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Prevention of Infection Following Gynecological Surgery
Saturday, March 7, 2009
Definition of Infection
Terms such as inflflammation, contamination, infection, sepsis, and febrile morbidity may mean different things to different clinicians. It is important, therefore, that in audits of surgical outcomes, reports of research fifindings, and comparisons of studies, terminology is defifined; an example of this process is given in Table 1.1. The defifinitions of various systemic inflfl ammatory responses and their associated clinical fifindings and laboratory test results are shown in Table 1.2.
Pathogenesis
The vagina contains more microorganisms than any other site in the body except the bowel. Uterine manipulation through the vagina, e.g., surgical termination of pregnancy (TOP), or operations that open the vagina, e.g., hysterectomy, will result in contamination of normally sterile sites by bacteria that are normally resident in the vagina. Whether these organisms become established and cause infection and inflflammation depends on a mixture of surgical and host-related factors, including low socioeconomic status, poor nutrition, smoking, or preexisting medical conditions, such as impaired immunocompetence. These risk factors may be interrelated, e.g., diabetes, obesity, increased blood loss, duration of surgery, and prolonged hospital stay, and many of the measures that can be taken to reduce the rate of postoperative infectious morbidity focus on reducing the impact of these risk factors. The risk of postoperative infection also depends on the virulence and size of the bacterial inoculum. Normal vaginal flflora is composed mainly of organisms of low virulence, dominated by lactobacilli species, which, by producing lactic acid from glycogen in vaginal secretions, render the pH of the vagina very acid (<4.5), in which milieu the growth of other potentially pathogenic organisms is suppressed.
At this low-acid pH, lactobacilli are particularly effificient at producing H2O2, which is toxic to bacteria. Under conditions where there is an increase in the
Source: Adapted from and reproduced with kind permission from Tamussino [1].
alkalinity of the vagina (bleeding, semen, douching) or a change in the delicate vaginal ecosystem (few or poor-quality lactobacilli, antibiotics, changes in endocrine status, or phage virus parasitization of lactobacilli), much less H2O2 is produced. This results in a 1000-fold increase in other organisms, particularly anaerobes that produce keto acids such as succinate. Succinate blunts the chemotactic response of neutrophils and reduces their killing ability. This
Source: Reproduced with kind permission from Tamussino [1].
1. Prevention of Infection Following Gynecological Surgery
results in a synergistic increase in other organisms such as Mobiluncus spp and more anaerobes. The result is a polymicrobial imbalance of large numbers of potentially pathogenic organisms, yet no cellular inflflammatory response. This condition is called bacterial vaginosis (BV) [2]. As a result, the causative organisms of postoperative infectious morbidity are rarely unimicrobial or exogenous organisms and are more likely to be polymicrobial and endogenous organisms, such as the polymicrobial condition of BV or BV-related organisms, e.g., anaerobes, Mobiluncus, mycoplasmas, and ureaplasmas.
In 2001, the Clinical Effectiveness Group of the Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases produced national guidelines for the management of BV. They listed the complications associated with BV as postabortal sepsis, post-hysterectomy vaginal cuff cellulitis, and abscess post–vaginal hysterectomy. They concluded (level of evidence A) that treatment was indicated for symptomatic women, some pregnant women, and women undergoing some surgical procedures. Most of the evidence pertaining to the use of antibiotics in women undergoing surgery relates to hysterectomy and surgical TOP as an example of transvaginal manipulation of the uterus.
Prophylactic Antibiotics for Hysterectomy
Vaginal Hysterectomy
Hirsch [3] reviewed those studies in which antibiotics were used prophylactically in women undergoing vaginal hysterectomy. As early as 1985, Hirsch was able to fifind 48 studies of 5524 patients, of whom 3037 had been treated and 2487 were used as controls. Febrile morbidity occurred in 444 (15%) of 3037 women who received antibiotics compared to 988 (40%) of 2487 women who did not receive antibiotics (relative risk [RR] = 0.37; 95% confifidence interval [CI] = 0.33–0.41; P < 0.01). Similarly, pelvic infections occurred in 105 (5%) of 2099 women who received antibiotics compared to 354 (25%) of 1391 women who did not receive antibiotics (RR = 0.2; CI = 0.16–0.24; P < 0.01).
