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Knisely A, Iniesta MD, Marten CA, Chisholm G, Schmeler KM, Taylor JS. Metronidazole and cefazolin vs cefazolin alone for surgical site infection prophylaxis in gynecologic surgery at a comprehensive cancer center. Am J Obstet Gynecol 2024; 231:326.e1-326.e13. [PMID: 38599478 DOI: 10.1016/j.ajog.2024.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Surgical site infection is one of the most common complications of gynecologic cancer surgery. Current guidelines recommend the administration of cefazolin preoperatively to reduce surgical site infection rates for patients undergoing clean-contaminated surgeries such as hysterectomy. OBJECTIVE To evaluate the impact of a quality improvement project adding metronidazole to cefazolin for antibiotic prophylaxis on surgical site infection rate for women undergoing gynecologic surgery at a comprehensive cancer center. STUDY DESIGN This retrospective, single-center cohort study included patients who underwent surgery in the gynecologic oncology department from May 2017 to June 2023. Patients with penicillin allergies and those undergoing concomitant bowel resections and/or joint cases were excluded. The preintervention group patients had surgery from May 2017 to April 2022, and the postintervention group patients had surgery from April 2022 to June 2023. The primary outcome was a 30-day surgical site infection rate. Sensitivity analyses were performed to compare surgical site infection rates on the basis of actual antibiotics received and for those who had a hysterectomy. Factors independently associated with surgical site infection were identified using a multivariable logistic regression model adjusting for confounding variables. RESULTS Of 3343 patients, 2572 (76.9%) and 771 (23.1%) were in the pre-post intervention groups, respectively. Most patients (74.7%) had a hysterectomy performed. Thirty-four percent of cases were for nononcologic (benign) indications. Preintervention patients were more likely to receive appropriate preoperative antibiotics (95.6% vs 90.7%; P<.001). The overall surgical site infection rate before the intervention was 4.7% compared with 2.6% after (P=.010). The surgical site infection rate for all patients who underwent hysterectomy was 4.9% (preintervention) vs 2.8% (postintervention) (P=.036); a similar trend was seen for benign cases (4.4% vs 2.4%; P=.159). On multivariable analysis, the odds ratio for surgical site infection was 0.49 (95% confidence interval, 0.38-0.63) for the postintervention compared with the preintervention group (P<.001). In a sensitivity analysis (n=3087), the surgical site infection rate was 4.5% for those who received cefazolin alone compared with 2.3% for those who received cefazolin plus metronidazole, with significantly decreased odds of surgical site infection for the cefazolin plus metronidazole group (adjusted odds ratio, 0.40 [95% confidence interval, 0.30-0.53]; P<.001). Among only those who had a hysterectomy performed, the odds of surgical site infection were significantly reduced for those in the postintervention group (adjusted odds ratio, 0.63 [95% confidence interval, 0.47-0.86]; P=.003). CONCLUSION The addition of metronidazole to cefazolin before gynecologic surgery decreased the surgical site infection rate by half, even after accounting for other known predictors of surgical site infection and differences in practice patterns over time. Providers should consider this combination regimen in women undergoing gynecologic surgery, especially for cases involving hysterectomy.
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Affiliation(s)
- Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claire A Marten
- Division of Pharmacy, Department of Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gary Chisholm
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Zheng T, Wang R, Wu C, Li S, Cao G, Zhang Y, Bu X, Jiang J, Kong Z, Miao Y, Zheng L, Tao G, Tao Q, Ding Z, Wang P, Ren J. Assessing morinidazole for surgical site infection in class III wounds prevention: a multi-centre, randomized, single-blind, parallel-controlled study. J Hosp Infect 2024; 151:186-194. [PMID: 38964506 DOI: 10.1016/j.jhin.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/11/2024] [Accepted: 06/15/2024] [Indexed: 07/06/2024]
Abstract
INTRODUCTION Surgical site infections (SSIs) are significant postoperative risks; antibiotic prophylaxis is crucial due to the presence of anaerobic bacteria. This study investigated the efficacy and safety of a novel nitroimidazole, morinidazole, in SSI reduction in class III wounds, as there is currently a lack of evidence in the existing literature. METHODS A multi-centre randomized clinical trial was conducted from December 2020 to October 2022 in the general surgery departments of 12 tertiary hospitals in China, including 459 patients in two treatment groups using morinidazole plus ceftriaxone or ceftriaxone alone. Efficacy and safety were evaluated including SSI incidence, adverse events, and compliance. Statistical analysis employed SAS 9.4 software. Data analysis was performed from February to May 2023. RESULTS A total of 440 participants (median (interquartile range, IQR) age, 63.0 (54.0, 70.0) years; 282 males (64.09%); 437 patients were of Han race (99.32%) and were randomized. The experimental group exhibited a significantly lower SSI rate compared with the control group (31 (14.49%) vs 52 (23.01%); risk difference, 1.76%, 95% confidence interval (CI) 1.08-2.88%; P=0.0224). The superficial incisional site infections revealed a marked reduction in the experimental group (12 (5.61%) vs 31 (13.37%); risk difference, 2.68%; 95% CI 1.34-5.36%; P=0.0042). Non-surgical site infections, severe postoperative complications, and total adverse events showed no statistically significant differences between the groups (P>0.05). CONCLUSION The significant decrease in SSI rates and superficial incisional infections demonstrates morinidazole to be a valuable prophylactic antibiotic. Our findings provide valuable insights for clinical practice, where this new-generation nitroimidazole can play a crucial role in SSI prevention.
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Affiliation(s)
- T Zheng
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - R Wang
- Department of General Surgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - C Wu
- Department of Emergency Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - S Li
- Department of Emergency Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - G Cao
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Y Zhang
- Department of Gastrointestinal Surgery, The People's Hospital of Maanshan, Maanshan, China
| | - X Bu
- Department of General Surgery, The First People's Hospital of Zhenjiang, Affiliated People's Hospital of Jiangsu University, Zhenjiang, China
| | - J Jiang
- Department of General Surgery, Changshu No. 1 People's Hospital, Affiliated Changshu Hospital of Soochow University, Suzhou, China
| | - Z Kong
- Department of General Surgery, The First People's Hospital of Taicang, Taicang Affiliated Hospital of Soochow University, Suzhou, China
| | - Y Miao
- The General Surgery Department of Second People's Hospital of Lianyungang & The General Surgery Department Oncology Hospital of Lianyungang, Lianyungang, China
| | - L Zheng
- General Surgery Department. Nanjing Jiangbei Hospital, Nanjing, China
| | - G Tao
- Department of General Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Q Tao
- Department of General Surgery, Zhongda Hospital, Southeast University, Nanjing, China
| | - Z Ding
- Department of General Surgery, Wuxi Traditional Chinese Medicine Hospital Affiliated to Nanjing Traditional Chinese Medicine University, Wuxi, China
| | - P Wang
- Department of Emergency Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - J Ren
- Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China.
