 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 III C-LD 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 IIb B-NR 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 Hepatic embolization and chemoembolization IIb C-LD, C-EO 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 III B-NR 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 IIa C-EO S. aureus, S. epidermis, Streptococcus spp., Escherichia coli, vaginal flora

6 ▪Antibiotic Prophylaxis during IR Procedures: Practice Parameter Chehab et al ▪JVIR continued Amoxicillin/clavulanic acid 875 mg twice daily for similar duration if allergic to moxifloxacin NA NA NA NA 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 (iv) 1 g ceftriaxone IV (hepatic chemoembolization or renal, splenic embolization) First-Choice Antibiotic Suggested Anti- biotic Regimens Other Antibiotic Regimens Comments No consensus (i) 1 g ceftriaxone IV; (ii) 1.5–3g ampicillin/ sulbactam IV; (iii) 1 g cefotetan IV þ 4 g mezlocillin IV; (iv) 2 g ampicillin IV þ 1.5 mg/kg gentamicin IV; (v) if penicillin- allergic, can use vancomycin or clindamycin and aminoglycoside 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 Not in average-risk patients; antibiotics recommended for patients with hemobilia No consensus No consensus With competent sphincter of Oddi: none Clean, clean contaminated (if history of biliary colonization) Clean, clean contaminated (if history of biliary colonization) IIb C-LD, C-EO Streptococcus, Staphylococcus Clean Antibiotics recommended if > 70% of spleen is expected to be embolized Table 2. Suggested Antibiotic Regiments for Vascular and Interventional Radiology Procedures (continued) Gastrointestinal embolization IIb C-LD, C-EO Streptococcus, Staphylococcus; if evidence of hemobilia: enteric organisms, eg, E. coli, Enterococcus spp., anaerobes Partial splenic embolization for hypersplenism preparation of neomycin 1 g þ 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 Radioembolization IIb C-LD S. aureus, S. epidermidis, enteric flora: anaerobes, eg, Bacteroides spp., Enterococcus spp., Enterobacteriaceae spp. (E. coli, Klebsiella spp., Lactobacillus spp.), Candida spp. Procedure Class of Recommendation Level of Evidence Potential Organ- isms Encountered Procedure Classification Routine Prophy- laxis Recommended

Volume ▪▪Number ▪▪Month ▪2018 7 continued NA Recommendations primarily for percutaneous sclerotherapy/ ablation of slow flow venous or First-Choice Antibiotic Suggested Anti- biotic Regimens Other Antibiotic Regimens Comments No consensus 1–2 g cefazolin IV NA Vancomycin recommended in penicillin-allergic patients Clean, clean contaminated No except in cases of embedded IVC filters with known bowel penetration IIb C-LD, C-EO S. aureus, S. epidermidis Clean No, except in high-risk patients, including immunocompromise III C-LD, C-EO S. aureus, S. epidermidis Clean No None NA NA NA Table 2. Suggested Antibiotic Regiments for Vascular and Interventional Radiology Procedures (continued) 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) Totally implanted central venous access ports IIb B-R, C-EO S. aureus, S. epidermidis Clean No No consensus 1–2 g cefazolin IV NA Vancomycin recommended in penicillin-allergic patients Tunneled dialysis catheters IIb B-R, C-EO 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 Lower-extremity superficial venous insufficiency treatment Procedure Class of Recommendation Level of Evidence Potential Organ- isms Encountered Procedure Classification Routine Prophy- laxis Recommended IVC filter placement III C-LD, C-EO S. aureus, S. epidermidis Clean No None NA NA NA 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 IIa C-EO 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 IIb C-EO 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 IVC filter retrieval IIb C-EO S. aureus, S. epidermidis, possibly polymicrobial colonic flora including anaerobes

8 ▪Antibiotic Prophylaxis during IR Procedures: Practice Parameter Chehab et al ▪JVIR continued NA Vancomycin or clindamycin- gentamycin recommended for penicillin-allergic patients NA Vancomycin or clindamycin/ gentamycin recommended for penicillin-allergic patients 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 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 First-Choice Antibiotic Suggested Anti- biotic Regimens Other Antibiotic Regimens Comments 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 No consensus (i) 1–2 g ceftriaxone IV single dose; (ii) 1.5–3 g ampicillin/ sulbactam IV every 6 h þ 5 mg/kg gentamycin IV single dose Yes except in routine catheter exchange for low-risk patients Contaminated, dirty Yes for new placement and routine exchanges Clean, clean contaminated Yes No consensus (i) 1 g ceftriaxone IV; (ii) 1.5–3 g ampicillin/ sulbactam Clean contaminated Yes for push and pull type Push type, cefazolin single dose; pull type, cefazolin/ cefalexin for 6 d Clean contaminated, contaminated, or dirty IIb C-LD, C-EO 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 III C-EO S. aureus, S. epidermis Clean No None None NA – Table 2. Suggested Antibiotic Regiments for Vascular and Interventional Radiology Procedures (continued) Percutaneous nephrostomy tubes IIb C-LD, C-EO E. coli, Proteus, Klebsiella, and Enterococcus spp. Percutaneous transhepatic biliary drain and cholecystostomy venolymphatic malformations. Varicocele embolization (transcatheter) TIPS IIb C-LD, C-EO S. aureus, Enterococcus faecalis, E. coli, Klebsiella spp., Lactobacillus acidophilus, Gemella morbillorum, Acinetobacter spp., Streptococcus sanguinis, Streptococcus gallolyticus, and Candida albicans NA Patients with indwelling ureteral catheters, ureteroileal anastomosis should be considered high- risk; vancomycin recommended in penicillin-allergic patients Gastrostomy tube placement IIb B-NR, C-LD Push type, S. aureus, S. epidermis, pull type, S. aureus, S. epidermidis, and oropharyngeal flora (eg, S. viridans (a- hemolytic), Lactobacillus spp., non-diphtheroid Corynebacterium spp., anaerobes Bacteroides spp., Actinobacillus spp.) Procedure Class of Recommendation Level of Evidence Potential Organ- isms Encountered Procedure Classification Routine Prophy- laxis Recommended