Abdominal Hysterectomy
As part of the same review [3], Hirsch reviewed those studies in which antibiotics were used prophylactically in women undergoing abdominal hysterectomy. Hirsch found 30 studies involving 3752 patients, of whom 2165 had been treated and 1587 were used as controls. Febrile morbidity occurred in 348 (16%) of 2165 women who received antibiotics compared to 444 (28%) of 1587 women who did not receive antibiotics (RR = 0.57; CI = 0.51–0.65; P < 0.01). Pelvic infection occurred in 57 (5%) of 1196 women who received antibiotics compared to 114 (10%) of 1144 women who did not receive antibiotics (RR = 0.48; CI = 0.35–0.65; P < 0.001). The nature of the abdominal hysterectomy procedure provided a third outcome category—wound infection—for analysis. In this category, 45 (3%) of 1434 women who received antibiotics developed a wound infection compared to 98 (8%) of 1194 women who did not receive antibiotics (RR = 0.38; CI = 0.27–0.54; P < 0.01).
Vaginal Versus Abdominal Hysterectomy
Around the time of the Hirsch review [3], 2 studies [4,5] reported on postoperative complications of vaginal versus abdominal hysterectomy. Shapiro et al. [4] found that a higher incidence of infection at the operation site was associated with increased duration of the procedure, lack of antibiotic prophylaxis, younger age, and an abdominal approach. Correcting for these associations, there was no predictive value of the following: obesity, preoperative functional and anatomical diagnosis, postoperative anatomical and pathological diagnosis, estimated blood loss, menopausal status, or surgeon who performed the procedure. Dicker et al. [5] studied 1851 women from 9 institutions. They found that vaginal hysterectomy when compared to abdominal hysterectomy was associated with signifificantly fewer complications but more unintended surgical procedures. Vaginal hysterectomy was associated with less febrile morbidity, less bleeding requiring transfusion, and less hospitalization and convalescence. Bearing in mind the results of these studies [4,5] and the review by Hirsch [3], in which there were more studies (48 versus 30) and more patients (5524 versus 3752) in which prophylactic antibiotics were used for vaginal hysterectomy compared to abdominal hysterectomy, it seems likely that up to 1985, antibiotics were used preferentially for vaginal hysterectomy compared to abdominal hysterectomy, though the logic of this choice is unclear. This is emphasized by the conclusion of Dicker et al. [5], who claimed that while vaginal hysterectomy with antibiotics had a better outcome than abdominal hysterectomy, the differences were probably attributable to the prevalence and effificacy of antibiotic usage in vaginal hysterectomy.
Bacterial Vaginosis and Post-hysterectomy Infectious Morbidity
Two studies [6,7], in neither of which antibiotic prophylaxis was used, highlighted the association between BV and post-hysterectomy vaginal cuff cellulitis. Soper et al. [6] found that 11 (34%) of 32 women with BV developed post-hysterectomy vaginal cuff cellulitis compared to only 11 (11%) of 102 of women with normal flflora (RR = 3.2; CI = 1.5–6.7; P < 0.005). Larsson et al. [7] found that 7 (35%) of 20 women with BV developed post-hysterectomy vaginal cuff infection compared to 4 (8%) of 50 with normal flflora (R = 4.4; CI = 1.4– 13.3; P < 0.01).
1. Prevention of Infection Following Gynecological Surgery
Choice of Antibiotics
With the important association of BV and BV-related organisms and the development of post-hysterectomy infectious morbidity, it is important that the antibiotics used prophylactically are active against those organisms, particularly anaerobes. In a metaanalysis, Mittendorf et al. [8] identifified 25 randomized controlled trials of antibiotic prophylaxis that used vigorous protocols. They performed metaanalyses and cumulative metaanalyses for all the trials. Separate metaanalyses were performed for cefazolin, metronidazole, and tinidazole. Overall, 21% (373/1768) of patients who did not receive antibiotic prophylaxis had serious infection after abdominal hysterectomy. In comparison, of women who received any antibiotics, only 9% (166/1836) had serious postoperative infections (P = 0.00001). Among those who received cefazolin, metronidazole, or tinidazole, 11.4% (70/615; P = 0.00021), 6.3% (17/269; P = 0.015), and 5% (5/101; P = 0.034), respectively, had serious postoperative morbidity. The metaanalyses for individual studies and a cumulative metaanalysis are shown in Figure 1.1. Mittendorf et al. concluded that randomized controlled trials of antibiotic prophylaxis in abdominal hysterectomy that used controls who received no treatment are no longer justifified. Moreover, they concluded, if the results of the various studies had been pooled at an earlier date, the inappropriateness of controls who received no treatment would have been discovered in 1980 for cefazolin, in 1984 for metronidazole, and in 1986 for tinidazole.