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Ribero L, Santía MC, Borchardt K, Zabaneh F, Beck A, Sadhu A, Edwards K, Harrelson M, Pinales-Rodriguez A, Yates EM, Ramirez PT. Surgical site infection prevention bundle in gynecology oncology surgery: a key element in the implementation of an enhanced recovery after surgery (ERAS) program. Int J Gynecol Cancer 2024:ijgc-2024-005423. [PMID: 38876786 DOI: 10.1136/ijgc-2024-005423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
Surgical site infection rates are among 5-35% in all gynecologic oncology procedures. Such infections lead to increased patient morbidity, reduction in quality of life, higher likelihood of readmissions, and reinterventions, which contribute directly to mortality and increase in health-related costs. Some of these are potentially preventable by applying evidence-based strategies in the peri-operative patient setting. The objective of this review is to provide recommendations for the individual components that most commonly comprise the surgical site infection prevention bundles that could be implemented in gynecologic oncology procedures. We searched articles from relevant publications with specific topics related to each surgical site infection intervention chosen to be reviewed. Studies on each topic were selected with an emphasis on meta-analyses, systematic reviews, randomized control studies, non-randomized controlled studies, reviews, clinical practice guidelines, and case series. Data synthesis was done through content and thematic analysis to identify key themes in the included studies. This review intends to serve as the most up-to-date frame of evidence-based peri-operative care in our specialty and could serve as the first initiative to introduce an enhanced recovery after surgery (ERAS) program.
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Affiliation(s)
- Lucia Ribero
- Division of Gynecologic Surgery, European Institute of Oncology, Milan, Italy
| | - María Clara Santía
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Kathleen Borchardt
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Firaz Zabaneh
- Department of System Infection Control, Houston Methodist Hospital, Houston, Texas, USA
| | - Amanda Beck
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Archana Sadhu
- Department of Endocrinology, Houston Methodist Hospital, Houston, Texas, USA
| | - Karen Edwards
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Monica Harrelson
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Aimee Pinales-Rodriguez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Elise Mann Yates
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
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Lin Z, Chen X. Comparison of the Efficacy of Cephalosporins and Non-cephalosporins in Preventing Surgical Site Infections in Colorectal Surgery Patients: An Updated Systematic Review and Meta-Analysis. Am Surg 2024:31348241259037. [PMID: 38867547 DOI: 10.1177/00031348241259037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
OBJECTIVE This study aims to compare the efficacy of cephalosporin and non-cephalosporin antibiotics in preventing surgical site infections (SSIs) in patients undergoing colorectal surgery, providing a scientific basis for the selection of perioperative antibiotics through systematic review and meta-analysis. METHODS Adhering to the PRISMA guidelines, this research employed an extensive literature search strategy across multiple databases to identify relevant studies, including randomized controlled trials (RCTs) and observational studies. Inclusion criteria were studies on adults undergoing colorectal surgery who received preoperative prophylaxis with either cephalosporin or non-cephalosporin antibiotics. Exclusion criteria included preoperative diagnosis of infectious diseases and preoperative use of antimicrobial agents. Meta-analysis was conducted using RevMan 5.3 software to assess the effectiveness of both antibiotic classes in preventing SSIs, including subgroup analyses. RESULTS Eight studies met the inclusion criteria, comprising 872 patients. Meta-analysis revealed that the incidence of SSI in the cephalosporin group was lower than in the non-cephalosporin group (14.8% vs 25.1%), with statistical significance (OR = 1.94, 95% CI: 1.38-2.74, PP = =0.0001). However, no significant difference in SSI risk was observed between the groups within 30 days (OR = =1.92, 95% CI: 1.08-3.42). Subgroup analysis indicated that higher-quality studies were associated with larger effect sizes. CONCLUSION This study suggests that cephalosporin antibiotics may be superior to non-cephalosporins in preventing SSIs following colorectal surgery, especially in the short term. However, their long-term efficacy in SSI prevention may be similar. The selection of perioperative antibiotics should consider factors such as the antimicrobial spectrum, pharmacokinetic properties, and bacterial resistance.
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Affiliation(s)
- Zhenxi Lin
- Department of Pharmacy, The 95th Hospital of Putian, Putian, China
| | - Xuebai Chen
- Department of Pharmacy, The 95th Hospital of Putian, Putian, China
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Huber D, Hurni Y. Sentinel Lymph Node Mapping by Retroperitoneal vNOTES for Uterus-Confined Malignancies: A Standardized 10-Step Approach. Cancers (Basel) 2024; 16:2142. [PMID: 38893261 PMCID: PMC11171674 DOI: 10.3390/cancers16112142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/22/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
(1) Background: Sentinel lymph node (SLN) mapping represents an accurate and feasible technique for the surgical staging of endometrial and cervical cancer. This is commonly performed by conventional laparoscopy or robotic-assisted laparoscopy, but in recent years, a new retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach has been described and developed by Jan Baekelandt. This technique provides easy visualization of lymphatic afferent vessels and pelvic lymph nodes, early SLN assessment, and a coherent mapping methodology following the lymphatic flow from caudal to cranial. However, only a few publications have reported it. Following the IDEAL (Idea Development Exploration Assessment Long-term follow-up) framework, research concerning this technique is in Stage 2a, with only small case series as evidence of its feasibility. Its standardized description appears necessary to provide the surgical homogeneity required to move further. (2) Methods: Description of a standardized approach for retroperitoneal pelvic SLN mapping by vNOTES. (3) Results: We describe a 10-step approach to successfully perform retroperitoneal vNOTES SLN mapping, including pre-, intra-, and postoperative management. (4) Conclusions: This IDEAL Stage 2a study could help other surgeons approach this new technique, and it proposes a common methodology necessary for evolving through future IDEAL Stage 2b (multi-center studies) and Stage 3 (randomized controlled trials) studies.
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Affiliation(s)
- Daniela Huber
- Department of Gynecology and Obstetrics, Valais Hospital, Av. Du Grand-Champsec 80, 1951 Sion, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Bd. de la Cluse 30, 1205 Geneva, Switzerland;
| | - Yannick Hurni
- Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Bd. de la Cluse 30, 1205 Geneva, Switzerland;
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Park LJ, D'Souza D, Kazi T, Rodriguez F, Griffiths C, McKechnie T, Mertz D, Serrano PE. Comparing cefazolin/ metronidazole, piperacillin-tazobactam, or c efoxitin as surgical antibiotic prophylaxis in patients undergoing pancreaticoduodenectomy: A retrospective cohort study. J Surg Oncol 2024; 129:1413-1419. [PMID: 38664921 DOI: 10.1002/jso.27641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/15/2024] [Accepted: 04/01/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Preoperative antibiotic options for pancreaticoduodenectomy (PD) include cefoxitin (CX), piperacillin-tazobactam (PT), or combined cefazolin and metronidazole (CM). Recent studies suggest the superiority of PT over CX, but evidence for CM is unclear. OBJECTIVE To explore the impact of preoperative antibiotic selection (CM vs. PT and CX vs. PT) on the development of surgical site infections (SSI). METHODS Consecutive adult patients at one institution who underwent PD from November 2017 to December 2021 and received either CM, PT, or CX preoperatively, were included. The primary outcome was SSI. Secondary outcomes included postoperative infections and clinically significant postoperative pancreatic fistula (POPF). Logistic regression models were used. RESULTS Among 127 patients included in the study, PT, CM, and CX were administered in 46 (36.2%), 44 (34.6%), and 37 (29.4%) patients, respectively. There were 32 (27.1%) SSI, 20 (36.1%) infections, and 21 (22.9%) POPF events. PT use was associated with reduced risk of SSI compared to CX (OR: 0.32, 95% CI: 0.11-0.89, p = 0.03), but there was no difference as compared to CM (OR: 0.75, 95% CI: 0.27-2.13, p = 0.59). There were no differences in secondary outcomes. CONCLUSION PT reduced SSI rates compared to CX but was no different to CM among patients undergoing PD at our center.
