Moxalactam versus cefazolin prophylaxis for vaginal hysterectomy

Antibiotic Prophylaxis Using Cefpirome Sulfate in Gynecologic Surgery and Elimination Rate of Enterococcus faecalis from the Vagina

Seventy-five patients undergoing total abdominal hysterectomy were given 1g of cefpirome sulfate (CPR) intravenously twice daily from immediately after surgery through the second postoperative day (CPR group). The results were compared with data from our previous study (1984-1985) in which 85 patients were given either piperacillin, cefazolin, or cefmetazole in the same dosage pattern after the same surgery (PIPC-CEZ-CMZ group). In the CPR group, the incidence of postoperative infection, febrile morbidity, and a persistent temperature of ≥37.5°C after the seventh postoperative day was 0%, 6.7%, and 6.7%, respectively. In the PIPC-CEZ-CMZ group, these values were 1.2%, 4.7% and 8.2%, respectively. There were no significant differences between the two groups (chi-square test), and no evidence could be found that CPR was more beneficial. Unlike other cephems, CPR is reported to show in-vitro activity against Enterococcus faecalis, which is frequently found in the vagina after gynecologic surgery. In this study, the postoperative vaginal colonization rate of E. faecalis was 24% (18/75) in the CPR group, which was lower than that in patients given other cephems in another study (1985-1990), including cefazolin (6/18), cefapirin (CEPR) (8/16), cefmetazole (12/25), and latamoxef (6/10). The vaginal elimination rate of E. faecalis was 60% (6/10) in the CPR group, and this was significantly higher than that in patients who were given other cephems (0/14, P=0.0354, chi-square test). This elimination rate supported the in vitro data of CPR's high activity against E. faecalis.

[Antibiotic prophylaxis in gynecologic surgery]

Hysterectomies are contaminated procedures; surgical wound related sepsis ranges from 10 to 25%. Several randomised controlled studies demonstrated a significant benefit with prophylactic antibiotics. The study results were more controversial for abdominal hysterectomies. Ureidopenicillins, cephamycins and other antibacterial agents active on Gram negative rods and anaerobes can be recommended as a preoperative flash at anaesthesia induction, followed by a second injection whenever the procedure duration exceeds 3 hours. In case of extended hysterectomy for cancer, broad spectrum antibiotic prophylaxis is usual; some recent studies demonstrated the efficacy of a short duration antibacterial agent use. Mastectomies are at low risk for postoperative infection. Antibacterial prophylaxis is common, especially in plastic surgery.

Intraoperative wound contamination during abdominal hysterectomy

Qualitative bacterial culture of specimens taken from several operative sites during abdominal hysterectomy has not been of value in predicting postoperative infection. We have therefore studied the relationship between the magnitude of contamination and the likelihood of the development of postoperative infection, in the course of a trial comparing the efficacy of cefotetan with ampicillin-plus-metronidazole for chemoprophylaxis in 163 women undergoing abdominal hysterectomy. Forty women who did not receive chemoprophylaxis were also studied. From each patient, an intraoperative sample of pelvic fluid was obtained after closure of the vaginal vault and examined quantitatively for anaerobic, aerobic and microaerophilic bacteria. The incidence of postoperative infectious morbidity (wound infection and febrile morbidity) was correlated with bacterial counts. Analyses by step-up multiple logistic regressions were performed on all the variables and only the total and microaerophilic bacterial counts were significant. Of the 40 patients with total bacterial counts greater than or equal to 10(4) cfu ml-1, 42.5% developed postoperative infectious morbidity, compared with 12.6% of 135 of patients with counts of less than or equal to 10(3) cfu ml-1. The contaminating bacteria were similar to those of the vaginal and skin flora, with anaerobes occurring in 52.9% and microaerophiles in 63.9% of positive fluid samples. Thus, we have concluded that the magnitude of contamination during abdominal hysterectomy is an important determinant in the development of postoperative infectious morbidity.

Piperacillin for prophylaxis in gynecological surgery

The effectiveness of perioperative Piperacillin for prevention of operative-site infection after gynaecological surgery was studied in a total of 100 patients. In an open randomized clinical trial of 52 women undergoing abdominal or vaginal hysterectomy Piperacillin was compared to the combination Gentamicin/Metronidazole. Piperacillin was well-tolerated. Surgical-site infection was diagnosed in the Piperacillin group in two patients and in the Gentamicin/Metronidazole group in one patient. The occurrence of postoperative febrile morbidity was also similar between the two group. In 48 patients undergoing complicated gynecological surgery of long duration, only Piperacillin was administered perioperatively. Thirty-five of these 48 women underwent oncological operations and the mean operative length was 3.3 h. One patient developed a transient rash after the administration of Piperacillin. No other adverse side-effects were observed. Nine of these 48 patients developed a surgical-site infection postoperatively, and this was found to be significantly more often than in the first group of 52 patients. It was concluded that Piperacillin seems to be a valuable alternative for perioperative prophylaxis in gynecological surgery. Its effectiveness in vaginal and abdominal hysterectomy is similar to the combination of Gentamicin/Metronidazole, but after complicated surgery of long duration a decreased effectiveness should be reckoned with.