The Swedish National Study of Infection after Hysterectomy (1996), which took place before publication of the Mittendorf metaanalysis, involved 1060 women from 42 centers, yet included only 236 women (22%) who were given preoperative or postoperative antibiotics [9]. Not surprisingly, the postoperative infection rate was high, at 23%, 9.4% of whom had an infection that was situated either in the wound, in the vaginal cuff, or deep in the pelvis. Thirteen percent had a urinary tract infection (UTI), and 4% had infections distant from the site. Only 50% of the wound, cuff, and deep-pelvic infections were detected before discharge from the hospital. An increased risk of postoperative infection was associated with Wertheims-Meigs hysterectomy (21.4%; RR = 3.0; P <> 1000 mL (15%; RR = 2.4; P < rr =" 2.3;"> 0.05). Admitting that the publication of Mittendorf et al. (1993) [8] had not been drawn to their attention until after preparation of their manuscript, Henriksson et al. (1998) [10] reported that 500 mg of metronidazole administered intravenously to 134 women immediately before total abdominal hysterectomy resulted in a signifificantly lower erythrocyte sedimentation rate on day 6 (50 mm/hr vs 56 mm/hr, P < 0.05), rate of infection (9% vs 17%; P < 0.04), and duration of postoperative hospitalization (7.9 vs 8.8 days; P < 0.02).
1. Prevention of Infection Following Gynecological Surgery
Prevention of Infection Associated with Termination of Pregnancy
Following an unpublished pilot study in Swansea, Wales, in women presenting for TOP, in which the rate of pelvic infection was higher than expected, a larger, more formal study was performed. The study recruited 400 women attending for termination of pregnancy. One hundred twelve women (28%) had BV, 95 (24%) had candida, 3 (0.75%) had Trichomonas, and 1 (0.25%) had gonorrhea. Of 32 women (8%) with chlamydia, 63% developed postabortal pelvic infection, requiring 7 to be readmitted to the hospital. As a result, the authors recommended that, since the estimated cost of hospital admission due to chlamydia was twice the estimated cost of screening for and treating chlamydia, screening for chlamydia was essential, and prophylactic antibiotics should cover both chlamydia and BV [11].
The incidence of postabortal sepsis (PAS) is estimated to be between 4% and 12%. Those women with BV have a 3-fold increased risk of PAS compared to women with Lactobacillus spp–dominated flflora [12]. Prophylactic metronidazole reduces PAS by 66% [13,14]. In a randomized, double-blind, placebo-controlled trial of 231 women attending for TOP who were given either 500 mg of metronidazole or placebo for 10 days starting the week preoperatively, the incidence of PAS was 3.8% in the metronidazole group compared with 12.2% in the placebo group (P < style="font-weight: bold;">Infections Postoperative Hysteroscopy
While accepting the recommendations and guidelines from national bodies, clinical effectiveness groups, professional bodies, RCOG study groups, and expert advisory groups concerning the use of antibiotic prophylaxis to prevent infection when uterine instrumentation is involved, a recent report of 1952 operative hysteroscopies from Marseille, France, recorded a remarkably low incidence of postoperative infection despite the fact that no antibiotic prophylaxis was used. Following 782 resections of leiomyomata, 422 endo metrial polypectomies, and 90 uterine septa resections, together with 623 endometrectomies and 199 lyses of intrauterine synechiae, the incidence of endometritis and UTI was extremely low at 18 (0.9%) of 1952 and 12 (0.6%) of 1952, respectively [20].
