Prophylactic antibiotic administration prior to hysterectomy: a quality improvement initiative

OBJECTIVE: To determine whether institution of a preoperative antibiotic policy could increase the use of prophylactic antibiotics prior to hysterectomy. STUDY DESIGN: A retrospective cohort study of 400 women who underwent abdominal, vaginal or laparoscopic hysterectomy for benign indications at Women and Infants Hospital was performed. Rates and timing of prophylactic preoperative antibiotic administration were determined, as were the rates of postoperative febrile morbidity. These data were compared to data collected in a medical record review of 686 hysterectomies performed prior to institution of the antibiotic policy. RESULTS: Prior to the institution of the antibiotic policy, 50% of patients (342/686, 95% CI 46.0, 53.7) received prophylactic preoperative antibiotics. After introduction of the antibiotic policy, 91.2% (95% CI 88.0, 93.8) of patients received prophylactic preoperative antibiotics. Approximately 66% of the antibiotics were administered within the 60 minutes preceding the surgical incision. Postoperative febrile morbidity was noted in 14% of patients prior to the antibiotic policy as compared to 11% of patients after the policy was instituted. Abdominal surgical approach was found to be a clinically and statistically significant risk factor for febrile morbidity (OR = 7.0; 95% CI 2.3, 20.9). CONCLUSION: Rates of prophylactic preoperative antibiotic administration significantly increased after institution of a hospital policy advocating routine antibiotic prophylaxis prior to hysterectomy. Additional steps must be taken to ensure more routine and appropriately timed administration of antibiotics prior to hysterectomy and to continuously monitor the use of prophylactic antibiotics.     

A comparison of piperacillin, cephalothin and cefoxitin in the prevention of postoperative infections in patients undergoing vaginal hysterectomy

A randomized, double-blind, multicenter trial was initiated to compare the safety and efficacy of piperacillin, cephalothin and cefoxitin in the prophylactic treatment of patients undergoing vaginal hysterectomy. The total dose of each antibiotic was 6 grams given in three equally divided doses. A satisfactory prophylactic response was obtained in 143 of 151 (95 per cent) patients treated with piperacillin, in 82 of 87 (94 per cent) patients treated with cephalothin and in 57 of 60 (95 per cent) patients treated with cefoxitin. The pooled data indicated that the piperacillin treatment group did not differ from the combined cephalosporin treatment groups with respect to prophylactic response, presence of febrile morbidity, fever index, duration of postoperative hospitalization and incidence of reported adverse experiences.     

Controlled, comparative study of moxalactam and cefazolin for prophylaxis of abdominal hysterectomy

Moxalactam was compared with cefazolin and a control group to determine the efficacy and value of a third generation cephalosporin in abdominal hysterectomy antibiotic prophylaxis. One hundred patients were prospectively randomized in a double-blind manner between moxalactam and cefazolin. An additional 50 patients who were either allergic to penicillin or refused participation in this study were simultaneously observed to establish a base line level of infection on our service during this time period. Dosage for both antibiotic groups was 1 gram given intravenously or intramuscularly on call to the operating room followed by two 1 gram doses at six and 12 hours after the first dose. Standard febrile morbidity was 36, 30 and 42 per cent for moxalactam, cefazolin and control groups, respectively. Postoperative surgical infection requiring antibiotic treatment occurred in 8, 6 and 4 per cent, respectively; urinary tract infection or symptomatic findings, or both, requiring treatment occurred in 8, 10 and 10 per cent, respectively. No pelvic abscesses occurred in this series. In every statistical evaluation of postoperative morbidity, there were no differences noted among the three groups. Our results suggest no benefit from the use of prophylactic antibiotics in abdominal hysterectomy in terms of standard febrile or infectious morbidity or urinary tract pathologic findings. In addition, there was no difference between the two antibiotic groups.     

