Prospective randomized comparison of single-dose versus 1-day cefazolin for prophylaxis in gynecologic surgery

BACKGROUND: The purpose of this prospective, randomized study was to compare the efficacy of single-dose versus 1-day cefazolin prophylaxis for the prevention of postoperative gynecologic infections. METHODS: From June 2001 to January 2003, 548 patients were randomized to receive either single-dose (1 g of cefazolin intravenously before surgery, 273 patients) or 1-day cefazolin (1 g intravenously before surgery and three more doses every 6 hr after surgery, 275 patients) prophylaxis. RESULTS: A total of 531 (267 patients in the single-dose group and 264 in the 1-day group) completed the study. Only one of 267 (0.37%) patients in the single-dose group developed a trocar wound infection and one of 264 (0.37%) patients in the 1-day group developed a vaginal cuff infection. Had a single dose of prophylactic antibiotics been administered to all patients, the antibiotic cost would have been reduced by 75-80%. CONCLUSIONS: The use of single-dose preoperative cefazolin prophylaxis was as effective as four doses of cefazolin for preventing serious infectious morbidity among our patients. Shortening the duration of antibiotics prophylaxis also reduced medical costs and microorganism resistance.     

Local prevention of infection with metronidazole before vaginal hysterectomy--comparative effect compared with systemic prevention?]

A prospective clinical trial was designed to examine the influence of a local intravaginal application of metronidazole on postoperative infectious morbidity in 114 women undergoing vaginal hysterectomy. On the evening before vaginal hysterectomy, 51 patients received a vaginal suppository of metronidazole (500 mg). These patients were compared with a group of 63 patients who were given a single-shot prophylaxis with 1,500 mg cefuroxime intravenously. With regard to febrile morbidity, urinary tract infection and pelvic infection there was no significant difference in the two treatment groups. There was no statistically significant difference in the postoperative duration of hospital stay and additional antibiotic therapy between the two groups either. We did not see serious infections in our examination. Our results suggest that a local single-dose application of metronidazole in vaginal hysterectomy might have the same efficacy on postoperative infectious morbidity than a systemic antibiotic prophylaxis and that it can reduce antibiotic costs.     

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.     

Single-dose antibiotic prophylaxis in high-risk patients undergoing cesarean section

A prospective, double-blind, placebo-controlled study was performed to determine the effectiveness of single-dose antibiotic prophylaxis in decreasing infectious complications after primary cesarean section. One hundred women at high risk for postoperative infectious morbidity were randomly assigned to receive either placebo or one 2-g dose of ceftizoxime at cord clamping. The incidence of endometritis in the antibiotic group was 6.0 versus 24.5% in the placebo group (P less than .05). The incidence of febrile morbidity in the group receiving one dose of ceftizoxime was 14.0 versus 32.7% in the placebo group (P less than .05). Single-dose ceftizoxime prophylaxis significantly reduced the incidence of endometritis and febrile morbidity in high-risk patients undergoing cesarean section.     

Postoperative infections and antibiotic prophylaxis in radical hysterectomy. Retrospective study]

Radical hysterectomy is associated with a high risk of postoperative infectious morbidity. A series of 73 patients who underwent abdominal radical hysterectomy with pelvic lymphadenectomy is presented. Hospital charts were reviewed to determine the influence of surgical characteristics and of different antibiotic prophylaxis regimens on postoperative septic complications. The overall incidence of postoperative infections was 31.5%; in 13 patients had urinary tract infections (17.7%), 3 surgical site-related infections (4.1%) and 6 febrile morbidity (8.2%). There were also 3 cases of phlebitis and 3 infectious events at distant sites. No interaction was observed between the examined risk factors and the overall infectious morbidity. Time of surgical procedure and average blood transfusion show a trend toward increased values in patients with complications compared to patients with regular postoperative course. The most important current controversy about the use of prophylaxis in radical hysterectomy concerns the duration of postoperative treatment. In this series the major part of the subjects received a long-term antibiotic prophylaxis regimen (greater than 72 hours), and only 18% received a perioperative prophylaxis. Women without postoperative complications were more frequently treated with a long-term antibiotic prophylaxis (82%) compared to women with infectious morbidity (65%). Moreover, in patients with complications, the proportion of cases who needed an additional antibiotic therapy was lower in the group receiving long-term prophylaxis (20%) compared to the short-term group (83%).     