Conclusion
On July 3, 1909, at the age of 47, Herman Pfannenstiel (1862–1909), the Berlin gynecologist who gave his name to the low transverse incision so commonly used in obstetrics and gynecology, died of septicemia 1 week after a needle-stick injury to his left middle fifinger, sustained while operating on a patient with a tubo-ovarian abscess. With the introduction of antibiotics, postoperative infections are no longer the danger they were for patients or their surgeons but are still common, potentially life threatening, and a drain on health care. The following bullet points represent the evidence available for the prevention of infection following gynecological surgery.
1. Prevention of Infection Following Gynecological Surgery
ing for sexually transmitted infection such as Chlamydia trachoma-tis, gonococcus, and Trichomonas is more likely to result in positive cultures, with the added advantage of genito-urinary medicine (GUM) referral and contact tracing.
Terms such as inflflammation, contamination, infection, sepsis, and febrile morbidity may mean different things to different clinicians. It is important, therefore, that in audits of surgical outcomes, reports of research fifindings, and comparisons of studies, terminology is defifined; an example of this process is given in Table 1.1. The defifinitions of various systemic inflfl ammatory responses and their associated clinical fifindings and laboratory test results are shown in Table 1.2.
Pathogenesis
The vagina contains more microorganisms than any other site in the body except the bowel. Uterine manipulation through the vagina, e.g., surgical termination of pregnancy (TOP), or operations that open the vagina, e.g., hysterectomy, will result in contamination of normally sterile sites by bacteria that are normally resident in the vagina. Whether these organisms become established and cause infection and inflflammation depends on a mixture of surgical and host-related factors, including low socioeconomic status, poor nutrition, smoking, or preexisting medical conditions, such as impaired immunocompetence. These risk factors may be interrelated, e.g., diabetes, obesity, increased blood loss, duration of surgery, and prolonged hospital stay, and many of the measures that can be taken to reduce the rate of postoperative infectious morbidity focus on reducing the impact of these risk factors. The risk of postoperative infection also depends on the virulence and size of the bacterial inoculum. Normal vaginal flflora is composed mainly of organisms of low virulence, dominated by lactobacilli species, which, by producing lactic acid from glycogen in vaginal secretions, render the pH of the vagina very acid (<4.5), in which milieu the growth of other potentially pathogenic organisms is suppressed.
At this low-acid pH, lactobacilli are particularly effificient at producing H2O2, which is toxic to bacteria. Under conditions where there is an increase in the
| Definition | |
|---|---|
| Inflammation | Localized protective response elicited by injury or tissue damage |
| Contamination | Pathogenic microorganism(s) in normally sterile tissue without an |
| inflammatory response | |
| Infection | Pathogenic microorganism(s) in normally sterile tissue with a local |
| inflammatory response | |
| Sepsis | Infection with a local and systemic inflammatory response |
| Febrile morbidity | Temperature of >38.0°C on 2 occasions at least 6 hours apart, |
| excluding the first 24 hours after the procedure | |
Source: Adapted from and reproduced with kind permission from Tamussino [1].
alkalinity of the vagina (bleeding, semen, douching) or a change in the delicate vaginal ecosystem (few or poor-quality lactobacilli, antibiotics, changes in endocrine status, or phage virus parasitization of lactobacilli), much less H2O2 is produced. This results in a 1000-fold increase in other organisms, particularly anaerobes that produce keto acids such as succinate. Succinate blunts the chemotactic response of neutrophils and reduces their killing ability. This
| Clinical Findings, Laboratory | ||
|---|---|---|
| Definition | Tests | |
| Systemic | Signs and symptoms of | Fever, tachypnea, tachycardia, |
| inflammatory | disseminated infection or | leukocytosis, or leukopenia |
| response | toxins | |
| Sepsis | Infection with a local and | Tachypnea (>20 breaths/min) |
| systemic inflammatory | Tachycardia (>90 bpm) | |
| response | Hyperthermia or hypothermia | |
| (>38.4°C or <35.6°c)> | ||
| Severe sepsis | Sepsis plus evidence of organ | Metabolic acidosis, acute |
| dysfunction | encephalopathy, oliguria, | |
| hypoxemia, disseminated | ||
| intravascular coagulation, | ||
| hypotension | ||
| Septic shock | Infection with an | Hypotension (<90> |
| overwhelming systemic | 40 mm Hg below baseline) | |
| inflammatory response | ||
| leading to shock | ||
| Sepsis syndrome or | Sepsis plus evidence of altered | Hypoxia, increased plasma |
| multiple-organ | organ perfusion | lactate, altered mental state, |
| syndrome | oliguria | |
Source: Reproduced with kind permission from Tamussino [1].
