Prophylactic antibiotics in obstetrics–gynecology: a current asset, a future liability?

A randomized controlled trial to compare antibiotic prophylaxis in elective gynecological surgeries: Single dose of cefazolin versus single dose of cefazolin and tinidazole

Objectives:

To evaluate if addition of an anti-anaerobic agent to standard drug-cefazolin for antimicrobial prophylaxis would further decrease postoperative infectious morbidity or not. This is relevant as most of the infections in gynecological surgeries are anaerobic but cefazolin does not protect against anaerobes.

Materials and Methods:

The study design was a parallel randomized controlled trial. Two hundred patients undergoing benign gynecological surgeries were divided into two groups of 100 each. Group A received 2 g cefazolin 30–60 min before incision and Group B received 2 g cefazolin 30–60 min and 1.6 g tinidazole 60–120 min before incision. The patients were followed for any infectious morbidity for 1 month postoperatively. The analysis was done separately for abdominal, laparoscopic, and vaginal surgeries. The analysis was also done for surgeries according to the wound category, i.e. clean and clean-contaminated.

Results:

The two groups were comparable for age and body mass index (BMI). The two groups were comparable for the factors affecting infectious morbidity such as duration of surgery, blood loss, blood transfusions, duration of hospital stay, and need for additional antibiotics. The postoperative infectious morbidity was analyzed in terms of fever, surgical site infection (SSI), and urinary tract infection (UTI). No patient in vaginal and laparoscopic groups suffered from infectious morbidity. In abdominal surgeries group, postoperative fever occurred in 6/74 (8.1%) and 11/74 patients (14.8%) in Groups A and B, respectively (P = 0.38). SSI occurred in 1/74 (1.3%) and 2/74 (2.7%) patients in Groups A and B, respectively (P = 1.0). UTI occurred in 5/74 patients (6.7%) and 2/74 patients (2.7%) in Groups A and B, respectively (P = 0.44). The data were also analyzed for infectious morbidity for clean and clean-contaminated wound categories, and the results were nonsignificant between both groups for each type of wound category (P > 0.05).

Conclusion:

Cefazolin alone is a sufficient antibiotic prophylaxis for benign gynecological procedures.

Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure

Background

Conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project, this study aimed to identify key elements for a global definition of responsible antibiotic use based on diverse stakeholder input.

Methods

A three-step RAND-modified Delphi method was applied. First, a systematic review of antibiotic stewardship literature and relevant organization web sites identified definitions and synonyms of responsible use. Identified elements of definitions were presented by questionnaire to a multidisciplinary international stakeholder panel for appraisal of their relevance. Finally, questionnaire results were discussed in a consensus meeting.

Results

The systematic review and the web site search identified 17 synonyms (e.g. appropriate, correct) and 22 potential elements to include in a definition of responsible use. Elements were grouped into patient-level (e.g. Indication, Documentation) or societal-level elements (e.g. Education, Future Effectiveness). Forty-eight stakeholders with diverse backgrounds [medical community, public health, patients, antibiotic research and development (R&D), regulators, governments] from 18 countries across all continents participated in the questionnaire. Based on relevance scores, 21 elements were retained, 9 were rephrased and 1 was added. Together, the 22 elements and associated best-practice descriptions comprise an exhaustive list of elements to be considered when defining responsible use.

Conclusions

Combination of concepts from the literature and stakeholder opinion led to an international multidisciplinary consensus on a global definition of responsible antibiotic use. The widely diverging perspectives of stakeholders providing input should ensure the comprehensiveness and relevance of the definition for both individual patients and society. An aspirational goal would be to address all elements.

