Antimicrobial prophylaxis in vaginal gynecologic surgery: a prospective randomized study comparing amoxicillin-clavulanic acid with cefazolin

Perioperative Antibiotic Choice and Postoperative Infectious Complications in Pelvic Organ Prolapse Surgery

OBJECTIVE

The objective of this study was to determine how rates of postoperative infectious complications after pelvic organ prolapse surgery differ based on perioperative antibiotic administered. In particular, we sought to determine whether anaerobic coverage is associated with reduced rates of infectious complications.

DESIGN

This was a retrospective cohort study.

SETTING

Premier Healthcare U.S. national database, a comprehensive all-payer dataset capturing patients from urban and rural nonprofit, community, and teaching hospitals.

PARTICIPANTS

Adult patients who underwent vaginal, laparoscopic, and/or abdominal prolapse surgery with or without hysterectomy from January 2000 to March 2020. Procedures with and without mesh were included.

INTERVENTIONS

Rates of infectious complications were compared among patients who received guideline-concordant antibiotic regimens, including those with anaerobic coverage. The primary outcome was any surgical site infection within 30 days of surgery without mesh or 90 days of surgery involving mesh.

RESULTS

Among 130,198 prolapse surgeries, the most common antibiotic regimens were cefazolin (n = 97,058, 74.5%), second-generation cephalosporin (n = 16,442, 12.6%), clindamycin + aminoglycoside (n = 8,397, 6.4%) and cefazolin + metronidazole (n = 4,328, 3.3%). On multivariable logistic regression, only clindamycin + aminoglycoside was associated with a higher rate of surgical site infections (OR = 1.37; 95% CI 1.09-1.72) and other infectious morbidity (OR = 1.26; 95% CI 1.12-1.42) when compared to cefazolin alone. The addition of metronidazole to cefazolin was not associated with reduced rates of surgical site infections (OR = 1.09; 95% CI 0.82-1.45). Obesity (OR = 1.22; 95% CI 1.03-1.43), diabetes without complication (OR = 1.30; 95% CI 1.08-1.57), Charlson comorbidity score >0 (OR = 1.24; 95% CI 1.06-1.45), and tobacco use (OR = 1.22, 95% CI 1.05-1.40) were also associated with increased composite surgical site infection.

CONCLUSION

Compared with cefazolin alone, the use of alternative perioperative antibiotics, including those with anaerobic coverage, was not associated with reduced infectious complications after pelvic organ prolapse surgery in this U.S. national sample.

Cefazolin prophylaxis in minimally invasive gynecologic surgery - are dosage and timing appropriate? Prospective study using resampling simulation

OBJECTIVE

Cefazolin is a widely used antimicrobial prophylactic agent, however the appropriate dosage, timing, pharmacology and microbial coverage have not been well-established for gynecologic procedures. We aimed to describe serum concentrations and pharmacokinetics of Intravenous cefazolin given to women prior to scheduled minimally invasive gynecologic surgeries, and to determine whether appropriate antimicrobial coverage had been achieved in short time from prophylactic administration to surgical start time.

METHODS

A prospective cohort analysis study, using a resampled dataset, of women undergoing scheduled gynecological surgeries in a university affiliated tertiary medical center. IV cefazolin (1 or 2 gr) was administered prior to incision to women weighing <80 kg (Group A) and ≥80 kg (Group B), respectively. Cefazolin serum levels were obtained at the time of skin incision (Time 0) and 30 min later (Time 30), measured by high-pressure liquid chromatography (HPLC). Appropriate antimicrobial coverage was defined when cefazolin serum levels were above minimal inhibitory concentrations (MIC) for Enterobacteriaceae.

RESULTS

Overall, 21 women were included. The mean time interval between drug administration and incision did not differ between the two groups (18 ± 10 min vs. 11 ± 10 min, respectively, p = .0.25). A hierarchical mixed linear regression model, using a simulation of multiple random bootstrap resampling (n = 1,000), revealed that cefazolin serum levels exceeded MIC, regardless of the timing of administration in the sampling intervals. Mean cefazolin serum levels in time 0 and time 30 min were not affected by BMI in patients receiving 1 gr.

CONCLUSION

A single dose of IV cefazolin given shortly prior to skin incision provides serum concentrations above minimal inhibitory concentrations for susceptible pathogens in most women undergoing scheduled minimally invasive gynecologic surgery.

No. 275-Antibiotic Prophylaxis in Gynaecologic Procedures

OBJECTIVE

To review the evidence and provide recommendations on antibiotic prophylaxis for gynaecologic procedures.

OUTCOMES

Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in gynaecologic procedures.

EVIDENCE

Medline and The Cochrane Library were searched for articles published between January 1978 and January 2011 on the topic of antibiotic prophylaxis in gynaecologic procedures. Results were restricted to systematic reviews, randomized control trials/ controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to June 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence obtained was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Guideline implementation should result in a reduction of cost and related harm of administering antibiotics when not required and a reduction of infection and related morbidities when antibiotics have demonstrated a proven benefit.

RECOMMENDATIONS

No 275 - Antibioprophylaxie dans le cadre d'interventions gynécologiques

OBJECTIF

Analyser les données et formuler des recommandations sur l'antibioprophylaxie dans le cadre d'interventions gynécologiques.

ISSUES

Parmi les issues évaluées, on trouvait la nécessité du recours aux antibiotiques et leur efficacité pour ce qui est de la prévention des infections dans le cadre d'interventions gynécologiques. RéSULTATS: Des recherches ont été menées dans Medline et The Cochrane Library afin d'en tirer les articles publiés entre janvier 1978 et janvier 2011 sur le sujet de l'antibioprophylaxie dans le cadre d'interventions gynécologiques. Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en juin 2011. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales.