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Affiliation(s)
- Lily J Park
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Daniel D'Souza
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tania Kazi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Felipe Rodriguez
- NYU Langone Health, New York University, New York, New York, USA
| | - Christopher Griffiths
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tyler McKechnie
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Medicine, Division of Infectious Diseases, McMaster University, Hamilton, Ontario, Canada
| | - Pablo E Serrano
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
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Knochenhauer HE, Lim SL, Havrilesky LJ, Dotters-Katz SK. Screening for Bacterial Vaginosis Prior to Delivery: A Cost-Effectiveness Study. Am J Perinatol 2024. [PMID: 38688320 DOI: 10.1055/a-2316-8955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
OBJECTIVE The objective of this study was to compare the cost and effectiveness of three strategies for screening and/or treating bacterial vaginosis (BV) during pregnancy prior to delivery: (1) the current standard of care was neither test nor treat for BV (Treat None); (2) test all patients for BV at 36 weeks' gestation; treat if positive (Test Treat); and (3) treat all patients undergoing cesarean delivery with intravenous metronidazole at time of surgery (Treat All Cesarean). Effectiveness was defined as avoidance of postpartum surgical site infection (SSI). STUDY DESIGN A decision analytic cost-effectiveness model was designed from a third-party payer perspective using clinical and cost estimates obtained from the literature, American College of Surgeons National Surgical Quality Improvement Program participant use file (2005-2019), 2019 National Vital Statistics, Medicare costs, and wholesale drug costs. Cost estimates were inflated to 2020 U.S. dollars. For this study, effectiveness was defined as avoidance of postpartum SSIs. RESULTS The base case analysis that is the current standard of care of not routinely testing and treating patients for BV (Treat None) was the most expensive and least effective strategy, with a mean cost of $59.16 and infection rate of 3.71%. Empirically treating all patients for BV without testing (Treat All Cesarean) was the most effective and the least expensive strategy, with a mean cost of $53.50 and an infection rate of 2.75%. Testing all patients for BV and treating those positive for BV (Test Treat) was also relatively inexpensive and effective, with an infection rate of 2.94% and mean cost of $57.05. Compared with Treat None, we would expect the Treat All Cesarean strategy to reduce the infection rate by 26%. CONCLUSION These findings suggest that treating pregnant patients with intravenous metronidazole at time of cesarean delivery could be an effective and cost-saving strategy. Testing and treating for BV could also be considered a reasonable strategy, as it has the added benefit of preserving antibiotic stewardship. In no analysis was the standard of care strategy of neither testing nor treating for BV before delivery the preferred strategy. KEY POINTS · BV colonization may increase surgical site infection risk after cesarean section.. · Treatment of BV before or during delivery may be cost-saving strategies as treatment could prevent costs associated with infection.. · Further study is needed to best balance the risk of surgical site infection with antibiotic stewardship..
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Affiliation(s)
- Hope E Knochenhauer
- Department of Obstetrics and Gynecolgy, Staten Island University, Northwell Health, Staten Island, New York
| | - Stephanie L Lim
- Department of Obstetrics and Gynecology, Duke University, Duke University Medical Center, Durham, North Carolina
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University, Duke University Medical Center, Durham, North Carolina
| | - Sarah K Dotters-Katz
- Department of Obstetrics and Gynecology, Duke University, Duke University Medical Center, Durham, North Carolina
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Pradhan T, Zhang H, Kadesh A, Buskwofie A, Patankar S, Menon S, Ryntz T, Grimes CL. PROJECT PREVENT: a randomized controlled trial of preoperative vaginal metronidazole to decrease patient issues and infections after hysterectomy. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2024; 6:e000241. [PMID: 38596254 PMCID: PMC11002362 DOI: 10.1136/bmjsit-2023-000241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/20/2024] [Indexed: 04/11/2024] Open
Abstract
Objectives To evaluate if vaginal metronidazole for 5 days before hysterectomy decreases postoperative infections and patient issues. Design This randomized trial compared vaginal metronidazole for 5 days before a scheduled hysterectomy to no intervention. Sample size calculation was based on a 20% difference in issues and infection (30% incidence and 10% in the intervention arm) with 80% power and an alpha error of 0.05 and indicated 62 subjects needed in each arm. Setting Outpatient gynecology clinics at a single academic institution. Participants 154 subjects were screened for eligibility between July 2020 and September 2022. 133 underwent hysterectomy including 68 subjects (51.1%) randomized to the metronidazole and 65 (48.9%) controls. Overall, the population was racially and ethnically diverse. There was no significant difference in characteristics between the two groups. Interventions Vaginal metronidazole for 5 days before hysterectomy. Main outcome measures Postoperative patient issues and documented postoperative infections at 4-8 weeks after surgery. Results There was no difference in the composite rate of patient-reported issues and/or documented postoperative infection (53/133 (39.8%) with no difference between groups (29/68 (42.6%) vs 24/65 (36.9%), p=0.50). There was no difference in patient-reported issues which was 51/133 (38.3%) with no difference between groups (28/68 (41.2%) vs 23/65 (33.8%), p=0.49) or in documented infections with a rate of 25/133 (18.8%) with no significant difference between groups (15/68 (22.0%) vs 10/65 (15.4%), p=0.33). In the intervention arm, the compliance rate was 73.5% for all 5 days of vaginal metronidazole, and a per-protocol analysis was performed which resulted in no significant difference between groups. Conclusions There is insufficient evidence to suggest a significant benefit of preoperative vaginal metronidazole to prevent surgical site infections and postoperative patient issues in patients undergoing hysterectomy. Trial registration number ClinicalTrials.gov, NCT04478617.
