1 2

Draft Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery Section: Hysterectomy

3 4

Background. Hysterectomy is second only to cesarean delivery as the most frequently

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performed major gynecologic operation in the United States, with over 600,000

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hysterectomies being performed annually.326A Uterine fibroid tumors account for 40% of all

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presurgical diagnoses leading to hysterectomy.326a,327 Other common diagnoses are

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dysfunctional uterine bleeding, genital prolapse, endometriosis, chronic pelvic pain,

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pelvic inflammatory disease, endometrial hyperplasia, and cancer.

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Hysterectomy involves the removal of the uterus and, occasionally, one or two

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fallopian tubes, the ovaries, or a combination of ovaries and fallopian tubes.327a Radical

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hysterectomy entails removal of the uterus, fallopian tubes, and ovaries and extensive

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stripping of the pelvic lymph nodes in patients with extension of cervical cancer.

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Hysterectomies are performed by a vaginal or abdominal approach using a laparoscopic-

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or robot-assisted method. During a vaginal hysterectomy, the procedure is completed

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through the vagina with no abdominal incision. Abdominal hysterectomy involves an

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abdominal incision. Laparoscopic and robotic methods involve small incisions, require

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additional equipment, increased operator experience, and increased length of

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procedures.327b-327d In the United States between 2000 and 2004, the abdominal approach

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for hysterectomy was used in 67.9% of operations and vaginal in 32.1%, of which 32.4%

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were performed laparoscopically.326a The American College of Obstetrics and

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Gynecology Committee (ACOG) on Gynecologic Practice recommends vaginal

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hysterectomy as the approach of choice for benign disease, due to evidence of better

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outcomes and fewer complications. Laparoscopic abdominal hysterectomy is an

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alternative when vaginal route is not indicated or feasible.327e,327f Of note, the ACOG

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stated that the supracervical approach, removal of uterus with preservation of cervix,

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should not be recommended as a superior technique for hysterectomy due to the lack of

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advantage in postoperative complications, urinary symptoms or sexual function and the

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increased risk of future trachelectomy to remove the cervical stump.327g

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Infections after hysterectomy include superficial and organ space (vaginal cuff infection, pelvic cellulitis, and pelvic abscess) surgical site infections.307 The reported

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surgical site infection rate, between January 1992 and June 2004 in the United States,

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based on National Nosocomial Infections Surveillance (NNIS) risk index category, was

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1.31 per 100 operations for vaginal hysterectomy and 1.36 to 5.17 per 100 operations for

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abdominal hysterectomy.307a Infection rates in a multicenter surveillance study after

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overall hysterectomy was 2.53%. Rates of infection were significantly lower with

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laparoscopic compared with open approach (1.15% and 3.44%, respectively).307b

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Risk factors for infection after vaginal or abdominal hysterectomy include longer

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duration of surgery, young age, diabetes, obesity, peripheral vascular disease, collagen

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disease, anemia, transfusion, poor nutritional status, and previous history of postsurgical

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infection.309,328,334,335,337,338,338a,338b The depth of subcutaneous tissue is also a significant risk

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factor for infection after abdominal hysterectomy.336 Additional risk factors for infection

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with radical hysterectomy for cervical cancer include presence of malignancy, prior

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radiation therapy, and presence of indwelling drainage catheters.337,338

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Organisms. The vagina is normally colonized with a wide variety of bacteria, including

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gram-positive and gram-negative aerobes and anaerobes. The normal flora of the vagina

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include staphylococci, streptococci, enterococci, lactobacilli, diphtheroids, E. coli,

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anaerobic streptococci, Bacteroides species, and Fusobacterium species.307,339

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Postoperative vaginal flora differ from preoperative flora; enterococci, gram-negative

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bacilli, and Bacteroides species increase postoperatively. Postoperative changes in flora

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may occur independently of prophylactic antimicrobial administration and are not by

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themselves predictive of postoperative infection.307,340,341 Postoperative infections

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associated with vaginal hysterectomy are frequently polymicrobial; enterococci, aerobic