Volume ▪▪Number ▪▪Month ▪2018 9 continued NA NA Antibiotics should cover anticipated organisms for empiric treatment and then be adjusted for final culture results (i) 1 g ceftriaxone þ 1.5 g/kg gentamycin, (ii) 160 mg trimethoprim/ 800 mg sulfamethoxazole orally as single dose 1 h before biopsy Metronidazole in combination with ciprofloxacin, levofloxacin, ceftazidime, ampicillin, sulbactam, or cefepime Single-agent regimens for intraabdominal infections: meropenem, imipenem/cilastatin, doripenem, piperacillin/ tazobactam First-Choice Antibiotic Suggested Anti- biotic Regimens Other Antibiotic Regimens Comments No consensus For transrectal prostate biopsy: (i) 500 mg ciprofloxacin þ 1.5 mg/kg gentamycin No consensus In low-risk patients, 1–2 g cefazolin IV In high risk patients, (i) oral levofloxacin 500 mg/d þ oral metronidazole 500 mg twice daily beginning 2 d before and continuing for 14 d after ablation þ 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 No, except for transrectal prostate biopsy No, except in patients with colonized urothelium Yes, especially in high- risk patients (eg history of biliary– enteric anastomosis, cirrhosis, diabetes) Clean, transrectal biopsies, contaminated Clean contaminated, contaminated if sphincter of Oddi dysfunction IIb C-EO S. aureus, S. epidermis Clean Yes NA NA IIb C-EO Skin and respiratory flora Clean, clean contaminated (lung) Table 2. Suggested Antibiotic Regiments for Vascular and Interventional Radiology Procedures (continued) Paracentesis and thoracentesis IIb C-EO 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 I B-R, B-LD Transrectal Gram- negative bacteria Enterococcus spp., E. coli, Bacteroides spp., other anaerobes 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 IIb C-EO Polymicrobial Dirty Yes if not already on antibiotics Location of abscess influences organisms encountered No consensus 1 g ceftriaxone IV Clindamycin/ gentamycin recommended for penicillin-allergic patients Other tumor ablation (lung, adrenal, bone) Renal tumor ablation IIb C-LD, C-EO E. coli, Proteus, Klebsiella spp. Clean contaminated, contaminated if urothelial colonization Procedure Class of Recommendation Level of Evidence Potential Organ- isms Encountered Procedure Classification Routine Prophy- laxis Recommended Liver tumor ablation IIb C-LD, C-EO S. aureus, S. epidermidis, E. coli, Clostridium perfringens, Enterococcus spp.

10 ▪Antibiotic Prophylaxis during IR Procedures: Practice Parameter Chehab et al ▪JVIR NA NA First-Choice Antibiotic Suggested Anti- biotic Regimens Other Antibiotic Regimens Comments 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 IIb C-LD, C-EO S. aureus, S. epidermis Clean No NA NA NA NA AV ¼ arteriovenous; EO ¼ expert opinion; IV ¼ intravenous; IVC ¼ inferior vena cava; LD ¼ limited data; NA ¼ not applicable; NR ¼ nonrandomized; TIPS ¼ transjugular intrahepatic portosystemic shunt. When routine antibiotic prophylaxis is recommend or suggested, please see Appendix C for pediatric dosing recommendations. Table 2. Suggested Antibiotic Regiments for Vascular and Interventional Radiology Procedures (continued) 1–2 g cefazolin IV Vancomycin recommended in penicillin-allergic patients Salivary gland Botox injections IIb C-LD, C-EO S. aureus, S. epidermis Clean No NA NA NA NA Percutaneous cecostomy insertion IIa C-LD, C-EO Polymicrobial-including anaerobes from colonic flora, S. aureus, S. epidermidis Procedure Class of Recommendation Level of Evidence Potential Organ- isms Encountered Procedure Classification Routine Prophy- laxis Recommended* Percutaneous vertebral body augmentation Bone interventions (osteoid osteoma ablation, sclerotherapy)