Risk factors for febrile morbidity after hysterectomy

OBJECTIVE: To identify risk factors for febrile morbidity after hysterectomy for nonmalignant indications. METHODS: We performed a retrospective cohort study of 686 women who had a hysterectomy between January and September 1997 by abdominal (n = 408), laparoscopic-assisted vaginal (n = 90), or vaginal (n = 188) approaches. Potential risk factors for febrile morbidity were extracted from the medical records. By means of multivariable logistic regression, we evaluated demographic, reproductive, clinical, and operative risk factors for febrile morbidity. RESULTS: The risk of postoperative febrile morbidity in this population was 14%. Only 50% of women received prophylactic antibiotics, whereas almost 20% received no antibiotics at all, and 30% were administered antibiotics after surgical incision. Risk factors for febrile morbidity after hysterectomy, after controlling for age, body mass index, operative time, and prophylactic antibiotic administration, were abdominal approach (odds ratio 2.7; 95% confidence interval 1.6, 4.3) and blood loss at surgery of more than 750 mL (odds ratio 3.5; 95% confidence interval 1.8, 6.8). CONCLUSION: Hysterectomy by abdominal approach and increased blood loss at the time of surgery significantly increase the risk of febrile morbidity. Preventive efforts should focus on methods to reduce postoperative febrile morbidity, including meticulous surgical technique and routine use and appropriate timing of prophylactic antibiotic therapy.     

Effectiveness of perioperative preventive use of antibiotics with metronidazole or doxycycline in vaginal hysterectomy

To prove the effectiveness of perioperative antibiotics prophylaxis (PABP) in prevention of postoperative infections after vaginal hysterectomy the efficacy of rectale Metronidazole application (5 times 500 mg; n = 192) was compared with that of Doxycyclin (2 times 200 mg intravenously; n = 116). The infectious morbidity after both prophylactic antibiotic regimes was compared to that of an untreated group (n = 186). In spite of additionally colporrhapies the feverish standard morbidity without prophylaxis was 13.4%, after Metronidazole application 13.5% and after Doxycyclin 2.6% (p less than 0.05). Simultaneously the rate of necessary antibiotic treatment decreased significantly. Pelvic infections complicated 16.7% of vaginal hysterectomies having no prophylaxis, but only 4.3% after Doxycyclin medication (p less than 0.05). Postoperative urinary tract infections (UTI)--mostly asymptomatic bacteriuria--were not influenced by any PABP. Whereas UTI after bladder catheter duration shorter than two days occurred in 26.0% (without PABP), 29.9% (Metronidazole) respectively 18.2% (Doxycyclin; p greater than 0.05), the rates after a longer stay were 69.6%, 76.8% and 65.7%. It is concluded, that the febrile standard morbidity and pelvic infections were reduced as well as the rate of necessary antibiotics therapies by a prophylactic application of Doxycyclin, but not with Metronidazole. The incidence of postoperative UTI was not reduced by prophylaxis.     

Low-dose carbenicillin prophylaxis for vaginal and abdominal hysterectomy.

A double-blind prospective study of 99 patients undergoing vaginal and abdominal hysterectomy was performed at North Carolina Baptist Hospital of the Bowman Gray School of Medicine at Wake Forest University. The study indicated that low-dose intravenous carbenicillin begun preoperatively and continued for 24 hours resulted in decreased febrile morbidity, postoperative infection rate, and shortened hospital stay in patients undergoing both vaginal and abdominal hysterectomy. The indications for operation, clinical characteristics of patients, and operative and postoperative management were similar for the control and study groups. For the vaginal hysterectomy group, febrile morbidity was reduced from 34.6% in the control group to 7.7% in the group receiving carbenicillin. For patients undergoing abdominal hysterectomy, febrile morbidity was reduced from 54.1% in the control group to 4.0% in the group receiving prophylactic carbenicillin. Similar reductions for the carbenicillin study group in fever index and average total hospital stay were also noted. Urinary tract infections were determined to be present more commonly in the group of patients with febrile morbidity receiving no prophylactic antibiotics. The incidence of pelvic infections were reduced in both carbenicillin-treated groups. This investigation suggests that low-dose carbenicillin prophylaxis is beneficial in reduction of morbidity following both vaginal and abdominal hysterectomy.     

Prophylaxis of minor febrile and major infectious morbidity following hysterectomy.