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gram-negative bacilli, and Bacteroides species are isolated most frequently. Postoperative

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wound infections after abdominal and radical hysterectomy are also polymicrobial; gram-

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positive cocci and enteric gram-negative bacilli predominate, and anaerobes are frequently

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isolated.341,342

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Efficacy. A meta-analysis of 25 randomized controlled trials demonstrated the efficacy

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of antimicrobial prophylaxis, including first- and second-generation cephalosporins and

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metronidazole, in the prevention of infections after abdominal hysterectomy.404 The

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infection rate was 21.1% with placebo or no prophylaxis and 9.0% with any

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antimicrobial. A second meta-analysis found the rate of postoperative infection (surgical

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and pelvic sites) in women undergoing vaginal hysterectomy administered placebo or no

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prophylactic antimicrobials ranged from 14% to 57%, which was significantly higher

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than the 10% rate reported with antibiotics.394

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Malignant disease as the reason for hysterectomy is a common exclusion from

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studies of antimicrobial prophylaxis. Older prospective, placebo-controlled studies found

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a lower rate of surgical site infection with antimicrobial prophylaxis after radical

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hysterectomy.337,411–414 The applicability of these results are limited by small sample size

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and inclusion of antibiotics not available in the United States. Radical hysterectomy is

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primarily completed through an abdominal approach, but can also be performed by

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vaginal approach and using laparoscopic or robotic methods.414a Therefore, antimicrobial

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prophylaxis would be warranted regardless of approach.

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No placebo-controlled studies have been conducted to evaluate the efficacy of

77 78

antimicrobial prophylaxis when used for laparoscopic hysterectomy.

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for prophylaxis in vaginal and abdominal hysterectomy. Studies directly comparing

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different cephalosporins have shown no significant differences in rates of infection in

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vaginal hysterectomy and indicate that first-generation cephalosporins (primarily

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cefazolin) are equivalent to second- and third-generation agents.367–370, 372–381,382

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In abdominal hysterectomy, no differences in rates of serious infections were noted

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between second- and third-generation cephalosporin regimens.376,387–392,405–407,382b Few

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comparisons have been made between second-generation cephalosporins and cefazolin.

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Cefazolin has been at least as effective in preventing infectious complications as second-

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and third-generation cephalosporins.369,384,399,408 However, in one double-blind, controlled

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study of 511 women undergoing abdominal hysterectomy found the risk of major surgical

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site infection requiring antimicrobial therapy was significantly higher in the group

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receiving preoperative cefazolin 1 g (11.6%; relative risk, 1.84; 95% confidence interval,

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1.03–3.29) than with cefotetan 1 g (6.3%).334 A multicenter, randomized, double-blind,

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active- and placebo-controlled study compared single-doses of ampicillin, cefazolin or

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placebo administered to women undergoing elective total abdominal hysterectomy at two

Choice. Cephalosporins are the most frequently used and studied antimicrobials

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centers in Thailand.334a The study found a significantly lower infection rate, including

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superficial and deep surgical site infections, urinary tract infections, vaginal cuff

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infection and pneumonia, with cefazolin (10.3%) compared with placebo (26.9%) and

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ampicillin (22.6%). No difference was seen between ampicillin and placebo. Authors

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concluded that cefazolin was more effective than ampicillin for elective total abdominal

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hysterectomy.

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A randomized controlled study of 511 patients undergoing laparoscopic

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gynecologic operations at one center in Italy compared single-doses of

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amoxicillin/clavulanic acid 2.2 g and cefazolin 2 g administered intravenously 20-30

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minutes before operation.334b A second dose was given if surgery was longer than three

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hours or extensive blood loss (> 1500 ml). No significant differences were found between

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groups for any postoperative infection, including surgical site infections. The statistical

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power of the study was not stated.