1. Prevention of Infection Following Gynecological Surgery
results in a synergistic increase in other organisms such as Mobiluncus spp and more anaerobes. The result is a polymicrobial imbalance of large numbers of potentially pathogenic organisms, yet no cellular inflflammatory response. This condition is called bacterial vaginosis (BV) [2]. As a result, the causative organisms of postoperative infectious morbidity are rarely unimicrobial or exogenous organisms and are more likely to be polymicrobial and endogenous organisms, such as the polymicrobial condition of BV or BV-related organisms, e.g., anaerobes, Mobiluncus, mycoplasmas, and ureaplasmas.
In 2001, the Clinical Effectiveness Group of the Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases produced national guidelines for the management of BV. They listed the complications associated with BV as postabortal sepsis, post-hysterectomy vaginal cuff cellulitis, and abscess post–vaginal hysterectomy. They concluded (level of evidence A) that treatment was indicated for symptomatic women, some pregnant women, and women undergoing some surgical procedures. Most of the evidence pertaining to the use of antibiotics in women undergoing surgery relates to hysterectomy and surgical TOP as an example of transvaginal manipulation of the uterus.
Prophylactic Antibiotics for Hysterectomy
Vaginal Hysterectomy
Hirsch [3] reviewed those studies in which antibiotics were used prophylactically in women undergoing vaginal hysterectomy. As early as 1985, Hirsch was able to fifind 48 studies of 5524 patients, of whom 3037 had been treated and 2487 were used as controls. Febrile morbidity occurred in 444 (15%) of 3037 women who received antibiotics compared to 988 (40%) of 2487 women who did not receive antibiotics (relative risk [RR] = 0.37; 95% confifidence interval [CI] = 0.33–0.41; P < 0.01). Similarly, pelvic infections occurred in 105 (5%) of 2099 women who received antibiotics compared to 354 (25%) of 1391 women who did not receive antibiotics (RR = 0.2; CI = 0.16–0.24; P < 0.01).
Abdominal Hysterectomy
As part of the same review [3], Hirsch reviewed those studies in which antibiotics were used prophylactically in women undergoing abdominal hysterectomy. Hirsch found 30 studies involving 3752 patients, of whom 2165 had been treated and 1587 were used as controls. Febrile morbidity occurred in 348 (16%) of 2165 women who received antibiotics compared to 444 (28%) of 1587 women who did not receive antibiotics (RR = 0.57; CI = 0.51–0.65; P < 0.01). Pelvic infection occurred in 57 (5%) of 1196 women who received antibiotics compared to 114 (10%) of 1144 women who did not receive antibiotics (RR = 0.48; CI = 0.35–0.65; P < 0.001). The nature of the abdominal hysterectomy procedure provided a third outcome category—wound infection—for analysis. In this category, 45 (3%) of 1434 women who received antibiotics developed a wound infection compared to 98 (8%) of 1194 women who did not receive antibiotics (RR = 0.38; CI = 0.27–0.54; P < 0.01).
Vaginal Versus Abdominal Hysterectomy
Around the time of the Hirsch review [3], 2 studies [4,5] reported on postoperative complications of vaginal versus abdominal hysterectomy. Shapiro et al. [4] found that a higher incidence of infection at the operation site was associated with increased duration of the procedure, lack of antibiotic prophylaxis, younger age, and an abdominal approach. Correcting for these associations, there was no predictive value of the following: obesity, preoperative functional and anatomical diagnosis, postoperative anatomical and pathological diagnosis, estimated blood loss, menopausal status, or surgeon who performed the procedure. Dicker et al. [5] studied 1851 women from 9 institutions. They found that vaginal hysterectomy when compared to abdominal hysterectomy was associated with signifificantly fewer complications but more unintended surgical procedures. Vaginal hysterectomy was associated with less febrile morbidity, less bleeding requiring transfusion, and less hospitalization and convalescence. Bearing in mind the results of these studies [4,5] and the review by Hirsch [3], in which there were more studies (48 versus 30) and more patients (5524 versus 3752) in which prophylactic antibiotics were used for vaginal hysterectomy compared to abdominal hysterectomy, it seems likely that up to 1985, antibiotics were used preferentially for vaginal hysterectomy compared to abdominal hysterectomy, though the logic of this choice is unclear. This is emphasized by the conclusion of Dicker et al. [5], who claimed that while vaginal hysterectomy with antibiotics had a better outcome than abdominal hysterectomy, the differences were probably attributable to the prevalence and effificacy of antibiotic usage in vaginal hysterectomy.