A retrospective analysis was conducted of 668 consecutive cases using T-tube suction drainage and/or prophylactic antibiotics as infection prophylaxis for hysterectomy. The data are analyzed for the incidence of minor febrile morbidity (temperature greater than 100.4 for 2 days) and for major infection (hospital stay more than 14 days, reoperation or readmission for the management of pelvic abscess or pelvic thrombophlebitis). The study also compares a minor febrile and major infection group with a noninfected group by measuring parameters of patient discomfort, medical staff effort, and financial costs. It is concluded that 1) minor febrile morbidity frequently follows abdominal (20--30%) and vaginal (30--50%) hysterectomy; 2) minor febrile morbidity has temporary but significant consequences in the form of increased patient discomfort, medical staff effort, and financial costs; 3) major infections are rare following abdominal hysterectomy (less than 0.5%) and uncommon following vaginal hysterectomy (1--4%); 4) suction drainage used alone, prophylactic antibiotics used alone, or a combination of suction drainage and antibiotic prophylaxis is each associated with a statistically significant reduction in the incidence of minor febrile morbidity following both abdominal and vaginal hysterectomy (P = less than 0.01); and 5) such infection prophylaxis may also reduce the incidence of major infection following vaginal hysterectomy.     

Complications of hysterectomies]

The authors review results concerning 1,127 hysterectomies performed in the Department of Obstetrics and Gynecology of the La Grave Hospital (Toulouse, France). They compare those of abdominal hysterectomy and those of vaginal hysterectomy (359). With regard to vaginal procedures, they draw a distinction between simple hysterectomies and prolapse repairs. The results of this series are comparable with those in the literature: similar overall morbidity after vaginal (41 per cent) and abdominal (33 per cent) hysterectomy. This morbidity was lower in cases of simple vaginal hysterectomy (26 per cent). The majority of complications were infectious or febrile: 29 per cent of abdominal hysterectomies and 30 per cent of vaginal hysterectomies, including 16.4 per cent of simple vaginal hysterectomies. The authors compared abdominal hysterectomies and simple vaginal hysterectomies. The latter have many advantages: rarer mortality, overall morbidity and thrombo-embolic complications, shorter hospital stay, more comfortable and less costly postoperative course. Thus when the choice is available, gynecologists should opt for vaginal hysterectomy.     

An evaluation of prophylactic doxycycline in hysterectomy patients.

Although data now exist that the use of prophylactic antibiotics reduces postoperative febrile morbidity in hysterectomy patients, some controversy remains about this point of view. This prospective, double-blind, randomized study evaluated the use of doxycycline before and during the first three postoperative days after abdominal and vaginal hysterectomy in private patients. The results indicate a reduction in the febrile morbidity in the drug group as compared to the placebo group.     

Single-dose antibiotic prophylaxis in women undergoing vaginal hysterectomy

One hundred thirty-five patients undergoing vaginal hysterectomy were randomly assigned to one of three regimens of prophylactic antibiotics. There was no statistically significant difference among the three groups in the incidence of postoperative pelvic cellulitis, fever index, or duration of hospitalization. A single preoperative dose of cefazolin was as effective as three perioperative doses of cefazolin or a single dose of cefonicid in preventing postoperative infectious morbidity.     

The effect of prophylactic antibiotics on pelvic infection following vaginal hysterectomy

The effect of prophylactic penicillin and streptomycin on postoperative pelvic infection and hospital stay following vaginal hysterectomy was studied. 92 patients received 600,000 U procaine pencillin plus .5 gm streptomycin 12 hours prior to operation and every 8 hours following operation for 3 days. 8 patients allergic to penicillian received 1 gm cephaloridine rather than penicillian and streptomycin. 100 patients undergoing vaginal hysterectomy received no prophylactic antibiotics. Morbidity caused by pelvic infection was significantly reduced (p less than .01) from 19 to 1% and urinary tract infection decreased from 6 to 2% when prophylactic antibiotics were employed. Total postoperative morbidity was decreased from 37 to 8% (p less than .01) and postoperative hospital stay was reduced from 6.3 to 5 days (p less than .002) when prophylactic antibiotics were administered.     

