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Antibiotic prophylaxis for cardiac surgery — are we getting it right?

Frank Shann
Med J Aust 2010; 193 (1): . || doi: 10.5694/j.1326-5377.2010.tb03752.x
Published online: 5 July 2010

To the Editor: In her editorial, Christiansen states that the 2010 edition of Therapeutic guidelines: antibiotic (version 14) is very likely to recommend 24 hours of antibiotic prophylaxis for cardiac surgery,1 rather than the present regimen, which recommends that patients having routine cardiac surgery be given a large dose of cephazolin at induction, with a second dose if the operation is prolonged for more than 3 hours, and no doses after surgery.2 The only evidence presented in support of this proposed change is a single randomised controlled trial that purported to show a higher rate of surgical site infections after a single dose of cephazolin, than after a prolonged, multidose regimen.3 The study was flawed, for two reasons. First, cephazolin was not given until 20–30 minutes after induction of anaesthesia, which is likely to have been too late, because, as Christiansen points out, β-lactams should be given 30–60 minutes before incision.1 Second, the trial was analysed on a per-protocol, rather than an intention-to-treat basis, and 189 of the 1027 participants (18%) were excluded, so the findings may be seriously biased.4


  • Royal Children’s Hospital, Melbourne, VIC.


Correspondence: frank.shann@rch.org.au

  • 1. Christiansen K. Antibiotic prophylaxis for cardiac surgery — are we getting it right? Med J Aust 2010; 192: 117-118. <MJA full text>
  • 2. Antibiotic Expert Group. Therapeutic guidelines: antibiotic, version 13. Melbourne: Therapeutic Guidelines Limited, 2006.
  • 3. Tamayo E, Gualis J, Flórez S, et al. Comparative study of single-dose and 24-hour multiple-dose antibiotic prophylaxis for cardiac surgery. J Thorac Cardiovasc Surg 2008; 136: 1522-1527.
  • 4. Heritier SR, Gebski VJ, Keech AC. Inclusion of patients in clinical trial analysis: the intention-to-treat principle. Med J Aust 2003; 179: 438-440. <MJA full text>
  • 5. Conte JE, Cohen SN, Roe BB, Elashoff RM. Antibiotic prophylaxis and cardiac surgery. A prospective double-blind comparison of single-dose versus multiple-dose regimens. Ann Intern Med 1972; 76: 943-949.
  • 6. Austin TW, Coles JC, Burnett R, Goldbach M. Aortocoronary bypass procedures and sternotomy infections: a study of antistaphylococcal prophylaxis. Can J Surg 1980; 23: 483-485.
  • 7. Nooyen SM, Overbeek BP, Brutel de la Rivière A, et al. Prospective randomised comparison of single-dose versus multiple-dose cefuroxime for prophylaxis in coronary artery bypass grafting. Eur J Clin Microbiol Infect Dis 1994; 13: 1033-1037.
  • 8. McDonald M, Grabsch E, Marshall C, Forbes A. Single- versus multiple-dose antimicrobial prophylaxis for major surgery: a systematic review. ANZ J Surg 1998; 68: 388-396.

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