Bacterial Vaginosis and Post-hysterectomy Infectious Morbidity
Two studies [6,7], in neither of which antibiotic prophylaxis was used, highlighted the association between BV and post-hysterectomy vaginal cuff cellulitis. Soper et al. [6] found that 11 (34%) of 32 women with BV developed post-hysterectomy vaginal cuff cellulitis compared to only 11 (11%) of 102 of women with normal flflora (RR = 3.2; CI = 1.5–6.7; P < 0.005). Larsson et al. [7] found that 7 (35%) of 20 women with BV developed post-hysterectomy vaginal cuff infection compared to 4 (8%) of 50 with normal flflora (R = 4.4; CI = 1.4– 13.3; P < 0.01).
1. Prevention of Infection Following Gynecological Surgery
Choice of Antibiotics
With the important association of BV and BV-related organisms and the development of post-hysterectomy infectious morbidity, it is important that the antibiotics used prophylactically are active against those organisms, particularly anaerobes. In a metaanalysis, Mittendorf et al. [8] identifified 25 randomized controlled trials of antibiotic prophylaxis that used vigorous protocols. They performed metaanalyses and cumulative metaanalyses for all the trials. Separate metaanalyses were performed for cefazolin, metronidazole, and tinidazole. Overall, 21% (373/1768) of patients who did not receive antibiotic prophylaxis had serious infection after abdominal hysterectomy. In comparison, of women who received any antibiotics, only 9% (166/1836) had serious postoperative infections (P = 0.00001). Among those who received cefazolin, metronidazole, or tinidazole, 11.4% (70/615; P = 0.00021), 6.3% (17/269; P = 0.015), and 5% (5/101; P = 0.034), respectively, had serious postoperative morbidity. The metaanalyses for individual studies and a cumulative metaanalysis are shown in Figure 1.1. Mittendorf et al. concluded that randomized controlled trials of antibiotic prophylaxis in abdominal hysterectomy that used controls who received no treatment are no longer justifified. Moreover, they concluded, if the results of the various studies had been pooled at an earlier date, the inappropriateness of controls who received no treatment would have been discovered in 1980 for cefazolin, in 1984 for metronidazole, and in 1986 for tinidazole.
The Swedish National Study of Infection after Hysterectomy (1996), which took place before publication of the Mittendorf metaanalysis, involved 1060 women from 42 centers, yet included only 236 women (22%) who were given preoperative or postoperative antibiotics [9]. Not surprisingly, the postoperative infection rate was high, at 23%, 9.4% of whom had an infection that was situated either in the wound, in the vaginal cuff, or deep in the pelvis. Thirteen percent had a urinary tract infection (UTI), and 4% had infections distant from the site. Only 50% of the wound, cuff, and deep-pelvic infections were detected before discharge from the hospital. An increased risk of postoperative infection was associated with Wertheims-Meigs hysterectomy (21.4%; RR = 3.0; P <> 1000 mL (15%; RR = 2.4; P < rr =" 2.3;"> 0.05). Admitting that the publication of Mittendorf et al. (1993) [8] had not been drawn to their attention until after preparation of their manuscript, Henriksson et al. (1998) [10] reported that 500 mg of metronidazole administered intravenously to 134 women immediately before total abdominal hysterectomy resulted in a signifificantly lower erythrocyte sedimentation rate on day 6 (50 mm/hr vs 56 mm/hr, P < 0.05), rate of infection (9% vs 17%; P < 0.04), and duration of postoperative hospitalization (7.9 vs 8.8 days; P < 0.02).