A comparison of cefonicid and cefoxitin for preventing infections after vaginal hysterectomy

One hundred women who underwent vaginal hysterectomy were randomly and prospectively divided into two study groups, one to receive a single, 1-g preoperative dose of cefonicid and the other to receive 2 g of cefoxitin preoperatively and postoperatively for a total of four doses. There were no differences between the two groups in the rates of febrile morbidity, urinary tract infection, serious infection, noninfectious morbidity or duration of hospitalization. Both cefonicid and cefoxitin were equally effective in preventing postoperative infectious morbidity and demonstrated little difference in side effects. The single-dose regimen of cefonicid provides the advantages of decreased cost and prolonged therapeutic tissue levels when compared to cefoxitin. Perioperative antimicrobial prophylaxis with this single-dose cephalosporin provides a cost-effective regimen that is both safe and prophylactically effective.     

Prevention of infectious morbidity after elective abdominal hysterectomy

Objective

Our aim was to investigate whether posthysterectomy infectious morbidity could be reduced by intravaginal therapy before operations.

Materials and methods

Women expected to undergo elective total abdominal hysterectomy were included. Vaginal flora was evaluated by preoperative Gram-stained vaginal smears up to Nugent’s criteria. Study group were administered vaginal combination therapy including 500?mg metronidazole and 100?mg miconazole nitrate two times a day for 7?days. Control group were not given any preoperative vaginal therapy. Postoperative infectious morbidity was evaluated and compared.

Results

Ninety-five women in the study group and 97 women in the control group completed the study protocol. Women with abnormal flora had significantly more wound and vaginal cuff infections than the women with normal flora in the control group. Urinary infections were significantly higher in the study group (38.9 vs. 23.7?%) and vaginal cuff infections were significantly higher in the untreated control group (2.1 vs. 8.2?%).

Conclusions

We concluded that postoperative vaginal cuff infections can be decreased by treating abnormal vaginal flora before elective abdominal hysterectomies.     

Antibiotic prophylaxis of infective complications after cesarean section. Our experience

BACKGROUND: The efficacy of a single dose of antibiotic vs multiple doses of the same drug, in reducing maternal infections following the cesarean section, is evaluated. METHODS: A total of 206 pregnant women undergoing elective or emergency cesarean section from 1st June 1998 to 30 June 1999, at the Department of Obstetrics and Gynecology of the University of L'Aquila, were included in a randomized study to compare the efficacy of prophylaxis with a single dose of piperacillin sodium (2 g i.v. after the umbilical cord clamping; group A) vs triple doses of the same antibiotic (2 g i.v. at 6 hourly intervals, beginning from the umbilical cord clamping; group B). RESULTS: The incidence of infective morbidity in group A was 7.3%, with a 2% wound infections, 1% urinary infections and 4.16% febrile morbidity. The incidence of infective morbidity in group B was not much higher (9%), with 2.7% wound infections, 1.8% urinary infections and 4.5% febrile morbidity. CONCLUSIONS: In order to obtain a useful antibiotic prophylaxis in cesarean sections, the single-dose seems to be preferable to the multiple-doses, since the single-dose not only has equal efficacy, but also less cost, smaller risk of super-infections by resistant organisms and it involves smaller care from the-medical and nursing staff.     

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.     

The hematologic effects of latamoxef sodium when used as a prophylaxis during surgical treatment

Latamoxef sodium, a third generation cephalosporin antibiotic, has been shown to provide good prophylaxis against postoperative infection. It has, however, been implicated as causing disturbances of hemostasis particularly when used in treatment. We have studied 40 patients who required antibiotic prophylaxis prior to surgical treatment randomizing and stratifying them according to age and type of operation, to receive either latamoxef or piperacillin. Five hematologic parameters were studied, prothrombin time, activated partial thromboplastin time, plasma factor II concentration, plasma factor VII concentration and platelet count. Minor differences were noted with latamoxef producing mild persistant elevation of prothrombin time (0.7 second) associated with depression of factor II and factor VII. In our study, we found that, when used as three dose, single agent prophylaxis, there was no difference between latamoxef and piperacillin in producing clinical disturbances of hemostasis. However, attention is drawn to the importance of recognizing that hemostatic disturbances can occur after the use of broad spectrum antibiotics as prophylaxis for surgical treatment Mechanisms of hemostatic disorders are reviewed and alternative hypotheses are suggested.     

Effectiveness of perioperative preventive use of antibiotics with ampicillin/gentamycin or cefotiam in abdominal cesarean section

To prove the effectiveness of perioperative antibiotics prophylaxis (pabp) in prevention of postoperative infections after caesarean section the efficiency of a Ampicillin/Gentamycin combination was compared with that of Cefotiam (Halospor). The infectious morbidity after both prophylactic antibiotic regimes was compared to that of an untreated sectioned group. The feverish standard morbidity (fsm) of all caesarean sections (between 1. 7. 1986-30. 6. 1988; n = 354) decreased by selective pabp from 25.3% to 16.7%. Compared with untreated patients (no infectional risk; fsm: 22.4%) the infectional morbidity after caesarean section was reduced by Ampicillin/Gentamycin (fsm: 10.0%; p less than 0.05) and also by Halospor (fsm: 13.7; p greater than 0.05). Uterine (14.5%) and urinary tract infections (6.6%) were the most frequent causes of fever during puerperium. After pabp the frequency of this causes decreased evidently. The rate of postoperative antibiotics therapies went down from 26.3% without pabp to 13.3% (p less than 0.05) with Ampicillin/Gentamycin respectively 13.7% (p less than 0.05) with Cefotiam. It is concluded, that the feverish standard morbidity was reduced by a selective papb both with Ampicillin/Gentamycin and Halospor. As a consequence of our results we are performing the pabp with a single dose of 2 g Halospor combined with 0.5 g Metronidazol in all sections generally.     