VALEURS

La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). AVANTAGES, DéSAVANTAGES ET COûTS: La mise en œuvre de la directive clinique devrait entraîner une baisse des coûts et des torts liés à l'administration superflue d'antibiotiques, ainsi qu'une atténuation des infections et des morbidités connexes dans les cas où il a été démontré que l'administration d'antibiotiques confère un avantage pour la patiente. RECOMMANDATIONS.

Do prophylactic antibiotics in gynecologic surgery prevent postoperative inflammatory complications? A systematic review

PURPOSE

The aim of this study was to systematically review the literature on antibiotic prophylaxis in gynaecologic surgeries to prevent inflammatory complications after gynaecological operations. The study was carried out as a systematic review.

METHODS

Only randomised controlled trials of women undergoing gynaecological surgery were included. The Medline and the Cochrane library databases were searched from 1966 to 2016. The trials must have investigated an antibiotic intervention to prevent an inflammatory complication after gynaecological surgery. Trials were excluded if they were not randomised, uncontrolled or included obstetrical surgery.

RESULTS

Prophylactic antibiotics prevent inflammatory complications after gynaecological surgery. Prophylactic antibiotics are more effective in surgery requiring access to the peritoneal cavity or the vagina. Cefotetan appears to be more capable in preventing the overall inflammatory complication rate than cefoxitin or cefazolin. No benefit has been shown for the combination of antibiotics as prophylaxis. No difference has been shown between the long-term and short-term use of antibiotics. There is no need for the primary use of an anaerobic antibacterial agent.

CONCLUSION

Antibiotics help to prevent postoperative inflammatory complications after major gynecologic surgeries.

Antibiotic prophylaxis in gynaecologic procedures

OBJECTIVE

To review the evidence and provide recommendations on antibiotic prophylaxis for gynaecologic procedures.

OUTCOMES

Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in gynaecologic procedures.

EVIDENCE

Medline and The Cochrane Library were searched for articles published between January 1978 and January 2011 on the topic of antibiotic prophylaxis in gynaecologic procedures. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to June 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence obtained was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Guideline implementation should result in a reduction of cost and related harm of administering antibiotics when not required and a reduction of infection and related morbidities when antibiotics have demonstrated a proven benefit.

RECOMMENDATIONS

(1) All women undergoing an abdominal or vaginal hysterectomy should receive antibiotic prophylaxis. (I-A) (2) All women undergoing laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy should receive prophylactic antibiotics. (III-B) (3) The choice of antibiotic for hysterectomy should be a single dose of a first-generation cephalosporin. If patients are allergic to cephalosporin, then clindamycin, erythromycin, or metronidazole should be used. (I-A) (4) Prophylactic antibiotics should be administered 15 to 60 minutes prior to skin incision. No additional doses are recommended. (I-A) (5) If an open abdominal procedure is lengthy (e.g., > 3 hours), or if the estimated blood loss is > 1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the initial dose. (III-C) (6) Antibiotic prophylaxis is not recommended for laparoscopic procedures that involve no direct access from the abdominal cavity to the uterine cavity or vagina. (l-E) (7) All women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence should receive a single dose of first-generation cephalosporin. (III-B) (8) Antibiotic prophylaxis is not recommended for hysteroscopic surgery. (II-2D) (9) All women undergoing an induced (therapeutic) surgical abortion should receive prophylactic antibiotics to reduce the risk of post-abortal infection. (I-A) (10) Prophylactic antibiotics are not suggested to reduce infectious morbidity following surgery for a missed or incomplete abortion. (I-E) (11) Antibiotic prophylaxis is not recommended for insertion of an intrauterine device. (I-E) However, health care professionals could consider screening for sexually transmitted infections in high-risk populations. (III-C) (12) There is insufficient evidence to support the use of antibiotic prophylaxis for an endometrial biopsy. (III-L) (13) The best method to prevent infection after hysterosalpingography is unknown. Women with dilated tubes found at the time of hysterosalpingography are at highest risk, and prophylactic antibiotics (e.g., doxycycline) should be given. (II-3B) (14) Antibiotic prophylaxis is not recommended for urodynamic studies in women at low risk, unless the incidence of urinary tract infection post-urodynamics is > 10%. (1-E) (15) In patients with morbid obesity (BMI > 35 kg/m²), doubling the antibiotic dose may be considered. (III-B) (16) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary procedure. (III-E).

Increased incidence of postoperative infections during prophylaxis with cephalothin compared to doxycycline in intestinal surgery

Background

The antibiotics used for prophylaxis during surgery may influence the rate of surgical site infections. Tetracyclines are attractive having a long half-life and few side effects when used in a single dose regimen. We studied the rate of surgical site infections during changing regimens of antibiotic prophylaxis in medium and major size surgery.

Methods

Prospective registration of surgical site infection following intestinal resections and hysterectomies was performed. Possible confounding procedure and patient related factors were registered. The study included 1541 procedures and 1489 controls. The registration included time periods when the regimen was changed from doxycycline to cephalothin and back again.

Results

The SSI in the colorectal department increased from 19% to 30% (p = 0.002) when doxycycline was substituted with cephalothin and decreased to 17% when we changed back to doxycycline (p = 0.005). In the gynaecology department the surgical site infection rate did not increase significantly. Subgroup analysis showed major changes in infections in rectal resections from 20% to 35% (p = 0.02) and back to 12% (p = 0.003).

Conclusion

Doxycycline combined with metronidazole, is an attractive candidate for antibiotic prophylaxis in medium and major size intestinal surgery.