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.     

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.     

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.     

Prophylactic antibiotics in gynecologic surgery.

A 2-year prospective double-blind study of prophylactic antibiotics in 317 patients undergoing elective total abdominal or vaginal hysterectomy was conducted. Patients randomly received placebo, penicillin, or cefazolin 30 minutes prior to surgery and at 6-hour intervals thereafter for 48 hours. Rigid criteria for postoperative morbidity were established. Vaginal hysterectomy patients given either penicillin or cefazolin prophylaxis had fewer postoperative infections (P less than 0.01) compared to those given placebo. A similar trend was noted among women undergoing abdominal hysterectomy; however, this trend was not statistically significant (P greater than 0.05). Despite continuous surveillance, no change in nosocomial flora or antibiotic sensitivity of bacterial isolates was noted. Adverse drug effects and antibiotic-resistant secondary infections were encountered with similar frequency in all treatment groups.     

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.     

Postoperative infections and antibiotic prophylaxis for hysterectomy in Sweden: a study by the Swedish National Register for Gynecologic Surgery

AIM: The purpose of the study was to evaluate the current use of antibiotic prophylaxis, the rate of postoperative infections, and risk factors for postoperative infections in patients undergoing elective hysterectomy for non-malignant pathology. METHODS: The study was performed during the time period July 2000 to 1 January 1 2003, using data from the Swedish National Register for Gynecologic Surgery, covering 26 of 49 clinics and approximately 50% of the Swedish population. During this time period, 3267 women undergoing elective hysterectomy for non-malignant pathology (mainly dysfunctional bleeding and fibromas) and with complete data on the use of antibiotic prophylaxis and postoperative follow up were included. A postoperative infection was considered to have developed if patients or the physician reported an infection related to the surgical site, together with reported use of antibiotic treatment. RESULTS: Among the 3267 patients, 341 (10.4%) were considered to have developed a postoperative infection. In cases where antibiotic prophylaxis had not been given, total abdominal hysterectomies and vaginal hysterectomies were associated with the highest frequency for postoperative infections P < 0.05 and P < 0.01, respectively. Notably, also women undergoing subtotal hysterectomy reported significantly lower rates of postoperative infections if prophylactic antibiotics had been given, P < 0.05. Risk factors for postoperative infection were non-use of antibiotic prophylaxis, hospital, age less than 40 years, and BMI > 30 kg/m(2). CONCLUSIONS: The study results have indicated the need of prospective clinical trials on antibiotic prophylaxis for patients undergoing supravaginal abdominal hysterectomy. Also, a need to further evaluate the current prophylactic antibiotic protocols used for obese patients and younger women undergoing any kind of hysterectomy is warranted.     

Effectiveness of infection prevention with latamoxef in vaginal hysterectomy. A prospective study

A prospective clinical trial was designed to examine the influence of a single-dose prophylaxis with 2 g Latamoxef on postoperative infectious morbidity in women undergoing vaginal hysterectomy. 91 vaginal hysterectomies with latamoxef prophylaxis were compared with a similar group of 99 patients without prophylaxis. Patients in the latamoxef group had significantly less postoperative infectious morbidity (23.1%) than those in the non prophylaxis group (45.1%). Prophylactic latamoxef reduced postoperative additional antibiotic therapy in the prophylaxis group significantly. The postoperative infectious morbidity (urinary tract infections, pelvic infections, febrile morbidity) was significantly reduced by a single-dose prophylaxis with 2 g Latamoxef.     

Predictors of antibiotic prophylactic failure in post-cesarean endometritis.

Despite the use of prophylactic antibiotics, endometritis occurs in 1-31% of patients after cesarean delivery. We sought to identify predictors of prophylactic antibiotic failure. In a retrospective review of 1800 cesarean deliveries, 766 patients had either ampicillin or cefazolin prophylaxis; 240 (31.3%) developed endometritis. Stepwise logistic regression identified the number of vaginal examinations (P less than .001), nulliparity (P = .001), low gestational age (P = .033), and cefazolin use (P = .002) as predictors of endometritis. One in two women with six or more vaginal examinations before cesarean delivery will have prophylactic failure. In preterm gestations (N = 177), the number of vaginal examinations was the single predictor of prophylactic antibiotic failure (P = .002). The number of vaginal examinations can be used to design new strategies to prevent a high rate of prophylactic failure.     