Radical hysterectomy: influence of recent conization on morbidity and complications.

From 1956 through 1975, 610 radical hysterectomies with pelvic lymphadenectomy were performed at the Mayo Clinic. Eighty-eight of these operations were done after conization of the cervix: 7, within 7 days; 74, between 8 and 28 days; and 7, on or after the 29th day. Operative febrile morbidity was not increased in the patients who had conization, and they also required fewer blood transfusions than the patients without previous conization. Incidences of all postoperative complications except pulmonary embolism were lower in the patients with cone biopsy than in those without. Of the 88 patients, 77% received antibiotics prophylactically during the operative period. There appeared to be no serious contraindications to performing radical hysterectomy and pelvic lymphadenectomy at any interval after diagnostic conization of the cervix.     

Randomized double-blind comparison of mezlocillin versus cefoxitin prophylaxis for vaginal hysterectomy

One hundred patients undergoing vaginal hysterectomy were enrolled in a randomized double-blind comparative antibiotic prophylaxis study. Forty-six patients received mezlocillin and 54 patients received cefoxitin. No significant difference was found among patients who developed febrile morbidity. Failure rate for mezlocillin was 17 per cent and for cefoxitin, 15 per cent. There was an increase in colonization of Streptococcus faecalis and Enterobacter species in patients receiving three doses of cefoxitin prophylaxis.     

Prophylactic antibiotics for women undergoing vaginal hysterectomy.

A triple-blind prospective study of women undergoing vaginal hysterectomy was conducted to compare cefazolin, cephaloridine and no antibiotic, Both cefazolin and cephaloridine were given preoperatively, whereas only cephaloridine was given postoperatively. One gram of cefazolin given intramuscularly on call to the operation room was found to be a safe and effective antibiotic for prophylaxis against febrile morbidity. The proper utilization of prophylactic antibiotics seems to be in the immediate preoperative period. The use of antibiotics after the first day of surgery is unnecessary.     

Preventing febrile complications of suction curettage abortion

To identify risk factors for febrile complications after suction curettage abortion, we analyzed the data of 26,332 women who underwent suction curettage abortion at five participating centers in the Joint Program for the Study of Abortion, Part III, from 1975 to 1978. We defined febrile morbidity as an oral temperature of greater than or equal to 38 degrees C for 2 days or longer. The febrile morbidity rate was 0.34 per 100 abortions. We performed a multivariate analysis using a linear logistic regression model. Prophylactic antibiotics proved to be the most protective factor, reducing the rate of febrile complications to about one third that of women who received no prophylactic antibiotics (relative risk 0.36; 95% confidence interval 0.18 to 0.70). Patients who had had one or more previous births also had a significantly lower risk of febrile morbidity (relative risk 0.54; 95% confidence interval 0.33 to 0.88). Other factors did not significantly affect the febrile complication rate.     

The prognostic significance of glandular involvement in cold knife conization biopsies in carcinoma in situ of the uterine cervix: an analysis of 136 cases

