S U RGI C A L PR O P H YL A X IS FO R C H EM O POR T I N SE R TI O N

I N S TI TU T K A N SE R N EG A R A
V e r s io n 2. 0, 2 02 2

BACKGROUND

Antimicrobial prophylaxis is one of essential measures to minimize risk surgical site

infection (SSI), by decreasing the bacterial load at the incision site. The goal of
antimicrobial prophylaxis is to prevent SSI by reducing the burden of microorganisms
at the surgical site during the operative procedure. Preoperative antibiotics are
warranted if there is high risk of infection or if there is high risk of detrimental
outcomes should infection develop at the surgical site in addition to patient-specific
risk factors.

This guideline applies to totally implantable venous-access port (more commonly

known as ChemoPort) insertion procedure in Institut Kanser Negara. The content of
the guideline is developed based on the best practice and the latest literature
available. Any deviation from the recommendation in this guideline should be
justified and evidence based. This should not displace clinical judgement or
Infectious Diseases specialist consultation when indicated.

OBJECTIVE

The main aim of this guideline is to assist practitioners make informed decisions,
based on latest evidence, on prophylactic antibiotic use for ChemoPort insertion.

CHOICE OF ANTIBIOTICS

First-generation cephalosporins are recommended due to their ease of

administration, desirable duration of action, spectrum of activity against organisms
commonly encountered in surgery, reasonable safety, and low cost. Second- and
third-generation cephalosporins have not been shown to offer clear advantages
over first-generation agents despite theoretically having broader coverage. These
agents are not recommended due to their higher cost, increasing resistance and
adverse events risks.

Allergy history to any drug especially antibiotics must be elicited prior to any
commencement of prophylactic or therapeutic antibiotics. Recommended
antimicrobials:

 In non-allergic patient : Cefazolin

 In beta-lactam allergies : Vancomycin
 Known MRSA Colonization : Cefazolin AND Vancomycin

Note: Vancomycin is not as effective as cefazolin for preventing post-operative

infections caused by methicillin-susceptible Staphylococcus aureus (MSSA)
ANTIBIOTIC TIMING AND DOSING

 In adult:

Administration duration
Antibiotic Dose
before skin incision

< 60 kg 1g

Cefazolin > 60 kg 2g Infusion over 1 hour

> 120 kg 3g

< 75 kg 1g Infusion over 1 hour

Vancomycin
> 75 kg 1.5 g Infusion over 1.5 hours

 In paediatric:

Pre-incision
Antibiotic
dose

Cefazolin 30 mg/kg

Vancomycin 15 mg/kg

 Patient with impaired renal function:

No dose modification is required for antimicrobial prophylaxis purposes. Also, repeat

doses are not recommended as the half-life of the antimicrobial agent is prolonged
in this population.

REPEAT DOSING

Re-administration of antimicrobial prophylaxis is not warranted for patients

undergoing clean procedures, however, can be considered in:

1. Prolonged surgery (> 4 hours)

2. Major blood loss (e.g. > 1.5 L in adults), following fluid resuscitation.

Half-life in Adults Redosing interval from the time of

Antibiotic
with normal renal function first preoperative dose

Cefazolin 1.2 - 2.2 hours 4 hours

Vancomycin 5 – 11 hours Not applicable

METHOD OF ADMINISTRATION

Antibiotic Administration Infusion time

As intravenous bolus:
1. Reconstitute injection cefazolin with
4 mL of water for injection or normal Slow bolus
saline. over 3-5 minutes
2. Dilute the reconstituted solution *for 1g dose ONLY
with 6 mL of water injection or
normal saline
Cefazolin

As intravenous infusion:
1. Reconstitute injection cefazolin with
Intravenous infusion
4 mL of water for injection or normal
over 30 - 60 minutes.
saline
*for 2-3g dose.
2. Dilute the reconstituted solution with
100 mL of normal saline

As intravenous infusion:
1. Reconstitute vancomycin with 10
Intravenous infusion
Vancomycin mL of water for injection
over 2 hours
2. Dilute the reconstituted solution with
100 mL normal saline

(Antimicrobial stewardship committee HCTM UKM, 2018; Chehab et al., 2018; Ministry of Health
Malaysia, 2019; Pharmaceutical Services Programme of Ministry of Health Malaysia, 2021; Anderson
and Sexton, 2022; South Australian expert Advisory Group on Antimicrobial Resistance (SAAGAR),
2022)
Cross References

Anderson, D.J. and Sexton, D.J. (2022) Antimicrobial prophylaxis for prevention of
surgical site infection in adults - UpToDate. Available at:
https://www.uptodate.com/contents/antimicrobial-prophylaxis-for-prevention-of-
surgical-site-infection-in-adults (Accessed: 15 September 2022).

Antimicrobial stewardship committee HCTM UKM (2018) HCTM PPUKM Surgical

Prophylaxis Guide 1st Edition. Available at: https://hctm.ukm.my/farmasi/wp-
content/uploads/2020/08/PPUKM-Surgical-Prophylaxis-2018-Oct18-3.pdf (Accessed:
15 September 2022).

Chehab, M.A. et al. (2018) ‘Adult and Pediatric Antibiotic Prophylaxis during
Vascular and IR Procedures: A Society of Interventional Radiology Practice
Parameter Update Endorsed by the Cardiovascular and Interventional Radiological
Society of Europe and the Canadian Association for Interventional Radiology’,
Journal of Vascular and Interventional Radiology, 29(11), pp. 1483-1501.e2. Available
at: https://doi.org/10.1016/J.JVIR.2018.06.007.

Ministry of Health Malaysia (2019) National Antibiotic Guideline. Available at:

https://www.pharmacy.gov.my/v2/sites/default/files/document-upload/national-
antimicrobial-guideline-2019-full-version-3rd-edition.pdf (Accessed: 15 September
2022).

Pharmaceutical Services Programme of Ministry of Health Malaysia (2021) Dilution

Guideline For Injectable Drugs. Available at:
https://www.pharmacy.gov.my/v2/sites/default/files/document-upload/dilution-
guideline-injectable-drugs-part-i-antimicrobial-april-2021-pdf_0.pdf (Accessed: 15
September 2022).

South Australian expert Advisory Group on Antimicrobial Resistance (SAAGAR) (2022)

Surgical Antimicrobial Prophylaxis Clinical Guideline v3.0. Available at:
https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+inte
rnet/resources/policies/surgical+antimicrobial+prophylaxis+clinical+guideline
(Accessed: 15 September 2022).

DOCUMENT OWNERSHIP

Main authors Antimicrobial Stewardship Team of IKN

External Reviewers Dr Tay Kim Heng
Version Number 2.0
Approved Date 13 / 12 / 2022