1. Prevention of Infection Following Gynecological Surgery
Prevention of Infection Associated with Termination of Pregnancy
Following an unpublished pilot study in Swansea, Wales, in women presenting for TOP, in which the rate of pelvic infection was higher than expected, a larger, more formal study was performed. The study recruited 400 women attending for termination of pregnancy. One hundred twelve women (28%) had BV, 95 (24%) had candida, 3 (0.75%) had Trichomonas, and 1 (0.25%) had gonorrhea. Of 32 women (8%) with chlamydia, 63% developed postabortal pelvic infection, requiring 7 to be readmitted to the hospital. As a result, the authors recommended that, since the estimated cost of hospital admission due to chlamydia was twice the estimated cost of screening for and treating chlamydia, screening for chlamydia was essential, and prophylactic antibiotics should cover both chlamydia and BV [11].
The incidence of postabortal sepsis (PAS) is estimated to be between 4% and 12%. Those women with BV have a 3-fold increased risk of PAS compared to women with Lactobacillus spp–dominated flflora [12]. Prophylactic metronidazole reduces PAS by 66% [13,14]. In a randomized, double-blind, placebo-controlled trial of 231 women attending for TOP who were given either 500 mg of metronidazole or placebo for 10 days starting the week preoperatively, the incidence of PAS was 3.8% in the metronidazole group compared with 12.2% in the placebo group (P < style="font-weight: bold;">Infections Postoperative Hysteroscopy
While accepting the recommendations and guidelines from national bodies, clinical effectiveness groups, professional bodies, RCOG study groups, and expert advisory groups concerning the use of antibiotic prophylaxis to prevent infection when uterine instrumentation is involved, a recent report of 1952 operative hysteroscopies from Marseille, France, recorded a remarkably low incidence of postoperative infection despite the fact that no antibiotic prophylaxis was used. Following 782 resections of leiomyomata, 422 endo metrial polypectomies, and 90 uterine septa resections, together with 623 endometrectomies and 199 lyses of intrauterine synechiae, the incidence of endometritis and UTI was extremely low at 18 (0.9%) of 1952 and 12 (0.6%) of 1952, respectively [20].
Conclusion
On July 3, 1909, at the age of 47, Herman Pfannenstiel (1862–1909), the Berlin gynecologist who gave his name to the low transverse incision so commonly used in obstetrics and gynecology, died of septicemia 1 week after a needle-stick injury to his left middle fifinger, sustained while operating on a patient with a tubo-ovarian abscess. With the introduction of antibiotics, postoperative infections are no longer the danger they were for patients or their surgeons but are still common, potentially life threatening, and a drain on health care. The following bullet points represent the evidence available for the prevention of infection following gynecological surgery.
- Prophylactic antibiotics signifificantly reduce infectious morbidity following hysterectomy and termination of pregnancy.
- Vaginal hysterectomy is associated with less infectious morbidity than total abdominal hysterectomy, but all hysterectomies should have antibiotic prophylaxis.
- Consensus guidelines also recommend antibiotic prophylaxis for other procedures that involve uterine instrumentation.
- Prophylactic antibiotics for TOP are as good as screening and treatment and probably more cost-effective. The possible exception to this rule is among women under the age of 20 years in whom screen
1. Prevention of Infection Following Gynecological Surgery
ing for sexually transmitted infection such as Chlamydia trachoma-tis, gonococcus, and Trichomonas is more likely to result in positive cultures, with the added advantage of genito-urinary medicine (GUM) referral and contact tracing.
- Prophylactic antibiotics for TOP should cover both chlamydia and BV (e.g., doxycycline 200 mg daily plus metronidazole 1 g per rectum twice daily or 400 mg three times daily, or erythromycin 500 mg four times daily and clindamycin 300 mg twice daily).
- Antibiotic prophylaxis for hysterectomy should be broad spectrum as well as antianaerobe to cover wound infection and UTI as well as cuff cellulitis and deep-pelvic infection (e.g., metronidazole 1 g per rectum before surgery plus 750 mg cefuroxime IV with induction of anesthesia or 1.2 g of co-amoxiclav with the induction of anesthesia).
- With the strength of evidence available to show the benefifits of antibiotic prophylaxis for hysterectomy and TOP, particularly with respect to covering both chlamydia and BV, together with many other sources of national clinical guidelines and recommendations from government and national expert advisory groups, failure to follow the advice would leave clinicians open to medical litigation.
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