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Affiliation(s)
- Tana Pradhan
- Obstetrics and Gynecology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Helen Zhang
- Obstetrics and Gynecology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Amanda Kadesh
- Obstetrics and Gynecology, Jefferson Abington Hospital, Abington, Pennsylvania, USA
| | - Ama Buskwofie
- Obstetrics and Gynecology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Sonali Patankar
- Obstetrics and Gynecology, RWJ Barnabas Health, New Brunswick, New Jersey, USA
| | - Sharifa Menon
- Obstetrics and Gynecology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Timothy Ryntz
- Obstetrics and Gynecology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Cara L. Grimes
- Obstetrics and Gynecology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
- Urology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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López CC, Villegas-Echeverri JD, De Los Rios JF, Vásquez-Trespalacios EM, Arango A, Cifuentes C, Orjuela J, Valencia V, Cárdenas L, López JD, López JD, Zambrano CP, Gómez SM, Bastidas C, Silva JB, Gallego DE. Metronidazole for Prevention of Pelvic Cellulitis and Abscess after Laparoscopic Hysterectomy: A Triple-blinded, Randomized, Placebo-controlled Clinical Trial. J Minim Invasive Gynecol 2023; 30:912-918. [PMID: 37463650 DOI: 10.1016/j.jmig.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 07/02/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023]
Abstract
STUDY OBJECTIVE To determine whether a postoperative 5-day treatment schedule with vaginal metronidazole added to conventional antibiotic prophylaxis with 2 g cefazolin modifies the risk of pelvic cellulitis (PC) and pelvic abscess (PA) after total laparoscopic hysterectomy (TLH). DESIGN A randomized, controlled, triple-blind, multicenter clinical trial. SETTING Two centers dedicated to minimally invasive gynecologic surgery in Colombia. PATIENTS A total of 574 patients were taken to TLH because of benign diseases. INTERVENTION Patients taken to TLH were divided into 2 groups (treatment group, cefazolin 2 g intravenous single dose before surgery + metronidazole vaginal ovules for 5 days postoperatively, control group: cefazolin 2 g intravenous single dose + placebo vaginal ovules for 5 days postoperatively). MEASUREMENTS AND MAIN RESULTS The absolute frequency (AF) of PC and PA and their relationship with the presence of bacterial vaginosis (BV) were measured. There was no difference in AF of PC (AF, 2/285 [0.7%] vs 5/284 [1.7%] in the treatment and placebo groups, respectively; risk ratio, 1.75; 95% confidence interval, 0.54-5.65; p = .261), nor for PA (AF, 0/285 [0%] vs 2/289 [0.7%]; p = .159, in the treatment and placebo groups, respectively). The incidence of BV was higher in the metronidazole group than the placebo group (42.5% vs 33.4%, p = .026). CONCLUSION The use of vaginal metronidazole ovules during the first 5 days in postoperative TLH added to conventional cefazolin prophylaxis does not prevent the development of PC or PA, regardless of the patient's diagnosis of BV.
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Affiliation(s)
- Claudia C López
- Clínica del Prado (Drs. De Los Ríos, C. López, Arango, Cifuentes, Orjuela, and Gallego), Medellín, Colombia
| | | | - Jose F De Los Rios
- Clínica del Prado (Drs. De Los Ríos, C. López, Arango, Cifuentes, Orjuela, and Gallego), Medellín, Colombia
| | | | - Adriana Arango
- Clínica del Prado (Drs. De Los Ríos, C. López, Arango, Cifuentes, Orjuela, and Gallego), Medellín, Colombia
| | - Carolina Cifuentes
- Clínica del Prado (Drs. De Los Ríos, C. López, Arango, Cifuentes, Orjuela, and Gallego), Medellín, Colombia
| | - Jerutsa Orjuela
- Clínica del Prado (Drs. De Los Ríos, C. López, Arango, Cifuentes, Orjuela, and Gallego), Medellín, Colombia
| | - Victor Valencia
- Facultad de Medicina (Drs. Valencia, Cárdenas, Bareño, Gómez, and Vásquez), Universidad CES, Medellín, Colombia
| | - Lina Cárdenas
- Facultad de Medicina (Drs. Valencia, Cárdenas, Bareño, Gómez, and Vásquez), Universidad CES, Medellín, Colombia
| | - José Duvan López
- Unidad Algia (Drs. Villegas, J. López, J. López, Zambrano, and Bastidas)
| | - Jorge Darío López
- Unidad Algia (Drs. Villegas, J. López, J. López, Zambrano, and Bastidas)
| | - Claudia P Zambrano
- Unidad Algia (Drs. Villegas, J. López, J. López, Zambrano, and Bastidas)
| | - Sandra M Gómez
- Facultad de Medicina (Drs. Valencia, Cárdenas, Bareño, Gómez, and Vásquez), Universidad CES, Medellín, Colombia
| | - Claudia Bastidas
- Unidad Algia (Drs. Villegas, J. López, J. López, Zambrano, and Bastidas)
| | - Jose Bareño Silva
- Facultad de Medicina (Drs. Valencia, Cárdenas, Bareño, Gómez, and Vásquez), Universidad CES, Medellín, Colombia
| | - Diego E Gallego
- Clínica del Prado (Drs. De Los Ríos, C. López, Arango, Cifuentes, Orjuela, and Gallego), Medellín, Colombia.
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10
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Okamura A, Isono W, Tsuchiya A, Honda M, Saito A, Tsuchiya H, Matsuyama R, Fujimoto A, Nishii O. Preventive effect of metronidazole vaginal tablets on vaginal bacteria-related postoperative complications with total laparoscopic hysterectomy. J Med Case Rep 2023; 17:47. [PMID: 36782233 PMCID: PMC9926539 DOI: 10.1186/s13256-023-03789-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 01/23/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND The use of total laparoscopic hysterectomy is increasing. However, as with conventional abdominal hysterectomy, vaginal bacteria-related postoperative complications need to be managed in total laparoscopic hysterectomy. Therefore, we started to combine metronidazole vaginal tablets with intravenous administration of cephem antibiotics immediately before starting surgery to reduce complications. To evaluate the effect of this combination, and to determine the risk factors for these complications, we retrospectively collected medical records from our hospital and performed a multivariate analysis. METHODS We reviewed the medical records of 520 patients who underwent total laparoscopic hysterectomy from 1 January 2015 to 31 December 2021. Among these cases, we identified 16 cases as having vaginal bacteria-related postoperative complications, defined as needing more than one additional day for treatment of postoperative complications, namely postoperative infection (10 cases) and vaginal dehiscence (6 cases). First, we evaluate the effect of metronidazole vaginal tablets by dividing the patients into two groups according to whether metronidazole vaginal tablets were used, and comparing the vaginal bacteria-related postoperative complication rates and other indices. Second, we performed a multivariate logistic regression analysis to assess the influence of each of 17 representative factors, including patient characteristics and symptoms, uterus and leiomyoma sizes, concomitant procedures such as laparoscopic cystectomy and pelvic lymphadenectomy, and others. RESULTS In the multivariate analysis of the 520 cases, we confirmed that the use of metronidazole vaginal tablets could reduce the vaginal bacteria-related postoperative complications rate by more than half (odds ratio, 0.36). In addition to metronidazole vaginal tablets use, concomitant laparoscopic cystectomy and blood transfusion were associated with significant increases in the vaginal bacteria-related postoperative complication rate. CONCLUSIONS The effect of the addition of metronidazole vaginal tablets to pre- and postsurgical treatment on the reduction of vaginal bacteria-related postoperative complications was confirmed. This easy, safe, and low-cost method may improve the management of total laparoscopic hysterectomy.