One hundred thirty-six cases of carcinoma in situ of the uterine cervix have been analyzed to determine the possible prognostic significance of endocervical glandular involvement in in situ tumor in the pretreatment conization biopsies.One hundred thirty conization biopsies were performed prior to initiation of any definitive therapy. Forty-five cases, or 34.7 per cent, were found to have involvement of the endocervical glands; 10, or 7.6 per cent, were negative for cancer; and the remainder were positive for cancer in situ without glandular involvement.Thirty-six, or 27.3 per cent of the 132 patients treated, were found to harbor residual tumor in the postoperative specimens. Fourteen, or 38.8 per cent of the cases with residual tumor in the postoperative specimen, were derived from the 45 conization biopsies with endocervical glandular involvement, for an incidence of 31.1 per cent. The remaining 22 cases, or 61.2 per cent, were derived from 75 conization biopsies without involvement of the endocervical glands, for an incidence of 29.3 per cent.Sixty-three patients, or 46.4 per cent of the total series, have been adequately followed since being treated and 73, or 53.6 per cent, have been lost to follow-up over a period of seven years. Twenty-one patients, or 15.4 per cent of the combined groups, have been free of recurrence over five years.Fourteen, or 18.8 per cent of the seventy-five patients without involvement of the endocervical glands in the conization biopsies, have been followed for five years without recurrence of disease, whereas 4, or 8.8 per cent of the 45 with glandular involvement in the conization biopsies, have attained the five-year salvage mark safely.Fifteen, or 15.6 per cent of the 96 patients without residual tumor in the postoperative specimens, were followed for five years without recurrence of disease, while 6, or 16.6 per cent of the 36 with residual disease in the post-operative specimens, were also followed uneventfully for a five-year period.Six patients in the series had extensive glandular involvement in the conization biopsies and no involvement of glands in the preceding quadrant biopsies, thus demonstrating a progression of the disease microscopically.Both cases of invasive cancer of the cervix diagnosed in the postoperative specimens in the series were preceded by extensive endocervical glandular involvement in the cones.There were 3 cases of residual tumor in the postoperative specimen that were preceded by conizations negative for evidence of cancer.There were 4 cases in the series that were diagnosed during pregnancy and treatment was individualized in each case as noted in Table XI.There have been no deaths in the series to date that could be attributed to carcinoma in situ of the uterine cervix to the best of our knowledge.     

Prophylactic antibiotics in cesarean section: A double-blind study

Sixty-one patients were prospectively evaluated as to the worth of prophylactic antibiotics in cesarean section. Ampicillin, kanamycin, and methicillin were administered in double-blind fashion before and 2 and 8 hours after operation. The patients were evaluated for morbidity. An over-all 27 per cent infection rate was found in the antibiotic group as compared to a 61 per cent rate in the placebo group. No correlation was noted in age, hospital stay, organism, or rupture of membranes. The repeat sections in the antibiotic group have a statistically significant lower infection rate.     

The timing of antibiotics at cesarean: a randomized controlled trial

We compared maternal and neonatal outcomes in women who received prophylactic antibiotics prior to skin incision to those who received antibiotics at cord clamp. We performed a randomized clinical trial at two sites. Eligible women included those undergoing nonemergency cesarean at 36 weeks' gestation or greater. Subjects were randomized (permuted blocks) into one of two treatments: "preoperative antibiotics" (cefazolin 1 g given <30 minutes prior to skin incision) or "intraoperative antibiotics" (cefazolin 1 g at cord clamping). Patients who reported an allergy to penicillin received clindamycin 900 mg. The trial primary outcome was a composite of maternal infectious morbidities, defined as having any one of the following: (1) postoperative fever (defined as oral temperature >38°C on two separate occasions more than 6 hours apart, after the initial 24-hour postoperative period); (2) wound infection (defined as purulent discharge from the incision); (3) endomyometritis (defined as fundal tenderness and fever malodorous lochia, fever); (4) urinary tract infection (defined as fever, positive urine culture). We enrolled a total of 434 subjects in this study, with 217 in each group. Overall, we found no difference in composite maternal infectious morbidity between those who received antibiotics preoperatively and those who received antibiotics at cord clamp (relative risk = 1.2, 95% confidence interval 0.7 to 1.5). Neonatal outcomes were also similar between the two intervention arms. The rate of suspected sepsis was similar between the two groups. There were no cases of antibiotic resistance in the neonates. Either preoperative antibiotic therapy or antibiotic administration after cord clamp is a reasonable clinical method for reducing the risk of postcesarean infectious morbidity.     

Evaluation of the method of delivery in breech presentation]

The authors report a retrospective study based upon 543 breech deliveries at term, collected between 1987 and 1990. The cesarean section rate was 18.4 per cent. It was prophylactic in 56 cases. When the possibility of vaginal delivery was accepted, cesarean section was performed in 9 per cent of cases. Fetal mortality and morbidity were higher with vaginal delivery. However, maternal morbidity was greater in the cesarean section group. Study of the literature shows that the increase in cesarean section rate in recent years is not the only factor responsible for improved fetal prognosis. It is therefore important to restrain this increase and find the optimum percentage rate.