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.     

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.     

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.     

Cefotaxime for cesarean section prophylaxis in labor. Intravenous administration vs. lavage

To compare the efficacy of antibiotic prophylaxis through uterine lavage in women undergoing cesarean section in labor to the efficacy of the more standard, perioperative intravenous method, we prospectively randomized 100 women to receive either 2 g of cefotaxime in 1,000 mL of normal saline with a lavage protocol or 1 g of cefotaxime intravenously after cord clamping followed by 1-g doses 6 and 12 hours later. The two groups were similar with respect to age, gestational age, race, weight, length of labor and of ruptured membranes, use of internal monitoring, blood loss and number of vaginal examinations. Standard febrile morbidity and postpartum endomyometritis requiring antibiotic therapy occurred in 18% and 12%, respectively, of the lavage group and in 16% and 12%, respectively, of the intravenous group. Before the routine use of prophylactic antibiotics for cesarean section in labor on our service, the febrile morbidity and endomyometritis rates were 36% and 32%, respectively. The results confirm the benefit of prophylactic antibiotics for cesarean section in labor and demonstrate that the lavage and intravenous methods are similar with respect to efficacy.     

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.     

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.     

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%).     

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.     

Role of antibiotic prophylaxis in retropubic surgery for stress urinary incontinence

The effectiveness of prophylactic antibiotics was studied prospectively in 26 women undergoing retropubic urethropexy for genuine stress incontinence. Each of the 14 patients in the antibiotic prophylaxis group received three 1-g doses of intravenous cefazolin administered before, during, and 6-8 hours after surgery. Twelve women served as a control group and did not receive prophylactic antibiotics. Postoperative febrile morbidity and hospital stay were significantly less (P less than .01 and P less than .05, respectively) in patients who received prophylactic antibiotics.     

Prevention of major infection after elective abdominal hysterectomy: individual determination required

A retrospective chart analysis of women undergoing elective abdominal hysterectomy in Parkland Memorial Hospital indicated significant postoperative antibiotic administration. For that reason, we conducted a prospective, double-blind, placebo-controlled study to determine the incidence of infection and febrile morbidity in this patient population and to evaluate the efficacy of perioperative cefoxitin in modifying the incidence of these conditions. Three 2 gm intramuscular doses of cefoxitin over 12 hours significantly reduced the incidence of major infection to 12% from 32% observed in the placebo group. The mean hospital stay for women given cefoxitin (5.6 days) was also significantly reduced when compared to that for women given placebo (6.4 days). The incidence of febrile morbidity not requiring therapy was significant and was not altered by perioperative cefoxitin. Febrile morbidity was observed in 42% of women given cefoxitin and in 34% of women given placebo. Administration of perioperative antimicrobial agents is necessary for women undergoing elective abdominal hysterectomy in our hospital, but we believe that individual determination is required.     

Audit of infective morbidity following caesarean section at a district general hospital.

This paper sets out to audit infectious morbidity before and after introduction of a policy of antibiotic prophylaxis following emergency and elective caesarean section in a district general hospital in Scotland with approximately 3800 deliveries a year. In the first 'loop of audit', case notes of 200 consecutive patients managed during 1992 were studied. Audit loop was completed by studying 224 patients prospectively in 1993-94 following the introduction of new guidelines, which required the intraoperative administration of a single dose of intravenous antibiotic, following delivery of the baby. A significantly greater proportion of women received prophylactic antibiotics in 1993 compared with 1992 (81% vs. 14%; Diff= 67%; 95% CI 60%, 74%). The incidence of infection related morbidity was significantly reduced after routine antibiotic prophylaxis (28,5% vs. 16%; Diff= 12.5%, 95% CI=(4.60%,20.4%). The incidence of wound infection was halved in 1993 (9% vs. 17.5% in 1992). None of the patients in 1993 had a serious postoperative infection. Postnatal stay was significantly shorter in 1993 compared with 1992 (P < 0.0001). Although the target of adherence to the guidelines of 90% coverage was not met, this audit demonstrates the benefits of antibiotic prophylaxis for emergency and elective caesarean sections. Further reduction in morbidity may be obtained by strictly implementing the guidelines, and also by considering the use of multiple doses of antibiotics.     

Preoperative hot conization of the cervix: a possible method to reduce postoperative febrile morbidity following vaginal hysterectomy.

Laboratory results indicate that the endocervix may be a source of bacterial contamination when vaginal hysterectomy is performed. In a series of 160 consecutive vaginal hysterectomies in premenopausal women, hot conization of the cervix was performed prior to the scrub with an iodophore. No preoperative antibiotics were used in this series. The postoperative febrile morbidity rate was 4.3 per cent and the average stay was 4.5 days. These results are compared with those of three other groups: (1) patients who received a three-dose parenteral prophylactic antibiotic course with the first dose two hours prior to surgery had a febrile morbidity rate of 8.6 per cent. (2) In patients who had prophylactic antibiotics for five days with the first dose given intraoperatively, the febrile morbidity rate was 10.1 per cent. (3) The febrile morbidity rate in the group with no antibiotic prophylaxis or hot conization was 49.1 per cent. Laboratory and clinical data suggest that preoperative conization may be effective in the reduction of postoperative febrile morbidity.     

