Table 22.7 Antibiotic Prophylaxis Regimens by Procedure aAlternatives include cefotetan, cefoxitin, cefuroxime, or ampicillin-sulbactam.bA 2-g dose is recommended in women with a body mass index greater than 35 or weight greater than 100 kg or 220 lb. cAntimicrobial agents of choice in women with a history of immediate hypersensitivity to penicillin.dCiproﬂoxacin or levoﬂoxacin or moxiﬂoxacin. eIf patient has a history of pelvic inﬂammatory disease or procedure demonstrates dilated fallopian tubes. No prophylaxis is indicated for a study without dilated tubes. Adapted from Antibiotic prophylaxis for gynecologic procedures. American College of Obstetricians and Gynecologists Practice Bulletin No. 104, May 2009.
using proper aseptic technique, minimizing tissue trauma, minimizing the amount foreign material in the surgical site, controlling diabetes, avoiding immunologic suppression, maximizing tissue oxygenation, draining blood and serum from the surgical site, and using prophylactic antibiotics. Antibiotic prophylaxis is given with the belief that antibiotics enhance the immune mechanisms in host tissues that resist infections by killing the bacteria that inoculate the surgical site during surgery (65).
Infections in the skin or pelvis that result from gynecologic surgery (e.g., parametritis, cuff cellulitis, pelvic abscess) typically are polymicrobial in nature. These infections are complex and often involve gram-negative rods, gram-positive cocci, and anaerobes. Antibiotic prophylaxis should be sufficiently broad to cover these potential pathogens (66) (Table 22.7).
The timing of antimicrobial prophylaxis is important. There is a relatively narrow window of opportunity for affecting outcomes (67). In the United States, it is customary to give antimicrobial prophylaxis shortly before or during the induction of anesthesia. Data revealed that a delay of 3 hours or more between the time of bacterial inoculation (i.e., skin incision) and administration of antibiotics may result in ineffective prophylaxis. Evidence indicates that for prophylaxis, one dose of antibiotic is appropriate. When the surgical procedure proceeds longer than 1 to 2 times the half-life of the drug or blood loss is greater than 1.5 L, additional intraoperative doses of antibiotics should be administered to maintain adequate levels of medication in serum and tissues (68,69). There are no data to support the continuation of prophylactic antimicrobial agents into the postoperative period for routine gynecologic procedures. For cases involving colorectal resection, a reduction in surgical site infections (SSI) was seen when antibiotics were continued for up to 24 hours. Other measures to reduce SSI incidence were taken, including tight glycemic control, maintenance of intraoperative normothermia, and placement of subcutaneous drains in obese patients (70).