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.     

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.     

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.     

Perioperative use of cefoxitin in primary cesarean section

We performed a randomized, double-blind trial on a relatively low-risk population comparing the use of three doses of cefoxitin vs. placebo in the prevention of infection following primary cesarean section. Major site-related morbidity (endometritis, wound infection and septicemia) was significantly reduced in the cefoxitin group (8.9% vs. 27.8%; p = 0.017). Febrile morbidity alone tended to occur in the cefoxitin group (15.6% vs. 3.7%; p = 0.091), and all five urinary tract infections occurred in the cefoxitin group as well. Total morbidity was therefore not significantly different (cefoxitin, 35.6%; placebo, 31.5% [not significant]). Duration of hospitalization (mean, 6.0 days) and need for further postoperative antibiotic therapy were similar in the two groups. Our study demonstrated a modest benefit from the perioperative use of antibiotics in relatively low-risk patients undergoing primary cesarean section. Issues that need further study include definition of the optimal prophylactic regimen and of high-risk populations for whom prophylaxis would be most helpful.     

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.     

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.     

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.     

Simplified Antibiotic Prophylaxis for Vaginal Hysterectomy

Single dose administration of antibiotics prior to vaginal hysterectomy was found to be an efficient and safe way of providing prophylaxis against infection. Metronidazole was as efficient as ampicillin in achieving a significant reduction in major morbidity, pelvic sepsis, and the "quantity" of postoperative fever. Antibiotic prophylaxis reduced hospital stay by an average of 3 days.     

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

Objective To test the hypothesis that intravenous antibiotics given intra-operatively reduce the failure rate of vesico-vaginal fistula repair.
Design A single blind, randomised controlled trial.
Setting A district hospital in Benin, West Africa.
Population Seventy-nine women undergoing repair of an obstetric vesico-vaginal fistula by a single surgeon at Hopital Evangelique; two women had repeat operations.
Methods Participants in the treatment group (  n = 41  ) received ampicillin 500 mg intra-operatively. Controls (  n = 40  ) received no prophylactic antibiotics.
Main outcome measures Failure of fistula closure and objective incontinence (a positive pad test) at hospital discharge. Secondary outcomes included febrile morbidity, other antibiotic use and urinary infection.
Results Antibiotic prophylaxis did not reduce the odds of failed repair (OR 2.1 95% CI 0.75–6.1) or of objective incontinence (OR 1.9; 95% CI 0.72–5.1). The women in the antibiotic prophylaxis group received less post-operative antibiotics and had less urinary infections at day 10.
Conclusions Prophylactic antibiotics should not be used in vesico-vaginal fistulae repair in the developing world outside randomised controlled trials.     

Prophylactic use of antibiotics for nonlaboring patients undergoing cesarean delivery with intact membranes: a meta-analysis

OBJECTIVE: We performed a meta-analysis to examine the role of antibiotic prophylaxis in preventing postoperative infections among nonlaboring women undergoing cesarean delivery with intact membranes. STUDY DESIGN: A computerized literature search was performed with MEDLINE. Studies were included if they contained data on patients undergoing cesarean delivery in the absence of labor and ruptured membranes. Only randomized trials with a placebo control group were included. RESULTS: Seven studies were found. Use of antibiotics decreased the risk of all infectious outcomes reported. When the results of 4 studies were pooled, prophylactic antibiotic use was associated with a significant reduction in postoperative fever (relative risk, 0.25; 95% confidence interval, 0.14-0.44). A similar reduction was noted for endometritis in 4 studies (relative risk, 0.05; 95% confidence interval, 0.01-0.38). Two studies reported on wound infection and showed a trend toward a protective effect (relative risk, 0.59; 95% confidence interval, 0.24-1.45). CONCLUSION: The prophylactic use of antibiotics reduces the risk of postoperative infectious complications after cesarean delivery even in the population at lowest risk.