Single-dose cefazolin prophylaxis for cesarean section

In a prospective, randomized trial, the efficacy of a single-dose, first-generation, long-acting cephalosporin was compared with a three-dose regimen in a group of 100 women undergoing cesarean section who were at high risk for postoperative febrile morbidity. Fifty women received a single 1 gm intravenous dose of cefazolin and 50 received 1 gm of the drug followed by two additional doses, 8 hours apart, to complete a three-dose regimen. Another 50 women, considered to be at low risk for postoperative febrile morbidity, were not given antibiotic prophylaxis. Outcomes of febrile morbidity (18% vs 12%) and particularly morbidity caused by endometritis (6% vs 8%, respectively) were similar for single-dose and three-dose groups. In the untreated low-risk group there were no cases of endometritis and the febrile morbidity was comparable to that of the prophylactically treated groups (14% vs 15%). Single-dose cefazolin prophylaxis appears to be comparable to multidose prophylaxis in reducing febrile morbidity after cesarean section.     

Single-dose cefotetan versus multidose cefoxitin for prophylaxis in cesarean section in high-risk patients

A prospective, randomized, open trial of a single intravenous dose of a new broad-spectrum and long-acting cephalosporin was compared with the effect of three doses of cefoxitin in a group of 70 women undergoing cesarean section who were at high risk for postoperative endomyometritis and wound infection. All patients either had ruptured membranes or were in active labor, or both, without clinically detectable chorioamnionitis at the time of prophylaxis. Forty-six women received a single 2 gm dose of cefotetan and 24 received 2 gm of cefoxitin every 4 hours to complete a three-dose regimen. Outcomes of infectious febrile morbidity due to endomyometritis (15% versus 8%), wound erythema (4% versus 12%), and other parameters were similar for cefotetan and cefoxitin, respectively. Both agents were well tolerated in this high-risk population. Within the limits of this study, single-dose cefotetan chemoprophylaxis appears to be comparable to multidose cefoxitin administration in reducing morbidity in operative site infections after cesarean section.     

T-tube suction drainage and/or prophylactic two-dose metronidazole in abdominal hysterectomy

The efficacy of a two-dose perioperative course of rectally administered metronidazole and/or suction drainage of the vaginal vault in preventing febrile and infectious morbidity was evaluated in a randomized study of 198 patients undergoing abdominal hysterectomy. When compared with the control values, the incidence of febrile morbidity was significantly reduced (from 49% to 10%, 24.5%, and 10% respectively) in the groups treated with metronidazole, T-tube suction drainage, and a combination of the two prophylactic measures. The incidence of infectious morbidity was significantly reduced by using prophylactic metronidazole alone or in combination with suction drainage, but the reduction was most significant in the group treated with metronidazole alone. In the group managed with suction drainage alone, no reduction in infectious morbidity was found. The rate of postoperative urinary tract infection was significantly lower in the group treated with metronidazole alone as compared with the control group. No side effects of metronidazole were encountered.     

Amoxycillin-clavulanic acid (Augmentin) versus metronidazole as prophylaxis in hysterectomy: a prospective, randomized clinical trial

Summary. In order to determine the most effective regimen for the prevention of infection after elective hysterectomy, 300 patients were randomly assigned to receive three perioperativc doses of either amoxycillin-clavulanic acid (1.2 g intravenous) or metronidazole (1 g suppository). Of the 280 patients who were assessable 138 were given amoxycillin-clavulanic acid and 142 received metronidazole; 268 underwent abdominal hysterectomy and 12 had vaginal hysterectomy. Patients in the amoxycillin-clavulanic acid group had significantly less infectious morbidity (13.8%) than those in the metronidazole group (33.1%). There were also statistically significant differences in favour of amoxycillin-clavulanic acid with respect to operative site infection, duration of hospital stay, need for postoperative antimicrobials, and surgery for operative site infection. But for one isolate of Bacteroides fragilis , all pathogens isolated from wound infections in the metronidazole group were aerobes. No anaerobes were isolated from patients in the amoxycillin-clavulanic acid group. The results suggest that prophylaxis for hysterectomy should consist of an agent, or combination of agents, with activity against both aerobic and anaerobic bacteria. Amoxycillin-clavulanic acid fulfils this criterion and appears to be effective and safe.     

