Single-dose prophylaxis for vaginal and abdominal hysterectomy

A standardized protocol for perioperative antibiotic prophylaxis is associated with improvement of timing and reduction of costs

The objectives of this study were to implement a uniform guideline for perioperative antibiotic prophylaxis (PAP) and to measure the impact on timing and costs of PAP. The effects of implementation of the new guideline describing the application of PAP were measured by comparing the choice of agents and their timing in a random sample of procedures before and after implementation. Before the intervention, 153 procedures from different specialties were observed; eight different antibiotics in different dosages were used and in 20% of the procedures, PAP was given after the incision. Two months after the intervention, 147 procedures were observed; three different antibiotics were given and all were used in the correct dosage. There was a significant reduction of administration of PAP after the incision from 20 to 7% (P=0.002). Besides the quality improvements, the modified PAP protocol resulted in a net annual savings of at least 112,000 US dollars. This study shows that the implementation of a uniform, simple and clear protocol for PAP is associated with improved dosing and timing. The costs of PAP were also reduced.

Preoperative assessment and risk reduction in gynecologic surgery patients

The prevention of complications during or after surgery is of interest to surgeon and patient alike. Identification of a patient's risk for perioperative complications requires a mix of good fundamental medicine, clinical and laboratory assessment tools, and clinical experience. Once identified, reduction of modifiable risk leads to better clinical outcomes. Active risk reduction is a combination of general strategies known to benefit all patients plus focal strategies designed to reduce individual patient risk. This article will review preoperative risk identification strategies and risk reduction techniques applicable to gynecologic surgery patients.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to summarize the various risk prediction strategies, explain the various methods used to identify risk, and describe potential ways to reduce perioperative risk.

Does pre- and postoperative metronidazole treatment lower vaginal cuff infection rate after abdominal hysterectomy among women with bacterial vaginosis?

OBJECTIVE

Bacterial vaginosis (BV) is a known risk factor for postoperative infection following abdominal hysterectomy. Vaginal bacterial flora scored as intermediate has been shown to have the same risk of postoperative infection as BV.

METHODS

Women undergoing total abdominal hysterectomy for benign diseases were open-randomized according to Zelen to either treatment with metronidazole rectally for at least 4 days or no treatment. At the preoperative gynecological examination a vaginal smear was collected and Gram stained. Women with BV or intermediate flora were merged to one group called abnormal vaginal flora.

RESULTS

In total 213 women were randomized to treatment or no treatment. After exclusion of 71 women, 142 women were eligible for analysis. Among the 59 women diagnosed with abnormal vaginal flora there were no vaginal cuff infections in the treated arm, compared with 27% in the 'no treatment' arm (p < 0.01). Treatment also reduced the vaginal cuff infection rate from 9.5 to 2% among the 83 women with lactobacilli flora. However, this difference was not statistically significant. Treatment had no effect on the rate of wound infections. Intention-to-treat analysis showed a significant reduction in vaginal cuff infections among women randomized to treatment.

CONCLUSION

Pre- and postoperative treatment for at least 4 days with metronidazole rectally reduces significantly vaginal cuff infection among women with abnormal vaginal flora.

Incidence, risk factors and outcome of infection in a 1-year hysterectomy cohort: a prospective follow-up study

A prospective study was performed following 687 patients who underwent abdominal, vaginal and laparoscopic hysterectomy for benign conditions in Turku University Hospital. This study evaluates and compares infection after hysterectomy and determines risk factors associated with postoperative infection. Infective episodes were recorded during hospital stay, convalescence for 4 to 6 weeks at home and for 1 year of follow-up. Factors found to be statistically significant for hospital-acquired infection on univariate analysis were subsequently assessed by means of multivariate analysis. During the hospital stay 23.7% of the study population became infected, 38.1% after vaginal hysterectomy, 23.4% after abdominal hysterectomy and 3.0% after laparoscopic hysterectomy. Over half of all hospital-acquired infections were lower urinary tract infections. Infection during convalescence occurred in 19.2% of patients: 29.5% in the vaginal hysterectomy group, 17.4% in the abdominal hysterectomy group and 16.7% in the laparoscopic hysterectomy group. One year of follow-up did not find any infection directly attributable to surgery. Five factors were found to be related to in-hospital infection on multivariate analysis. These were lack of antibiotic prophylaxis, blood loss during operation, intermittent catheterization, anaemia and medication for urinary or bowel dysfunction after operation.

A randomised controlled trial of antibiotic prophylaxis for vesico-vaginal fistula repair

OBJECTIVE

To test the hypothesis that intravenous antibiotics given intra-operatively reduce the failure rate of vesico-vaginal fistula repair.

DESIGN

A single blind, randomised controlled trial.

SETTING

A district hospital in Benin, West Africa.

POPULATION

Seventy-nine women undergoing repair of an obstetric vesico-vaginal fistula by a single surgeon at Hopital Evangelique; two women had repeat operations.

METHODS

Participants in the treatment group (n = 41) received ampicillin 500 mg intra-operatively. Controls (n = 40) received no prophylactic antibiotics.

MAIN OUTCOME MEASURES

Failure of fistula closure and objective incontinence (a positive pad test) at hospital discharge. Secondary outcomes included febrile morbidity, other antibiotic use and urinary infection.

RESULTS

Antibiotic prophylaxis did not reduce the odds of failed repair (OR 2.1 95% CI 0.75-6.1) or of objective incontinence (OR 1.9; 95% CI 0.72-5.1). The women in the antibiotic prophylaxis group received less post-operative antibiotics and had less urinary infections at day 10.