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Affiliation(s)
- Asuka Okamura
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1, Futago, Takatsu-Ku, Kawasaki, Kanagawa 213-8507 Japan
| | - Wataru Isono
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1, Futago, Takatsu-Ku, Kawasaki, Kanagawa 213-8507 Japan
| | - Akira Tsuchiya
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1, Futago, Takatsu-Ku, Kawasaki, Kanagawa 213-8507 Japan
| | - Michiko Honda
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1, Futago, Takatsu-Ku, Kawasaki, Kanagawa 213-8507 Japan
| | - Ako Saito
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1, Futago, Takatsu-Ku, Kawasaki, Kanagawa 213-8507 Japan
| | - Hiroko Tsuchiya
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1, Futago, Takatsu-Ku, Kawasaki, Kanagawa 213-8507 Japan
| | - Reiko Matsuyama
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1, Futago, Takatsu-Ku, Kawasaki, Kanagawa 213-8507 Japan
| | - Akihisa Fujimoto
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1, Futago, Takatsu-Ku, Kawasaki, Kanagawa 213-8507 Japan
| | - Osamu Nishii
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1, Futago, Takatsu-Ku, Kawasaki, Kanagawa 213-8507 Japan
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11
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Reduction in Rates of Symptomatic Urinary Tract Infection After Pelvic Reconstructive Surgery: A Quality Improvement Analysis. UROGYNECOLOGY (HAGERSTOWN, MD.) 2022; 28:763-769. [PMID: 36288115 DOI: 10.1097/spv.0000000000001242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Urinary tract infections contribute to high health care costs. OBJECTIVE This study aimed to determine if a combination of interventions was successful at reducing the rate of postoperative symptomatic urinary tract infections (SUTIs) in a female pelvic medicine and reconstructive surgery (FPMRS) practice. STUDY DESIGN Observational, retrospective quality improvement analysis looking at the rate of postoperative SUTI within 30 days of surgery in women who underwent gynecologic surgery performed by an FPMRS surgeon from October 2015 to October 2019. Symptomatic urinary tract infection was defined by symptoms and urinalysis, positive urine culture, or treatment for cystitis or urethritis within 30 days of surgery. Interventions were implemented between 2015 and 2016: perioperative cranberry use, intraoperative protocols for catheterization, and postoperative protocols for urinary retention management. In 2018, we added metronidazole to cefazolin for antibiotic prophylaxis. We developed a multivariable logistic regression to determine if postoperative SUTI rates decreased over the study period with adjustment for clustering by surgeons, patient factors, and surgery type. RESULTS Of 2,389 procedures performed, 284 (11.8%) involved patients who had an SUTI within 30 days of surgery. The annual infection rate decreased 50% (year 1, 14.7%; year 4, 7.3%). Adjusting for age, race, body mass index, length of stay, surgery type, and surgeon, the odds of SUTI decreased 19% each year (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.72-0.91; P < 0.001). Compared with women who had other gynecologic procedures, those who underwent vaginal prolapse surgery with or without incontinence procedures (OR, 2.75; 95% CI, 1.35-5.54; P = 0.01) or incontinence surgery alone (OR, 2.65; 95% CI, 1.25-5.62; P = 0.01) were more likely to have an SUTI. CONCLUSION Combining interventions can be highly effective in reducing postoperative SUTI rates.
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12
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Factors associated with surgical-site infection after total laparoscopic hysterectomy. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2022. [DOI: 10.1016/j.lers.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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13
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Miceli LM, Chang OH, Zhang S, Yao M, Propst K. Antimicrobial Stewardship in Patients with Penicillin Allergy Undergoing Hysterectomy for Benign Indications. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2021.0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lia M. Miceli
- Department of Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Olivia H. Chang
- Department of Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Salina Zhang
- Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Katie Propst
- Department of Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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14
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Needens J, Sloane E, Smith-Graham S, Leader T, Bou Zgheib N. Implementation of Novel Perioperative Protocol for Reducing Surgical Site Infections in Gynecologic Surgical Procedures. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2021.0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jordan Needens
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Emily Sloane
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Sydney Smith-Graham
- Ochsner Health, Department of Obstetrics/Gynecology Residency Program, New Orleans, Louisiana, USA
| | - Tori Leader
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Nadim Bou Zgheib
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
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15
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Cowley ES, Jacques L, Powell AM, Al-Niaimi A, Pop-Vicas A. Characterization of bacterial composition of surgical site infections after gynecologic surgery. Am J Obstet Gynecol 2022; 227:345-347. [PMID: 35248576 DOI: 10.1016/j.ajog.2022.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 02/27/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Elise S Cowley
- Department of Bacteriology, University of Wisconsin-Madison, Madison, WI; Microbiology Doctoral Training Program, University of Wisconsin-Madison, Madison, WI
| | - Laura Jacques
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Anna M Powell
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Ahmed Al-Niaimi
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI; Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Aurora Pop-Vicas
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI.
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16
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Salman SG, Rafiq M. Effect of vaginal scrubbing on post-C-section infection. HAMDAN MEDICAL JOURNAL 2022. [DOI: 10.4103/hmj.hmj_5_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Skeith AE, Morgan DM, Schmidt PC. Vaginal preparation with povidone-iodine or chlorhexidine before hysterectomy: a propensity score matched analysis. Am J Obstet Gynecol 2021; 225:560.e1-560.e9. [PMID: 34473965 DOI: 10.1016/j.ajog.2021.08.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 08/20/2021] [Accepted: 08/24/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Antiseptic vaginal preparation is recommended before gynecologic surgery; however, there is a lack of data regarding the effectiveness of different agents. OBJECTIVE To compare rates of postoperative infectious complications and hospital utilization with preoperative vaginal preparation using povidone-iodine or chlorhexidine before hysterectomy. STUDY DESIGN This was a retrospective analysis of patients who underwent hysterectomy for gynecologic indications at 70 hospitals in a statewide surgical collaborative between January 2017 and December 2019. The primary outcome was postoperative infectious complications (including urinary tract infection, surgical site infections involving superficial, deep, or organ space tissues, or cellulitis) within 30 days of surgery. To adjust for confounding, propensity score matching, 1:1 without replacement and with a caliper of.005 was performed to create cohorts that had vaginal preparation with either povidone-iodine or chlorhexidine and did not differ in observable characteristics. We compared the rates of infectious morbidity and hospital utilization (emergency department visits, readmission, reoperation) in the matched cohorts. RESULTS In the statewide collaborative, there were 18,184 patients who received povidone-iodine and 3018 who received chlorhexidine. After propensity score matching of 2935 pairs, the povidone-iodine and chlorhexidine groups did not differ in demographics, comorbidities, choice of preoperative antibiotics, benign vs malignant surgical indication, and surgical approach. Povidone-iodine was associated with a lower rate of infectious morbidity (3.0% vs 4.3%; P=.01), urinary tract infection (1.1% vs 1.7%; P=.03) and emergency department visits (7.9% vs 9.7%; P=.01) than with chlorhexidine. There were nonsignificant trends of lower rates of surgical site infection (2.0% vs 2.7%; P=.07) and reoperation (1.6% vs 2.1%; P=.18). CONCLUSION This propensity score matched analysis provides evidence that povidone-iodine is preferable to chlorhexidine for vaginal preparation before hysterectomy because of lower rates of infectious morbidity and fewer emergency department visits. However, the absolute differences in infectious morbidity rates were approximately 1%, and in the event of an iodine allergy, chlorhexidine appears to be a reasonable alternative.