The Maternal Infant Microbiome: Considerations for Labor and Birth

The human microbiome plays a role in maintaining health, but is also thought to attenuate and exacerbate risk factors for adverse maternal-child health outcomes. The development of the microbiome begins in utero; however, factors related to the labor and birth environment have been shown to influence the initial colonization process of the newborn microbiome. This "seeding" or transfer of microbes from the mother to newborn may serve as an early inoculation process with implications for the long-term health outcomes of newborns. Studies have shown that there are distinct differences in the microbiome profiles of newborns born vaginally compared with those born by cesarean. Antibiotic exposure has been shown to alter the microbial profiles of women and may influence the gut microbial profiles of their newborns. Considering that the first major microbial colonization occurs at birth, it is essential that labor and birth nurses be aware of factors that may alter the composition of the microbiome during the labor and birth process. The implications of various activities and factors unique to the labor and birth environment that may influence the microbiome of women and newborns during the labor and birth process (e.g., route of birth, antibiotic use, nursing procedures) are presented with a focus on the role of labor nurses and the potential influence of nursing activities on this process.

Antibiotic Prophylaxis for Gynecologic Procedures prior to and during the Utilization of Assisted Reproductive Technologies: A Systematic Review

The use of assisted reproductive technologies (ART) has increased steadily. There has been a corresponding increase in the number of ART-related procedures such as hysterosalpingography (HSG), saline infusion sonography (SIS), hysteroscopy, laparoscopy, oocyte retrieval, and embryo transfer (ET). While performing these procedures, the abdomen, upper vagina, and endocervix are breached, leading to the possibility of seeding pelvic structures with microorganisms. Antibiotic prophylaxis is therefore important to prevent or treat any procedure-related infections. After careful review of the published literature, it is evident that routine antibiotic prophylaxis is generally not recommended for the majority of ART-related procedures. For transcervical procedures such as HSG, SIS, hysteroscopy, ET, and chromotubation, patients at risk for pelvic infections should be screened and treated prior to the procedure. Patients with a history of pelvic inflammatory disease (PID) or dilated fallopian tubes are at high risk for postprocedural infections and should be given antibiotic prophylaxis during procedures such as HSG, SIS, or chromotubation. Antibiotic prophylaxis is recommended prior to oocyte retrieval in patients with a history of endometriosis, PID, ruptured appendicitis, or multiple prior pelvic surgeries.

Prevalence of the genital tract bacterial infections after vaginal reconstructive surgery

Due to frequent childbirth, heavy lifting and the structure of the lives of rural women in Shahrekord region, Iran, cystocele and rectocele are of the main medical problems of the women in this area and for its correction, vaginal reconstructive surgery is needed which causes infection. The purpose of this study was to identify the bacteria causing infection after vaginal reconstructive surgery and performing antibiogram to help these patients for faster recovery. Patients enrolled this study were 92 who had undergone previous vaginal reconstructive surgery and now had infection. After examination, the group of patients taking antibiotics (n = 26) were excluded and the remaining 66 completed the study questionnaire. A gynecologist performed sampling; related tests (aerobic and anaerobic culture using an anaerobic culture gas pack jar and type A which provides absolute anaerobic conditions) were performed; antimicrobial susceptibility testing using Disk Diffusion Method was carried out; and the results were recorded. All the positive samples were polymicrobial. Gardnerella vaginalis in 20 cases (31%), peptostreptococci and anaerobic cocci in 9 cases (13.6%), staphylococcus aureus in 8 cases (9.1%), bacteroides and fusobacterium in 7 cases (10.6%), streptococcus group B in 4 cases (6%), yeast cells in 11 cases (16.6%) and Trichomonas vaginalis in wet mount of 4 (6%) existed. Anaerobic bacteria showed 85% sensitivity to clindamycin, 82% to chloramphenicol, 85% sensitivity to ceftizoxime and 45% to penicillin. Facultative anaerobic bacteria showed a sensitivity rate of 90% to ceftizoxime, chloramphenicol and cephalothin. According to our findings, the rate of vaginal bacterial infection in women with vaginal reconstructive surgery has increased; from which, infections with anaerobic bacteria origins have increased dramatically. We recommend antibiotic prophylaxis prior to genital reconstructive surgeries.