CONCLUSIONS

Prophylactic antibiotics should not be used in vesico-vaginal fistulae repair in the developing world outside randomised controlled trials.

Intraoperative wound contamination during abdominal hysterectomy

Qualitative bacterial culture of specimens taken from several operative sites during abdominal hysterectomy has not been of value in predicting postoperative infection. We have therefore studied the relationship between the magnitude of contamination and the likelihood of the development of postoperative infection, in the course of a trial comparing the efficacy of cefotetan with ampicillin-plus-metronidazole for chemoprophylaxis in 163 women undergoing abdominal hysterectomy. Forty women who did not receive chemoprophylaxis were also studied. From each patient, an intraoperative sample of pelvic fluid was obtained after closure of the vaginal vault and examined quantitatively for anaerobic, aerobic and microaerophilic bacteria. The incidence of postoperative infectious morbidity (wound infection and febrile morbidity) was correlated with bacterial counts. Analyses by step-up multiple logistic regressions were performed on all the variables and only the total and microaerophilic bacterial counts were significant. Of the 40 patients with total bacterial counts greater than or equal to 10(4) cfu ml-1, 42.5% developed postoperative infectious morbidity, compared with 12.6% of 135 of patients with counts of less than or equal to 10(3) cfu ml-1. The contaminating bacteria were similar to those of the vaginal and skin flora, with anaerobes occurring in 52.9% and microaerophiles in 63.9% of positive fluid samples. Thus, we have concluded that the magnitude of contamination during abdominal hysterectomy is an important determinant in the development of postoperative infectious morbidity.

Review of cefotaxime sodium for surgical prophylaxis. A model for the evolution toward single-dose or short-course cost-effective regimens

Cefotaxime is a parenteral broad-spectrum cephalosporin, used extensively worldwide for chemotherapy of serious infections. Since its release in 1979, cefotaxime has also been studied to minimize surgery-related infections and, more than any other new compound, has been used in a volume of evaluable cases. Because of the current cost-containment medical practice environment, most cefotaxime prophylaxis studies have established single-dose or short-course regimens. Over 9000 published cefotaxime prophylaxis cases were reviewed, and 81 references were cited. Single-dose cefotaxime was clearly indicated for a wide variety of operations, including hysterectomy, cesarean sections, bone and joint procedures, upper gastrointestinal cases, biliary tract procedures, transurethral resections, open urologic procedures, and some vascular cases. Approximately 24 hr of prophylaxis (cefotaxime X 4 doses) may be required for colorectal resections, cardiac surgery, head and neck surgery, transplants, and some pediatric surgical cases. Although contaminated abdominal cases and trauma surgery were not a true prophylaxis use, cefotaxime regimens have reduced wound morbidity to less than or equal to 10%. Changing to one- to four-dose schedules will have very favorable clinical impact by reducing prophylaxis cost, pharmacy preparation time, adverse reactions, and antimicrobic-resistance pressures. Surgeons should not hesitate to employ new cephalosporins (cefotaxime and others) with proved limited dose indications that would greatly benefit their patients and the hospital environment.

Randomized, double-blind comparison of the efficacies, costs, and vaginal flora alterations with single-dose ceftriaxone and multidose cefazolin prophylaxis in vaginal hysterectomy

A comparison of efficacies, costs, and effects on vaginal microflora of one preoperative and three postoperative 1-g doses of cefazolin versus those of one preoperative 1-g dose of ceftriaxone was done with 65 and 73 women, respectively, undergoing elective vaginal hysterectomy. Patient infection rates were not statistically different between the cefazolin group (six events in 6 of 73 patients [8.2%]) and the ceftriaxone group (11 events in 9 of 65 patients [13.8%]). Side effects, including diarrhea, were minimal and similar between the two groups. Significant shifts in the cervicovaginal microflora of the patients occurred postoperatively, with a marked increase in enterococci and a drop in nonenterococcal streptococci. No shifts among aerobic, facultative gram-negative rods and staphylococci were observed. Among the anaerobes, a significant decrease in the number of patients harboring nonsporulating, gram-positive rods and a less striking concomitant increase in Bacteriodes species and members of the family Peptococcaceae were noted. No qualitative differences were noted between the two groups that received prophylactic therapy. Aside from enterococci, cefazolin or ceftriaxone resistance among vaginal isolates (greater than or equal to 10(3)/ml) was minimal. Selection of resistant isolates was not different between the treatment groups. We could not detect a difference between a single 1-g dose of ceftriaxone and multidose cefazolin for infection prophylaxis in patients undergoing a vaginal hysterectomy. However, the total acquisition, preparation, and administration costs were greater for the ceftriaxone regimen than they were for the cefazolin regimen. Cefazolin should therefore remain the drug of choice for infection prophylaxis in uncomplicated vaginal hysterectomies.

Prophylactic perioperative use of clindamycin and metronidazole in vaginal hysterectomy without pelvic floor repair

We studied the effect of perioperative clindamycin (3 x 600 mg in 100 ml 0.9% saline), metronidazole (3 x 500 mg in 100 ml 0.9% saline) and a placebo (3 x 100 ml of 0.9% saline) in 120 patients having a vaginal hysterectomy without colporrhaphy. The rate of postoperative urinary tract infections was significantly higher in the placebo group, but there was no significant difference between the three groups in the days of postoperative fever (a temperature above 37 degrees C) or in the length of hospital stay. One patient on placebo had a vault infection and another had a fever of unknown origin.