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Affiliation(s)
- Ashley E Skeith
- Department of Obstetrics and Gynecology, Michigan Medicine University of Michigan, Ann Arbor, MI.
| | - Daniel M Morgan
- Department of Obstetrics and Gynecology, Michigan Medicine University of Michigan, Ann Arbor, MI
| | - Payton C Schmidt
- Department of Obstetrics and Gynecology, Michigan Medicine University of Michigan, Ann Arbor, MI
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18
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Connect the Dots-October 2021. Obstet Gynecol 2021; 138:678-679. [PMID: 34623081 DOI: 10.1097/aog.0000000000004550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Seaman SJ, Han E, Arora C, Kim JH. Surgical site infections in gynecology: the latest evidence for prevention and management. Curr Opin Obstet Gynecol 2021; 33:296-304. [PMID: 34148977 DOI: 10.1097/gco.0000000000000717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Surgical site infection (SSI) remains one of the most common postoperative surgical complications. Prevention and appropriate treatment remain paramount. RECENT FINDINGS Evidence-based recommendations include recognition and reduction of preoperative risks including hyperglycemia and smoking, treatment of preexisting infections, skin preparation with chlorhexidine gluconate, proper use of preoperative antibiotics, and implementation of prevention bundles. Consideration should be given to the use of dual antibiotic preoperative treatment with cephazolin and metronidazole for all hysterectomies. SUMMARY Despite advancements, SSI in gynecologic surgery remains a major cause of perioperative morbidity and healthcare cost. Modifiable risk factors should be evaluated and patients optimized to the best extent possible prior to surgery. Preoperative risks include obesity, hyperglycemia, smoking, and untreated preexisting infections. Intraoperative risk-reducing strategies include appropriate perioperative antibiotics, correct topical preparation, maintaining normothermia, and minimizing blood loss. Additionally, early recognition and prompt treatment of SSI remain crucial.
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Affiliation(s)
- Sierra J Seaman
- Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, USA
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20
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Cox CK, Bugosh MD, Fenner DE, Smith R, Swenson CW. Antibiotic use during repair of obstetrical anal sphincter injury: a quality improvement initiative. Int J Gynaecol Obstet 2021; 156:95-101. [PMID: 33507531 DOI: 10.1002/ijgo.13623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 12/30/2020] [Accepted: 01/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the effects of a quality improvement initiative regarding the administration of antibiotics at the time of obstetric anal sphincter injury (OASIS) repair. METHODS At University of Michigan-a tertiary care center in Ann Arbor, MI, USA, we implemented a quality improvement intervention aimed at administering a single dose of broad-spectrum antibiotics at the time of OASIS repair. Best practice recommendations and reminders were presented to the department. Cefazolin plus metronidazole or clindamycin plus gentamycin were the recommended antibiotics. The effects of this intervention were assessed based on a chart review of deliveries between January 4, 2014 and February 13, 2019, which included patient data both pre-initiative and post-initiative to compare the prevalence of antibiotic use at the time of OASIS repair. RESULTS Recommended antibiotic use increased from 0.3% (1/372) pre-initiative to 75.7% (106/140) post-initiative (P < 0.001), and any antibiotic use increased from 6.5% (24/372) to 82.9% (116/140, P < 0.001). The proportion of cases complicated by wound infection/breakdown decreased by 55% after the quality improvement intervention (3.2% pre-intervention vs 1.4% post-intervention, P = 0.22). CONCLUSION Following a departmental quality improvement intervention aimed at increasing antibiotic administration at the time of OASIS repair, antibiotic use increased 13-fold. Although underpowered to detect a significant difference in wound complications, our study showed a clinically meaningful decrease in wound infection/breakdown with antibiotic administration.
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Affiliation(s)
- Caroline K Cox
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Meghan D Bugosh
- IHA Obstetrics and Gynecology, Ann Arbor, MI, USA.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Dee E Fenner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Roger Smith
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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21
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Brown O, Geynisman-Tan J, Gillingham A, Collins S, Lewicky-Gaupp C, Kenton K, Mueller M. Minimizing Risks in Minimally Invasive Surgery: Rates of Surgical Site Infection Across Subtypes of Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2020; 27:1370-1376.e1. [DOI: 10.1016/j.jmig.2019.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 11/30/2022]
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22
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Ni T, Meng Y, Li Y, Chen Q, Huang Y, Wang L, Qian X, Wang Y. <p>Effect of Time Interval Between LEEP and Subsequent Hysterectomy on Postoperative Infectious Morbidity</p>. Ther Clin Risk Manag 2020; 16:839-847. [PMID: 32982256 PMCID: PMC7490066 DOI: 10.2147/tcrm.s270590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/21/2020] [Indexed: 11/23/2022] Open
Abstract
Objective This study aimed to provide insight into the effect of time interval between loop electrosurgical excision procedure (LEEP) and subsequent hysterectomy on postoperative infectious morbidity in cervical neoplasia patients. Methods In this retrospective cohort study, a total of 1172 medical records of patients who were diagnosed with high grade cervical intraepithelial neoplasia (HSIL) or invasive cancer underwent a subsequent hysterectomy after LEEP at the International Peace Maternity and Child Health Hospital (IPMCH) in Shanghai, China from January 2008 to December 2019 were collected. The study outcome was postoperative infectious morbidity within 30 days after a hysterectomy. Overall and surgical approach specific effect of time interval on infectious morbidity was estimated using logistic regression in crude and adjusted models. Results There was an inverse association between time interval and postoperative infectious morbidity in HSIL or invasive cancer patients (OR=0.99, 95% CI: 0.98–1.00, p=0.0079). When trisecting time interval into three parts, the top tertile time interval (34–90 days) was also inversely associated with infectious morbidity compared with bottom tertile (0–16 days), independent of stage, surgical approach, operative time and estimated blood loss (OR=0.66,95% CI: 0.43–1.00, P=0.0487). A test for interaction between time interval and surgical approach on infectious morbidity was significant (P values for interaction= 0.0352). Longer time interval significantly reduced the risk of infectious morbidity in the laparoscopic group (OR = 0.37, 95% CI: 0.17–0.78), while no statistically significant effects were observed in patients who underwent vaginal or open abdominal hysterectomy. Conclusion The time interval and surgical approach can interactively affect the risk of postoperative infectious morbidity in cervical neoplasia patients who underwent a hysterectomy after LEEP. Our data suggest that compared with vaginal or open abdominal hysterectomy, laparoscopic hysterectomy required a longer time interval (34–90 days) to reduce the risk of infectious morbidity.