The development of fast-track principles in gynecological surgery

Fast-track is a multimodal strategy aimed at reducing the physiological burden of surgery to achieve an enhanced postoperative recovery. The strategy combines unimodal evidence-based interventions in the areas of preoperative preparation, anesthesia, surgical factors and postoperative care. The advantages of fast-track most likely extend to gynecology, although so far have scarcely been reported. This review summarizes current evidence concerning use of fast-track in general and in gynecological surgery. The main findings of this review are that there are benefits within elective gynecological surgery, but studies of quality of life, patient satisfaction and health economics in elective surgery are needed. Studies of fast-track within the field of non-elective gynecological surgery are lacking. Widespread education is needed to improve the rate of implementation of fast-track. Close involvement of the entire surgical team is imperative to ensure a structured perioperative care aiming for enhanced postoperative recovery.

Comparison of combinations of ciprofloxacin-metronidazole and ceftriaxone-metronidazole in controlling operative site infections in obstetrics and gynecological surgeries: A retrospective study

Objective:

To compare the effectiveness of the ciprofloxacin-metronidazole (CIP-MET) regimen with the ceftriaxone-metronidazole (CEF-MET) regimen for operative site infection control in women undergoing obstetrical and gynecological surgeries.

Materials and Methods:

One thousand and eighty-four case records of women who had undergone various obstetrical and gynecological surgeries who were given CIP-MET regimen and CEF-MET regimen were analyzed in predesigned and pretested proforma. Patients who were given CIP-MET regimen and CEF-MET regimen were classified as Group 1 and Group 2 respectively. The mode of administration of both the regimens was noted. Numbers of wound infections were recorded in the respective groups. Socioeconomic status and hemoglobin level of the patients were noted. Other data such as hospital stay, duration of operation were also noted.

Results:

Out of a total of 1084 case records, 31 (5.8%) and eight (0.7%) patients contracted wound infections in Group 1 and Group 2 respectively (P = 0.0001).

Conclusion:

The CEF-MET regimen was found superior to the CIP-MET regimen to control operative site infection in obstetrical and gynecological surgeries.

Postoperative outcomes associated with topical skin adhesives among women having hysterectomies

BACKGROUND

Multiple options are available for closure of hysterectomy incisions. This study compared postoperative clinical and economic outcomes using topical skin adhesive (2-octyl cyanoacrylate; OCA) vs. conventional skin closure in women undergoing total abdominal hysterectomy.

METHODS

A multi-hospital administrative database was used to identify women discharged in 2005 who had undergone total abdominal hysterectomy. Patients, classified by skin closure as suture (n = 21,201), staples (n = 23,441), OCA (n = 880), or staples + OCA (n = 489), were compared on length of inpatient stay (LOS), total inpatient cost, and non-prophylactic antibiotic treatment after day four.

RESULTS

The unadjusted mean LOS was 3.9, 4.5, 3.7, and 5.2 days for suture, staples, OCA, and staples + OCA, respectively; and the percentages of patients having antibiotic treatment were 12.93, 17.51, 11.14, and 23.72. There were overall differences in adjusted mean LOS, mean total cost, and antibiotic treatment (p < 0.0001). Pairwise comparisons indicated no difference between sutures and OCA, whereas the outcomes for each of the non-staple groups were more favorable than those for the staple group (p < 0.01). Results were similar in adjusted comparisons, with pairwise comparisons between OCA and staples at or near the threshold for significance.

CONCLUSIONS

2-octyl cyanoacrylate appears to be a safe and cost-effective alternative to topical sutures for patients having total abdominal hysterectomy. There were less favorable outcomes in groups receiving staples.

Complications of gynecologic surgery

Complications during gynecologic surgery result from the proximity of the uterus and ovaries to other critical pelvic structures. These structures include the urinary tract, bowel, nerves, and vasculature. Knowledge of pelvic anatomy is important when performing these procedures and is critical in cases of altered anatomy from adhesive disease and during intraoperative hemorrhage. Recognition and repair of an unintended injury gives the best chance for minimizing sequelae from these complications.