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Page 1

rr=cPil
~ Clinical Perspectives in Obstetrics and Gynecology

Series Editor:

Herbert J. Buchsbaum, M.D.

Page 2

rr==cPil Clinical Perspectives in Obstetrics and Gynecology
~

perspective noun: ... the capacity to view sub-
jects in their true relations or relative importance.

Each volume in Clinical Perspectives in Obstetrics and
Gynecology will cover in depth a major clinical area in the
health care of women. The objective is to present to the reader
the pathophysiologic and biochemical basis of the condition
under discussion, and to provide a scientific basis for clinical
management. These volumes are not intended as "how to"
books, but as a ready reference by authorities in the field.

Though the obstetrician and gynecologist may be the primary
providet of health care for the female, this role is shared with
family practitioners, pediatricians, medical and surgical
specialists, and geriatricians. It is to all these physicians that
the series is addressed.

Series Editor: Herbert J. Buchsbaum, M.D.

Published Volumes:

Buchsbaum (ed.): The Menopause
Aiman (ed): Infertility
Futterweit: Polycystic Ovarian Disease
Lavery and Sanfilippo (eds.): Pediatric and Adolescent Obstetrics

and Gynecology
Galask and Larsen: Infectious Diseases in the Female Patient

Forthcoming Volume:

Szulman and Buchsbaum (eds.): Gestational Trophoblastic Disease

Page 117

8. Prophylactic Antibiotics for Abdominal and Vaginal Hysterectomy 109

effective as was combination therapy in the
treatment of women with a variety of pelvic
infections.65-68 With such therapeutic efficacy,
the newer agents should be significantly more
effective at preventing infection than older
agents. This assumption has not been sup-
ported by clinical trials. The newer and older
agents appear to be of equal efficacy.47.50.51.58-60
The possibility exists that the newer agents
might be as effective as older agents, even
when given at significantly lower doses. Data to
confirm or refute this concept are not avail-
able. If this finding is confirmed with equiva-
lent doses, it would be medically and economi-
cally imperative that we utilize older agents for
prophylaxis, saving the newer agents for ther-
apy. This practice would allow fulfillment of
several of the prophylaxis guidelines proposed
by Ledg~r et al. 69 He also recommended that
prophylaxis should be terminated in the recov-
ery room.70

Cefotaxime was the first antimicrobial ap-
proved by the Food and Drug Administration

. for preoperative single-dose hysterectomy pro-
phylaxis. Approval was granted in 1984. Yet
many older studies have shown that a single
preoperative dose of antimicrobial was ef-
fective at preventing major infection after
both vaginal and abdominal hysterec-
tomy.IO,14,34,35,49,51,52,60,61,71 In many instances
the single dose was compared to multiple doses
of the same or other antibiotics. The benefits to
the patient and hospital from single-dose pro-
phylaxis are numerous and include, but are
not limited to, diminished toxic or allergic/ad-
verse reaction, minimal alteration in host flora,
decreased likelihood for the dev~lopment of
selective resistance in hospital and patient bac-
terial flora, decreased likelihood for the devel-
opment of superinfection, decreased phar-
macy and nursing service space and time
obligation, and reduced expense for both the
hospital pharmacy and the patient

Risks of Prophylaxis

The risks _ of true prophylaxis are relatively
small. Anaphylaxis is the most immediate and
potentially life-threatening adverse reaction;
its occurrence is extremely rare. Accurate doc-
umentation of a history of allergy should iden-

tify problems in this category. There may be
cross allergenicity between cephalosporins and
penicillin. Fatal reactions have been reported
following the administration of a cephalo-
sporin (cephalothin) to a patient with a peni-
cillin allergy.72 Approximately 10%-15% of
women un<.iergoing hysterectomy in our hospi-
tal admit to an allergy to penicillin. Skin testing
is not routi!lely performed. If the reaction to
penicillin does not indicate an anaphylactic or
immediate hypersensitivity reaction, we ad-
minister a cephalosporin for prophylaxis. In
the 1,900 women whom we have prospectively
evaluated, we observed a 0.2% incidence of
skin rash and pruritus without a rash. These
women denied antimicrobial allergy prior to
antibiotic administration. Theoretically, each
dose in excess of the preoperative dose in-
creases the potential for reaction by that order
of magnitude.