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Affiliation(s)
- Ting Ni
- Department of Gynecologic Oncology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai200030, People’s Republic of China
| | - Yaping Meng
- Department of Gynecologic Oncology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai200030, People’s Republic of China
| | - Yuhong Li
- Department of Gynecologic Oncology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai200030, People’s Republic of China
| | - Qinfang Chen
- Department of Gynecologic Oncology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai200030, People’s Republic of China
| | - Yong Huang
- Department of Gynecologic Oncology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai200030, People’s Republic of China
| | - Lihua Wang
- Department of Gynecologic Oncology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai200030, People’s Republic of China
| | - Xiaolei Qian
- Department of Gynecologic Oncology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai200030, People’s Republic of China
| | - Yudong Wang
- Department of Gynecologic Oncology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai200030, People’s Republic of China
- Shanghai Municipal Key Clinical Specialty, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai200030, People’s Republic of China
- Shanghai Key Laboratory of Embryo Original Disease, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai200030, People’s Republic of China
- Correspondence: Yudong Wang Email
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Reduction in abdominal hysterectomy surgical site infection rates after the addition of anaerobic antimicrobial prophylaxis. Infect Control Hosp Epidemiol 2020; 41:1469-1471. [PMID: 32856576 DOI: 10.1017/ice.2020.386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Song N, Gao M, Tian J, Gao Y. Choice for prophylactic antibiotics: Cefazolin plus metronidazole or cefoxitin alone for endometrial cancer surgical staging. J Obstet Gynaecol Res 2020; 46:1864-1870. [PMID: 32558128 DOI: 10.1111/jog.14348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/14/2020] [Accepted: 05/23/2020] [Indexed: 11/29/2022]
Abstract
AIM The use of prophylactic antibiotics has greatly reduced the incidence of surgical site infections after hysterectomy. It is worth discussing which antibiotic is better. The purpose of this study was to investigate the role of the combined utilization of cefazolin and metronidazole for the prevention of surgical site infection in laparoscopic staging surgery of endometrial cancer. METHODS A retrospective analysis was performed on the incidence of surgical site infection in patients with endometrial cancer who underwent laparoscopic surgical staging from January 2000 to June 2019 within 1 month after surgery. Logistic regression model was used for univariate and multivariate analysis. RESULTS A total of 1783 patients were included in this study, of which 641 were treated with cefazoline plus metronidazole (group 1) as a prophylactic antibiotic, while the other 1142 were treated with cefoxitin (group 2). There was no difference in clinical characteristics between the two groups. The rates of surgical site infection in groups 1 and 2 were 3.6% (n = 23) and 5.7% (n = 65), respectively. The most common site of infections was vaginal, with the incidence of 1.7% (n = 11) and 3.3% (n = 38) in groups 1 and 2, respectively. The multivariate analysis disclosed that cefazoline plus metronidazole significantly reduced the incidence of surgical site infections compared with cefoxitin (logistic, odds ratio = 2.213, 95% confidence interval 1.193 to 4.107). CONCLUSION Cefazolin plus metronidazole as prophylactic antibiotics for surgical staging of endometrial cancer can more effectively reduce the incidence of surgical site infections than cefoxitin.
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Affiliation(s)
- Nan Song
- Department of Gynecology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Min Gao
- Department of Gynecology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Juan Tian
- Department of Gynecology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Yunong Gao
- Department of Gynecology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
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Gil-Conesa M, Del-Moral-Luque JA, Climent-Martínez N, Delgado-Iribarren A, Riera-Pérez R, Martín-Caballero C, Campello-Gutiérrez C, Durán-Poveda M, Rodríguez-Caravaca G, Gil-de-Miguel A, Rodríguez-Villar D. [Evaluation of compliance with the antibiotic prophylaxis protocol in hysterectomy. Prospective cohort study]. REVISTA ESPANOLA DE QUIMIOTERAPIA 2020; 33:180-186. [PMID: 32232318 PMCID: PMC7262387 DOI: 10.37201/req/098.2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objetivo Las infecciones relacionadas con la asistencia sanitaria (IRAS) son un problema de salud pública, siendo las infecciones de localización quirúrgica (ILQ) las más frecuentes a nivel hospitalario. El objetivo de este estudio fue evaluar el efecto de la adecuación de la profilaxis antibiótica en la incidencia de infección quirúrgica en pacientes histerectomizadas. Material y métodos Se realizó un estudio de cohortes prospectivo entre octubre de 2009 y diciembre de 2018. Se estudió la incidencia de ILQ durante los primeros 30 días tras la cirugía. Se evaluó el grado de adecuación de la profilaxis antibiótica en histerectomía y el efecto de su inadecuación en la incidencia de infección con el riesgo relativo (RR) ajustado mediante un modelo de regresión logística. Resultados Se estudiaron 1.025 intervenciones en 1.022 mujeres. La incidencia acumulada de ILQ fue del 2,1% (n=22) y la etiología más frecuente Escherichia coli (23,1%) y Proteus mirabilis (23,1%). La profilaxis antibiótica estaba indicada en 1.014 intervenciones (98,9%) administrándose en 1.009 de ellas (99,5%), con una adecuación general al protocolo del 92,5%. La causa principal de no cumplimiento fue el tiempo de inicio (40,9%), seguida por la elección del antibiótico (35,2%). El efecto de la inadecuación de la profilaxis sobre la incidencia de infección fue de RR=0,9; IC95% 0,2-3,9; p>0,05. Conclusiones La adecuación de la profilaxis antibiótica fue muy alta, con una baja incidencia de infección quirúrgica. No se encontró asociación entre adecuación de la profilaxis e incidencia de infección en histerectomía. Se debe insistir en la mejora continua de la vigilancia epidemiológica en ginecología.
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Affiliation(s)
| | | | | | | | | | | | | | | | - G Rodríguez-Caravaca
- Gil Rodríguez-Caravaca, Unidad de Medicina Preventiva, Hospital Universitario Fundación Alcorcón C/ Budapest 1, 28922 Alcorcón (Madrid). Spain.
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Nguyen JMV, Sadeghi M, Gien LT, Covens A, Kupets R, Nathens AB, Vicus D. Impact of a preventive bundle to reduce surgical site infections in gynecologic oncology. Gynecol Oncol 2019; 152:480-485. [DOI: 10.1016/j.ygyno.2018.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/12/2018] [Accepted: 09/06/2018] [Indexed: 12/13/2022]
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Cefazolin as surgical antimicrobial prophylaxis in hysterectomy: A systematic review and meta-analysis of randomized controlled trials. Infect Control Hosp Epidemiol 2018; 40:142-149. [PMID: 30516122 DOI: 10.1017/ice.2018.286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Current practice guidelines recommend cefazolin, cefoxitin, cefotetan, or ampicillin-sulbactam as first-line antibiotic prophylaxis in hysterectomy. We undertook this systematic review and meta-analysis of randomized controlled trials (RCTs) to determine whether cefazolin, with limited antianaerobic spectrum, is as effective in preventing surgical site-infection (SSI) as the other first-choice antimicrobials that have more extensive antianaerobic activity. METHODS We searched PubMed, Scopus, Web of Science, Cochrane Central, and EMBASE for relevant randomized controlled trials (RCT) in any language up to January 23, 2018. We only included trials that measured SSI (our primary outcome) defined as superficial, deep, or organ space. We excluded trials of β-lactams no longer in clinical use. RESULTS In terms of SSI incidence, cefazolin use was not inferior to its comparator in 12 of 13 individual RCTs included in the analysis. The meta-analysis summary estimate showed a significantly higher SSI risk with cefazolin versus cefoxitin or cefotetan (risk ratio, 1.7; 95% CI, 1.04-2.77; P = .03). However, most studies included nonstandardized dosing and duration of antimicrobial prophylaxis, had indeterminate or high risk of bias, did not include patients with gynecological malignancies, and/or were older RCTs not reflective of current clinical practices. CONCLUSION Due to inherent limitations associated with old RCTs with limited relevance to contemporary surgery, an RCT of cefazolin versus regimens with significant antianaerobic spectrum is needed to establish the optimal choice for SSI prevention in hysterectomy.