Amoxycillin-clavulanic acid (Augmentin) versus metronidazole as prophylaxis in hysterectomy: a prospective, randomized clinical trial

In order to determine the most effective regimen for the prevention of infection after elective hysterectomy, 300 patients were randomly assigned to receive three perioperative doses of either amoxycillin-clavulanic acid (1.2 g intravenous) or metronidazole (1 g suppository). Of the 280 patients who were assessable 138 were given amoxycillin-clavulanic acid and 142 received metronidazole; 268 underwent abdominal hysterectomy and 12 had vaginal hysterectomy. Patients in the amoxycillin-clavulanic acid group had significantly less infectious morbidity (13.8%) than those in the metronidazole group (33.1%). There were also statistically significant differences in favour of amoxycillin-clavulanic acid with respect to operative site infection, duration of hospital stay, need for postoperative antimicrobials, and surgery for operative site infection. But for one isolate of Bacteroides fragilis, all pathogens isolated from wound infections in the metronidazole group were aerobes. No anaerobes were isolated from patients in the amoxycillin-clavulanic acid group. The results suggest that prophylaxis for hysterectomy should consist of an agent, or combination of agents, with activity against both aerobic and anaerobic bacteria. Amoxycillin-clavulanic acid fulfils this criterion and appears to be effective and safe.     

Single-dose and multidose prophylaxis in vaginal hysterectomy: a comparison of sodium cephalothin and metronidazole

A total of 79 patients underwent vaginal hysterectomy and were randomly assigned to three regimens of prophylactic antibiotics: multidose intravenous sodium cephalothin, single-dose intravenous sodium cephalothin, and single-dose oral metronidazole. Control groups were selected from two previous studies conducted at our institution. The incidence rates of infectious morbidity following all three regimens of antibiotics were substantially lower than in the control groups. There was no statistically significant difference in the incidence of standard febrile morbidity and serious pelvic infections among the three groups. The fever index was lowest in the single-dose sodium cephalothin group.     

Initial results of perioperative antibiotic premedication with halospor and gentamycin in cesarean section

The perioperative application of antibiotics in prophylaxis of infections is disputed. In a preliminary prospective study the infections morbidity of 44 patients after caesarean section was determined to investigate the effect of short term prophylaxis with halospor and gentamycine. A control group of 104 patients remained without any antibiotic prophylaxis. The patients of the prophylaxis group showed a statistically significant reduction of postoperative infectious morbidity. The costs are equalized by reduction in therapeutic applications of antibiotics.     

The selective use of vaginal hysterectomy in the management of adenocarcinoma of the endometrium

A prospective, blinded, placebo-controlled study was performed to determine the minimum effective duration of short-term antibiotic prophylaxis following cesarean section. Cefoxitin was selected as the study drug, and 189 women at high risk for postoperative infectious morbidity were randomly assigned to three cohorts, each receiving intravenous infusions at cord clamping and at 4 and 8 hours postoperatively. The incidence of endometritis in the placebo group was 29.3% versus 9.4% in patients receiving one dose of cefoxitin (2 gm) at cord clamping and 5.0% in patients receiving three doses of cefoxitin (p less than 0.0001). Cefoxitin prophylaxis significantly reduced the incidence of endometritis in patients with postoperative anemia. There were no serious complications or drug reactions in the treated groups.     

Ultra short-term antimicrobial prophylaxis in patients undergoing surgery for gynecologic cancer

OBJECTIVE: To evaluate the efficacy of ultra short-term antimicrobial prophylaxis with ceftazidime in patients undergoing radical gynecologic surgery. PATIENTS AND METHODS: Two hundred patients undergoing surgery for a malignant disease of the female genital tract were enrolled in a prospective trial to receive 2.0 g ceftazidime as a single dose, 30 minutes before induction of anaesthesia. After surgery, each patient was assessed to confirm febrile status and the presence of infections at the surgical site, urinary tract and respiratory tract. RESULTS: Postoperative morbidity occurred in 23 patients (11, 5%). Ten patients (5%) developed febrile morbidity, five (2, 5%) vaginal cuff infections, four asymptomatic bacteriuria and two each wound infiltration and urinary tract infection. Twelve patients had microbiological evidence of infection and Staphylococccus aureus was the most common pathogen isolated. Univariate analysis demonstrated that pre-existing systemic disease, extensive blood loss (more than 500 ml) and long duration of surgery (more than 150 minutes) were the only factors associated with a significant increase in postoperative febrile morbidity. CONCLUSIONS: Ultra short-term antimicrobial prophylaxis with ceftazidime is safe and effective in patients undergoing surgery for gynecologic cancer.