Comparison of lavage or intravenous antibiotics at cesarean section

The route of administration of prophylactic antibiotics was studied in a randomized prospective trial. Cefoxitin was administered to high-risk patients at cesarean section by three treatment regimens: intravenous antibiotic (2 g) for eight doses, irrigation of uterus and peritoneum with 2 g of antibiotic, and a combination of intravenous and irrigation as described. A control group received no antibiotic prophylaxis. The incidence of febrile morbidity was similar in each treatment group: intravenous, two of 39 (5%); irrigation, three of 42 (7%); intravenous and irrigation, two of 38 (5%), and were all significantly lower than the control group 14 of 39 (36%) (P less than .05). Similar results were found when prevention of endometritis was the end point: intravenous, two of 39 (5%); irrigation, two of 42 (5%); intravenous and irrigation, two of 38 (5%) compared with 13 of 39 (33%) in the control group (P less than .05). Administration of antibiotics by irrigation is equally effective in preventing postoperative febrile morbidity and endomyometritis as intravenous dosing and a combination of intravenous and irrigation. This affords a potential cost savings.     

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.     

Single-dose cefuroxime prophylaxis in non-elective cesarean section

A prospective randomized study was undertaken to evaluate the efficacy of a single dose of cefuroxime in alleviating infectious complications following non-elective cesarean section. One hundred and two women were allocated to receive 750 mg of cefuroxime after cord clamping and 99 were allocated to a control group not receiving any antibiotic prophylaxis. The incidence of febrile morbidity was 2.0% in the cefuroxime group and 19.2% in the control group (p less than 0.001). The incidence of endometritis in the two groups was 1.0% and 6.1%, respectively, the incidence of fever of unknown origin was 1.0% and 9.1%, respectively. Single-dose cefuroxime prophylaxis significantly reduced the incidence of febrile morbidity in patients undergoing non-elective cesarean section, without producing any side effects.     

Compliance with a risk-factor-based guideline for the prevention of neonatal group B streptococcal sepsis

Objective: The purpose of this study was to determine the compliance rate with a maternal risk-factor-based guideline for the prevention of neonatal group B streptococcal (GBS) sepsis.Methods: In August 1994, a risk-factor-based guideline for selective intrapartum prophylaxis against neonatal GBS was adopted by a group model health maintenance organization. This guideline identified the following maternal risk factors for neonatal GBS sepsis: preterm delivery, rupture of membranes for >18 h, fever/chorioamnionitis, and history of a previous GBS-affected child. Patients with one or more risk factors were to receive intrapartum antibiotic prophylaxis consisting of either ampicillin, erythromycin, or clindamycin. We conducted a retrospective chart review to record risk factors and use of antibiotics. We hypothesized that >90% of patients with risk factors would receive intrapartum chemoprophylaxis.Results: A total of 805 maternal charts were reviewed. Of these, 105 (13%) were candidates for intrapartum prophylaxis. We found an overall compliance rate of 65%. Compliance rates by risk factor were preterm delivery (51%), prolonged rupture of membranes (73%), fever/chorioamnionitis (87%), and previous affected child (100%).Conclusions: Our results show unexpectedly low compliance rates with a risk-factor-based guideline for the prevention of neonatal GBS sepsis. Only 65% of women with any risk factor for neonatal GBS sepsis received intrapartum antibiotic prophylaxis appropriately. Educational efforts to improve compliance with a risk-factor-based guideline should specifically address mothers delivering at 34-36 weeks gestation and mothers with prolonged rupture of membranes.     

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.     

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.     

Selective effect of cefoxitin prophylaxis on post-cesarean-section microbial flora

A double-blind study was done to test the efficacy of cefoxitin in the prevention of post-cesarean-section infection. The antibiotic was given in three 2-g doses; the initial dose was given immediately after the cord was clamped, and subsequent doses were given four and eight hours later. Cefoxitin prophylaxis significantly reduced morbidity serious enough to require therapeutic antibiotics or to prolong the hospital stay and led to an overall reduction in the anaerobic microbial flora of the endocervix. However, the antibiotic was selective for the overgrowth of enterococci, which were present in nearly half the postoperative cultures of patients who had received the drug. Enterococcal sepsis occurred in one patient, and three other patients had significant bacteriuria and/or urinary tract infections from enterococci. No cefoxitin-resistant strains of Enterobacteriaceae, among species normally sensitive to the drug, were isolated from the stool samples after prophylaxis. The risk of enterococcal colonization and superinfection must be weighted against the benefits of reduction of the infection risk when deciding upon routine antibiotic prophylaxis for cesarean section.     

Metronidazole Prophylaxis Before Surgical Abortion: Retrospective Review of 51 330 Cases

ObjectiveTo determine the effectiveness of a simple prophylactic antibiotic protocol in preventing postoperative infections, and to determine the risk factors most effective in predicting the presence of intercurrent Chlamydia infection.MethodsA retrospective cohort review of postoperative infection was carried out among women undergoing surgical abortion at four Canadian clinics from 2001 to 2006. All women received antibiotic prophylaxis using uniform observed single-dose metronidazole, with additional observed single-dose azithromycin for those meeting criteria for higher risk of infection.ResultsThe records of 51 330 women who underwent surgical bortion using this protocol were reviewed; 38% met criteria predicting a higher risk of infection, and 3.4% were Chlamydiapositive. Risk-factor screening correctly identified 69% of women with Chlamydia. Follow-up was available for 13 999 women (27%). Among these women, 17 (0.12%) developed postoperative infection requiring hospital admission.ConclusionAntibiotic prophylaxis prior to surgical abortion using universal metronidazole, with selective azithromycin for women meeting criteria for a higher risk of infection, was associated with a low rate of postoperative infection among those for whom follow-up information is available. This regimen offers the advantages of observed single-dose treatment. Prospective evaluation including outcome assessment for a higher proportion of the study population is warranted.