Opponents of the concept of prophylaxis de-
clare that the use of antimicrobial in the ab-
sence of infection results in the masking of
clinical signs and symptoms of infection during
the initial hospitalization, thereby delaying di-
agnosis and prolonging hospital stay. This de-
lay in diagnosis may extend into the period
after hospitalization, possibly resulting in the
need for hospital readmission and therapy. We
have monitored patients closely after dis-
charge, and have observed that few women
given antimicrobial prophylaxis at hysterec-
tomy develop a late infection after discharge
from the hospital. The number of patents with
late infection is significantly less now that we
give prophylaxis than it was before the institu-
tion of antimicrobial prophylaxis. Since the in-
ception of prospective evaluations, the most
significant infections after hospital discharge
were those observed in women receiving pla-
cebo. These infections can usually be treated
with oral antimicrobials on an outpatient basis.
It is imperative that we include these infections
in statistical analyses when infection rates and
success with various prophylactic regimens are
being evaluated.

Death from pseudomembranous enterocoli-
tis has been reported following prolonged pro-
phylactic use of regimens of ampicillin and
cephalothin, oral cephalosporins,73 and cepha-
loridine74 at hysterectomy. Pseudomembra-
nous enterocolitis has also been reported

Page 118

110 David L. Hemsell

following cephalothin and cephradine
"prophylaxis."75 Clostridium difficile, the anaer-
obic bacteria responsible for this condition, is a
gram-positive spore-forming bacillus. It is a
component of normal intestinal flora in only
about 3% of healthy human beings. Alteration
of the normal enteric flora by antibiotics with
resultant overgrowth of this bacteria and re-
lease of its toxin is the proposed pathophysiol-
ogy of this disease.

Alteration of host flora and hospital bacterial
resistance patterns may result from the pro-
phylactic use of antimicrobials, especially if
overutilized. Drug dosage appears to be an im-
portant factor. We found that a single preop-
erative dose of cefoxitin caused significantly
less alteration oflower reproductive tract flora,
manifested by the development of resistance,
than did three doses over 12 hr in women un-
dergoing both vaginal49 and abdominal52 hys-
terectomy. Long-term follow-up of hospital
bacterial flora and antibiotic sensitivity pat-
terns are important and necessary for ade-
quate patient care. Increased usage of multiple
antibiotics has resulted in their being less effec-
tive because of the development of in vitro bac-
terial resistance. Many strains of Staphylococcus
aureus are now resistant to penicillin G, and
more strains are demonstrating resistance to
methicillin. In earlier studies Bacteroides fragilis
was sensitive to tetracycline. Now, very few
Bacteroides species are sensitive to tetracycline,
and the numbers of strains resistant to cefox-
itin may be increasing. Clindamycin-resistant
strains have also been identified.76 Without
doubt, the longer an antibiotic is given, the
more likely it is that resistant organisms will
develop among patient flora and hospital bac-
teria.

Disulfiram- or Antabuse-like reactions occur
when individuals ingest alcohol within several
days of treatment with cephalosporins contain-
ing a methyltetrazolethiol side chain. These
antibiotics are cefamandole, cefoperazone, and
moxalactam. The reaction, believed to be
caused by accumulation of acetaldehyde due to
inhibition of acetaldehyde dehydrogenase, can
be preve!lted by avoiding alcohol after injec-
tion of these antibiotics. This reaction should
be an insignificant problem with the prophy-
lactic application of these antibiotics, since
women are usually in the hospital for at least 3

days after hysterectomy, and alcohol is not a
frequently prescribed medication.