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In light of the organisms encountered in the vaginal canal and comparative studies

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conducted among different classes of cephalosporins, cefazolin, cefotetan, cefoxitin,

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cefuroxime or ampicillin/sulbactam have been supported by as appropriate first-line

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choices for prophylaxis during vaginal or abdominal hysterectomy.382A,382B,383 Alternative

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agents for patients with a history of immediate hypersensitivity to penicillin include

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either clindamycin or metronidazole plus gentamicin or fluoroquinolone (ciprofloxacin,

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levofloxacin or moxifloxacin) or aztreonam (with clindamycin only).

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Cefazolin doses of 2 grams have been recommended for morbidly obese patients

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with body mass index greater than 35 kg/m2 or greater than 100 kg or greater than 220

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pounds.383 Additional discussion on dosing is provided in the common principles section

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of these guidelines.

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The optimal antisepsis agent for hysterectomy has not been clearly established.

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One multicenter, randomized, controlled study found that women undergoing total

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abdominal hysterectomy with povidone-iodine gel applied to the vaginal apex had a

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statistically lower rate of pelvic abscess compared with no gel.383a Antibiotic prophylaxis

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administration was noted to vary between centers from 3% to 99% of patients. The agents

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administered were not reported. Of note, no differences were noted in antibiotic

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treatment, abdominal surgical site infection, urinary tract infection, pelvic cellulitis. A

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small randomized controlled study of 50 patients undergoing vaginal hysterectomy

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compared preoperative scrub with povidone-iodine 10% and chlorhexidine 4% in

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addition to a single-dose of cefazolin 1 g (or clindamycin 900 mg and gentamicin 120

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mg) administered 30 minutes prior to operation start time.383b Significantly lower rates of

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contaminated specimens were found with chlorhexidine in the first postoperative interval

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(30 minutes after surgical scrub) and lower mean colony counts at the second interval (90

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minutes). No surgical site infections developed in either group. Neither study found an

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impact of the studied agents on infectious morbidity, including surgical site infection,

133 134

therefore the clinical significance of these findings are not yet known.383a,383b

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regimens of a different antimicrobial have shown the two regimens to be equally

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effective in postoperative infection rate in women undergoing vaginal and abdominal

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hysterectomy.346,356,368–371,373–378,384–392,400,409,410,403a The limited comparative trials

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involving single-dose cefazolin346,370,334b,370a or ampicillin/sulbactam334b,403a indicate that

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a single dose of antibiotic is sufficient prophylaxis for surgical site infections for vaginal

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hysterectomy. Single doses of cefotetan, ceftizoxime, or cefotaxime appear to be as

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effective as multiple doses of cefoxitin.380,387,388,390–392,406 A second dose of antibiotic is

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warranted when the procedure lasts three hours or longer or if blood loss exceeds 1500

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mL.334b,383

Duration. Studies comparing single-doses of one antimicrobial with multidose

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Pediatric Efficacy. No well-controlled studies have evaluated the efficacy of

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antimicrobial prophylaxis in adolescents undergoing vaginal or abdominal hysterectomy.

147 148

Recommendation. The recommended regimen for women undergoing hysterectomy by

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vaginal or abdominal approach, using an open or laparoscopic approach, is a single

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intravenous dose of cefazolin 1-2 g, cefotetan 1-2 g, cefoxitin 1-2 g, cefuroxime 1.5 g or

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ampicillin/sulbactam 1.5-3 g within 60 minutes prior to incision. Alternative agents for

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patients with a history of immediate hypersensitivity to penicillin include either

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clindamycin 600 mg or metronidazole 500 mg plus gentamicin 1.5 mg/kg or

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fluoroquinolone (ciprofloxacin 400 mg, levofloxacin 500 mg or moxifloxacin 400 mg) or

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aztreonam 1 g (with clindamycin only). A second dose of antibiotic is warranted when

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the procedure lasts three hours or longer or if blood loss exceeds 1500 mL. (Strength of

157

evidence for prophylaxis for hysterectomy = A.)

158 159

Pediatric. Based on data in adults, the same regimens are recommended for adolescent

160

women undergoing hysterectomy by vaginal or abdominal approach, using an open or

161

laparoscopic approach.

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