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 prophylaxis for vaginal and abdominal hysterectomy

The practice of administering perioperative antimicrobials to uninfected patients undergoing elective surgical procedures has been subjected to careful prospective investigative scrutiny during the past two decades. A wound classification system was developed, helping to identify procedures for which prophylaxis did not provide benefit to the patient. Guidelines for prophylaxis in hysterectomy were proposed and risk factors were sought. Pharmacokinetics and spectrum of antibacterial activity, although variables of paramount importance in predicting success in the treatment of established infections, were discovered to have questionable impact on prophylactic efficacy. Duration of antimicrobial administration has gradually diminished from the total length of hospital stay to a single preoperative dose without increased risk of infection; efficacy may be related to route of administration. The wisdom of using newer agents for prophylaxis is addressed and questioned.

Single-dose cephalosporin for prevention of major pelvic infection after vaginal hysterectomy: cefazolin versus cefoxitin versus cefotaxime

Antimicrobial overutilization accelerates the development of bacterial resistance. A prospective, randomized, blinded clinical trial of vaginal hysterectomy prophylaxis was designed to compare the efficacy, safety, and costs of cefazolin with those of cefoxitin and cefotaxime. Sixteen women (7.5%) developed febrile morbidity only, 10 (4.7%) developed major pelvic infection requiring parenteral antimicrobial therapy, and neither clinical nor laboratory adverse reactions of significance were observed. Anemia, diabetes, and additional surgical procedures were associated with a significantly increased incidence of postoperative infection; no regimen was more protective for women with or without these risk factors. Infections almost doubled hospital stay and the charges for health care. Diagnosis-related group reimbursement would have been more than $1,300 less than the mean hospital charge for women who developed infection. Utilizing cefazolin for prophylaxis and reserving cefoxitin and cefotaxime for therapy is cost and antimicrobial efficient.

Cost of antibiotic prophylaxis in cesarean section

Two hundred sixty-three patients were randomly assigned to receive either piperacillin or cefoxitin for prophylaxis in cesarean section. Although both drugs were considered effective, piperacillin achieved a level of 98 percent satisfactory prophylaxis compared with only 91 percent for cefoxitin. Costs of prophylactic failure in cesarean section were calculated and then assessed for four different antibiotic regimens (based on 100 patients). Because of its high failure rate, ampicillin was the most expensive antibiotic; piperacillin was the least expensive. It was suggested that highly effective prophylaxis with an antibiotic agent such as piperacillin can result in significant cost savings when used for high-risk patients undergoing cesarean section.

Third generation cephalosporin antibiotics in surgical practice

The new third generation cephalosporins have a significantly greater spectrum of action against gram-negative bacteria likely to be encountered in surgical infections. This expanded spectrum may permit these drugs to be used in place of combination therapy in patients with polymicrobial infections; however, current evidence does not indicate superior results with these agents over earlier generation choices for surgical prophylaxis. The toxicity profile of these drugs warrants close monitoring for serious complications.

Prophylactic antibiotics in obstetrics and gynecology

Studies throughout the world demonstrate the effectiveness of prophylactic antibiotics in vaginal hysterectomy and cesarean section. Febrile morbidity is reduced by more than one half, and pelvic infections are reduced one third to one fifth, respectively. Prophylactic antibiotics are most beneficial in high-risk cesarean section, such as in patients in labor and with ruptured membranes. In abdominal hysterectomy, the effect of prophylactic antibiotics is less pronounced, and the results of the individual studies are more controversial. Prophylactic antibiotics are commonly used in extensive oncologic surgery, infertility surgery, and in other procedures, but data for adequate evaluation are lacking. First- and second-generation cephalosporins are the antibiotics most frequently used. In vaginal hysterectomies, a single preoperative dose, and in cesarean section, three perioperative doses seem to be adequate. Infections occurring despite prophylactic antibiotics are often caused by resistant organisms.

Patient cost in the treatment of postsurgical female pelvic infection

Soft tissue female pelvic infections, that is, postpartum endomyometritis, pelvic cellulitis, and salpingitis, are frequently polymicrobial, involving aerobic and anaerobic bacteria. The most common antibiotic regimen employed for the treatment of these patients is clindamycin and an aminoglycoside. Single-agent therapy, utilizing the newer beta-lactams, is more economical, potentially less toxic, and as effective.

Surgical antimicrobial prophylaxis: principles and guidelines

Antimicrobial prophylaxis for surgical procedures is an area that is recognized as being subject to individual clinical variations. This review gives practitioners some basic principles of rational prophylaxis as defined by the medical literature. In addition, this literature is evaluated and condensed to provide clinicians with guidelines for particular procedures: obstetric, gynecologic, gastric, biliary, colonic, urologic, cardiac, thoracic, vascular, orthopedic and head and neck. Each section concludes with recommendations for the clinically most accepted prophylactic regimens. Antibiotics discussed include not only the older agents, but where good information exists, the newer cephalosporins. The suggested regimens consider efficacy, safety and cost as determinants in rational prescribing. Although research into even shorter, and perhaps more cost-effective, regimens continues, this compilation lists state-of-the-art recommendations.