In summary, it has been shown that data re-
lating to infection after hysterectomy are di-
verse, that generalizations may be misleading,
and that risk factors are unpredictable and in-
consistent. Surgeons in each hospital must de-
termine the incidence and importance of post-
operative temperature elevations, the in-
cidence of major infections requiring antimi-
crobial therapy following vaginal and abdomi-
nal hysterectomy, the incidence of antibiotic
administration for prophylaxis and also for
"therapy" following surgery, the efficacy of
various antibiotics and regimens in preventing
infection, the required duration of prophy-
laxis, and the impact of the antibiotics on hos-
pital flora. Prophylactic antibiotic usage is sig-
nificant, accounting for one-third of antibiotic
usage in many hospitals.77 It is our current im-
pression that antibiotics are being overutilized
at the time of hysterectomy for both prophy-
lactic and therapeutic endeavors. Appropriate
selection and application of antimicrobial regi-
mens for both prevention of and treatment of
major infection after hysterectomy is manda-
tory to protect the patient from the complica-
tions of overusage.

References
1. DiPiro ]T, Record KE, Schanzenbach KS, et al.

Antimicrobial prophylaxis in surgery: Part 1.
Am] Hosp Pharm. 1981; 38:320-334.

2. Dicker RC, Greenspan ]R, Strauss LT, et al.
Complications of abdominal and vaginal hyster-
ectomy among women of reproductive age in
the United States. The collaborative review of
sterilization. Am ] Obstet Gynecol. 1982;
144:841-848.

3. Gray LA. Open cuff method of abdominal hys-
terectomy. Obstet Gynecol. 1975; 46:42-46.

4. Falk HC, Bunkin IA. A study of 500 vaginal
hysterectomies. Am ] Obstet Gynecol. 1946;
52:623-630.

5. Ledger W], Child MA. The hospital care of pa-
tients undergoing hysterectomy: an analysis of
12,026 patients from the Professional Activity
Study. Am] Obstet Gynecol. 1973; 117:423-
433.

6. Mayer W, Gordon M, Rothbard MJ. Prophylac-
tic antibiotics. Use in hysterectomy. NY State]
Med. 1976; 76:2144-2147.

7. Appelbaum PC, Moodley ], Chatterton SA, et al.

Page 233

230 Index

Sutures (cont.)
single-layer closure, 70
Smead-Jones technique, 72, 73

Swan-Ganz catheterization, 137-140
Swyer syndrome, 176

T-tube drainage, 199-202
Tachypnea, 127, 140
Teflon sutures, 62, 65
Teratomas, 177
Tevdek sutures, 62, 65
Thoracoabdominal nerves, 32, 33
Thromboembolic disease, postoperative

venous
morbidity from, 145
natural history of, 145-148
predisposing factors to, 145-147
prevention of, 145, 148-157

antiplatelet agents for, 151
dextran for, 151
elastic stockings for, 152-153
heparin for, low-dose, 148-151
inferior vena cava interruption for, 154
mechanical methods, 152-154
pharmacologic methods, 148-152
pneumatic compression for, external, 153-

154
strategies for, 154-157
surveillance, 154
warfarin for, 151-152

risk levels for, 156
screening for, 145-146, 154

Thrombophlebitis, pelvic, 217
Ticron sutures, 62, 65
Transfusions, 117-119
Transureteroureterostomy, 84
Transversalis fascia, 30
Transversus abdominis muscle, 30
Tropocollagen, 60
Tumors

dysgerminomas, 177
gastrointestinal tract, 88
germ cell, 176-177
gonadoblastomas, 177
ovarian