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Dellinger EP. Cephalosporin Plus Metronidazole for Surgical Prophylaxis. Surg Infect (Larchmt) 2018; 19:359-361. [PMID: 29717907 DOI: 10.1089/sur.2018.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Danan E, Smith J, Kruer RM, Avdic E, Lipsett P, Curless MS, Jarrell AS. Use and Effectiveness of Peri-Operative Cefotetan versus Cefazolin Plus Metronidazole for Prevention of Surgical Site Infection in Abdominal Surgery Patients. Surg Infect (Larchmt) 2018; 19:388-396. [PMID: 29688837 DOI: 10.1089/sur.2018.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Current practice guidelines for antimicrobial prophylaxis in surgery recommend a cephamycin or cefazolin plus metronidazole for various abdominal surgeries. In February 2016, cephamycin drug shortages resulted in a change in The Johns Hopkins Hospital's (JHH) recommendation for peri-operative antibiotic prophylaxis in abdominal surgeries from cefotetan to cefazolin plus metronidazole. The primary objective of this study was to quantify the percentage of abdominal surgeries adherent to JHH peri-operative antibiotic prophylaxis guidelines. A sub-group analysis investigated whether prophylaxis with cefazolin plus metronidazole was associated with a lower rate of surgical site infections (SSIs) versus cefotetan. PATIENTS AND METHODS This retrospective cohort study included adult inpatients who underwent an abdominal surgery at JHH in September 2015 (Study Period I: cefotetan) or February to March 2016 (Study Period II: cefazolin plus metronidazole). RESULTS Two hundred abdominal surgery cases were included in the primary analysis. A subset of 156 surgical cases were included in the sub-group analysis. The overall adherence rate to JHH guidelines was 75% in Study Period I versus 17% in Study Period II (p < 0.001). The largest difference in adherence was attributed to pre-operative administration time (87% vs. 23%, p < 0.001), primarily because of the longer infusion time required for metronidazole. Surgical site infections occurred in 14% (12/83) of surgeries with cefotetan versus 8.2% (6/73) with cefazolin plus metronidazole for prophylaxis (p = 0.19). CONCLUSIONS Adherence to an institution-specific peri-operative antibiotic prophylaxis guideline for abdominal surgeries was limited primarily by the longer infusion time required for pre-operative metronidazole. A higher percentage of SSIs occurred among abdominal surgeries with cefotetan versus cefazolin plus metronidazole for prophylaxis.
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Affiliation(s)
- Eleanor Danan
- 1 Department of Pharmacy, The Johns Hopkins Hospital , Baltimore, Maryland
| | - Janessa Smith
- 2 Department of Pharmacy, Orlando Regional Medical Center , Orlando, Florida
| | - Rachel M Kruer
- 1 Department of Pharmacy, The Johns Hopkins Hospital , Baltimore, Maryland
| | - Edina Avdic
- 1 Department of Pharmacy, The Johns Hopkins Hospital , Baltimore, Maryland.,3 Antimicrobial Stewardship Program, The Johns Hopkins Hospital , Baltimore, Maryland
| | - Pamela Lipsett
- 4 Departments of Surgery, Anesthesiology, Critical Care Medicine , and Nursing, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland
| | - Melanie S Curless
- 5 Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital , Baltimore, Maryland
| | - Andrew S Jarrell
- 1 Department of Pharmacy, The Johns Hopkins Hospital , Baltimore, Maryland
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Bruce SF, Carr DN, Burton ER, Sorosky JI, Shahin MS, Naglak MC, Edelson MI. Implementation of an abdominal closure bundle to reduce surgical site infection in patients on a gynecologic oncology service undergoing exploratory laparotomy. Gynecol Oncol 2018; 149:560-564. [PMID: 29548786 DOI: 10.1016/j.ygyno.2018.03.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 03/07/2018] [Accepted: 03/11/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Surgical site infections (SSI) are associated with increased morbidity, mortality, and healthcare costs. This study investigated whether implementation of an abdominal closure bundle reduces surgical site infection rates. We aimed to identify sub-populations that would benefit the most from this intervention. METHODS We conducted a retrospective cohort study of all patients that underwent exploratory laparotomy by a Gynecologic Oncologist from January 1, 2011 to April 1, 2017. The abdominal closure bundle was implemented on May 6, 2014. SSI rates were assessed overall and within subgroups. RESULTS 875 patients were included in the analysis. Overall, SSI rate was reduced, albeit not significantly, from 48/471 (10.2%) to 32/404 (7.9%) (p=0.148) with implementation of the closing bundle. In patients that underwent a tumor debulking procedure, SSI was noted in 36/277 (13.0%) in the pre-bundle group and 14/208 (6.7%) in the post-bundle cohort (p=0.017). In patients with malignant pathology, the pre-bundle cohort had an SSI rate of 38/282 (13.5%), which reduced to 18/215 (8.4%) in the post-bundle group (p=0.049). In patients with FIGO stage III or IV disease, the SSI rate was reduced from 21/114 (18.4%) to 8/87 (8.4%) with implantation of the closure bundle (p=0.028). In patients with intra-operative ascites, SSI rate decreased from 19/119 (15.9%) pre-bundle to 4/104 (3.8%) in the post-bundle group (p=0.002). CONCLUSIONS Implementation of an abdominal closure bundle was not associated with a significant reduction in overall SSI rate. However, multiple subpopulations associated with advanced gynecologic cancer benefited from this intervention.
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Affiliation(s)
- Shaina F Bruce
- Department of Obstetrics and Gynecology, Abington Hospital-Jefferson Health, 1200 Old York Road, Price 109, Abington, PA 19001, United States.
| | - Danielle N Carr
- Department of Obstetrics and Gynecology, Abington Hospital-Jefferson Health, 1200 Old York Road, Price 109, Abington, PA 19001, United States
| | - Elizabeth R Burton
- Hanjani Institute for Gynecologic Oncology, Abington Hospital-Jefferson Health, Widener Building, First Floor, 1200 Old York Road, Abington, PA 19001, United States
| | - Joel I Sorosky
- Hanjani Institute for Gynecologic Oncology, Abington Hospital-Jefferson Health, Widener Building, First Floor, 1200 Old York Road, Abington, PA 19001, United States
| | - Mark S Shahin
- Hanjani Institute for Gynecologic Oncology, Abington Hospital-Jefferson Health, Widener Building, First Floor, 1200 Old York Road, Abington, PA 19001, United States
| | - Mary C Naglak
- Department of Medicine, Abington Hospital-Jefferson Health, Suite 2B, Elkins Building, 1200 Old York Road, Abington, PA 19001, United States
| | - Mitchell I Edelson
- Hanjani Institute for Gynecologic Oncology, Abington Hospital-Jefferson Health, Widener Building, First Floor, 1200 Old York Road, Abington, PA 19001, United States
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