Examining the Evidence
Q Are surgeons using the right prophylactic antibiotics?
<huc>A</huc> Right drugs, but the wrong timing in many cases. This national cohort study found that, while 92.6% of patients were given the recommended agents, the timing was often wrong. For example, the initial dose was given within 1 hour before incision in only 55.7% of patients, and the drugs were discontinued within 24 hours after surgery in only 40.7% of cases.
A substantial volume of literature points to reduced infectious morbidity when prophylactic antimicrobials are administered prior to hysterectomy. Although this study explored the type of drug administered and the time it was given—issues of concern to ObGyns as well as other surgeons—it may not accurately reflect gynecologic experience, since the mean age of 73.3 years is significantly older than the usual hysterectomy patient. Moreover, hysterectomy cases constituted only 8% of the study population; the other 92% consisted of cardiac, vascular, orthopedic, and colorectal cases, which are less likely to be elective.
Antibiotics were given in 99% of cases
According to the “results” of this retrospective study, less than 1% of cases failed to receive prophylactic antibiotics. This is better compliance than other published reports have demonstrated. However, only slightly more than half received the antibiotic within the specified time frame, and administration continued beyond 24 hours in roughly 60% of cases.
Other compelling evidence
This study addressed issues of great importance to gynecologic surgeons, since infection is a serious source of postoperative morbidity and mortality among hysterectomy patients, but other studies have greater application to our patient population. In a metaanalysis1 involving 2,752 women who underwent abdominal hysterectomy, those who received preoperative cephalosporin had significantly less febrile morbidity and fewer postoperative infections than the controls who received no antibiotic. Patients who have vaginosis and are not treated immediately prior to hysterectomy have a 27% deep cuff infection rate, compared with 0% in the treated group.1
I prefer to administer 1 g intravenous cefoxitin after the patient arrives in the operating room and discontinue the drug 24 hours postoperatively.2 Keep in mind the risk of inducing antibiotic resistance—particularly methicillin-resistant staphylococcal infections—if the recommended prophylactic regimen, including its proper timing, is abandoned.
1. Larsson PG, Carlsson B. Does pre- and postoperative metronidazole lower vaginal cuff infection rate after abdominal hysterectomy in women with bacterial vaginosis? Infect Dis Obstet Gynecol. 2002;10:133-140.
2. Baggish MS. Total and subtotal hysterectomy. Best practice and research. Clin Obstet Gynecol. 2005 [in press].