intestinal obstruction from, 88
pediatric, 177
ureteral obstruction from, 80

pediatric, 176-177
uterine

corpus and cervical carcinoma, 80
leiomyomata, 78
myomas, 78-80

vaginal, 177

Ultrasonography
of gastrointestinal tract, 90
of hematoma, posthysterectomy, 215

Ureteroneocystotomy,83
Ureters

blood supply to, 120
injury to, surgical

from abdominal surgery, 81-84
at angle of vagina, 83
at cardinal ligaments, 82-83
at infundibulopelvic ligament, 81-82
mechanisms of, 83
during reperitonealization, 83
surgical correction of, 83-84
uterine artery and, 82
from vaginal surgery, 84

obstruction of, conditions inducing, 78-80
uterine artery in relation to, 82

Urinalysis, 128-130
Urinary tract system

of elderly patient. See Elderly patient, renal
physiology of

injuries to, 80-84
from abdominal surgery, 80-84
from vaginal surgery, 84

monitoring of, in high-risk and critically ill
patients, 128-130

preoperative assessment of, 7-8, 77
for cervical carcinoma, 80
for endometriosis, 80
for genital anomalies, 77-78
for leiomyomata, 78-80
for ovarian and paraovarian tumors, 80
for pelvic inflammatory disease, 80
for uterine prolapse, 80
for uterine tumors, 80

Uterine artery, 82, 120
Uterus

anomalies of, 78
pediatric pathology involving, 177-178
prolapse of, 80
tumors of

corpus and cervical carcinoma, 80
leiomyomata, 78
myomas, 78-80

Vagina
atresia of, 174-176
disinfection of, preoperative, 49-50
pediatric pathology involving, 172-176
preparation of, for surgery, 49-50
prolapse of, 167
septa of, 176
tumors of, pediatric, 177

Page 234

Vaginal artery, 120
Vaginal surgery

for ambiguous genitalia, 173
for atresia, 174-176
for elderly patient, 191
hysterectomy. See Hysterectomy, abdominal and

vaginal
for imperforate hymen, 176
preparation for, mechanical and chemical, 49-

50
reconstructive techniques, 164-167, 174-176
for septa, 176
urinary tract injuries from, 84
for vaginal vault prolapse, 167

Vasoconstrictors
for hemorrhage control, 123
with heparin, for thromboembolism prophy-

laxis, 150
Veins. See also specific veins

for central venous pressure monitoring, 137
pelvic, surgical injury to, 123
postoperative thromboembolism of. See Throm-

boembolic disease, postoperative venous
stasis in, intraoperative, 152

Vena cava
interruption of, for thromboembolism prophy-

laxis, 154
surgical injury to, 123

Venous pressure monitoring, central, 135-137
Vesical artery, superior, 120
Vulvar reconstruction, 161-164
Vulvovaginoplasty, 165

Warfarin, 151-152
White blood cells in inflammatory response, 53,

56
Williams vulvovaginal plasty, 164

Wound closure
principles of, 67-69
surgical technique for, 69-75

delayed primary, 72-75
layer-by-layer, 71-72
mass closure, 72
Smead-Jones, 72, 73

Index 231

suture material as factor in, 68-69
of vertical vs transverse incisions, 68

Wound drainage
drains for. See Drains, surgical
historical perspectives on, 195
indications for, 195-196
technical aspects of, 203

Wound healing
of Cherney incision, 42
contraction of wound in, 60-61
epithelialization in, 56-57
fibroplasia in, 58-60
inflammatory phase of, 53-56
of Mackenrodt and Maylard incision, 40
maturation phase of, 60
mechanisms of, 53-61
of midline incisions, 33, 69-70
migratory phase of, 57-58
neovascularization in, 57
of paramedian incision, 34-35, 69
pathophysiology of, 53-61
of Pfannenstiel incision, 39
postoperative infection effect on, 45
proliferative phase of, 58-60
steroid effects on, 8
of transverse incision, 38, 68
of vertical incisions, 33, 34-35, 68

Wounds, operative
classification of, in relation to contamination, 46
disruption of, causative factors in, 69, 71
tensile strength of, 58, 67

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