Gynaecological Surgery and Procedures in Adults - Guideline for Antimicrobial Prophylaxis

Publication: 01/03/2010  
Last review: 17/08/2018  
Next review: 17/08/2021  
Clinical Guideline
CURRENT 
ID: 1739 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for Antimicrobial Prophylaxis during Gynaecological Surgery & Procedures in Adults

  1. Summary table of routine recommendations
  2. Background information
  3. Special antimicrobial prophylaxis recommendations

1. Summary table of routine recommendations

It is the responsibility of the surgical team to prescribe the antibiotics & the anaesthetist to ensure they are given before incision.

Procedure

Prophylaxis recommendations

Evidence level

Prophylaxis aims to reduce

NNT

Antimicrobial dose/route/ < 1 hours prior to procedure

Routine

MRSA risk* or true penicillin allergy

Major gynaecological cancer surgery

Recommended

A, C2,3,5

Wound & pelvic infection

 

Co-amoxiclav electronic Medicines Compendium IV 1.2g single dose 

Teicoplanin electronic Medicines Compendium IV 400mg IV & Gentamicin 2mg/kg IBW IV & Metronidazole electronic Medicines Compendium 500mg IV. All single dose

Hysterectomy (abdominal / vaginal / laparoscopic / total or subtotal)

Recommended

A, C2,3,5

Pelvic infection

4

Co-amoxiclav electronic Medicines CompendiumIV 1.2g single dose 

Teicoplanin electronic Medicines Compendium IV 400mg IV & Gentamicin 2mg/kg IBW IV & Metronidazole electronic Medicines Compendium 500mg IV.  All single dose. 

Hysterosalpingogram or chromotubation

Considered where history of PID or procedure demonstrates dilated fallopian tubes

C5, D

Wound & pelvic infection

 

Doxycycline electronic Medicines Compendium100mg 12-hourly starting pre-op & post-op for 5 days plus  Metronidazole electronic Medicines Compendium 1g PR stat 1 hour prior to procedure followed by 400mg orally three times daily for 5 days

Doxycycline electronic Medicines Compendium 100mg 12-hourly  starting pre-op & post-op for 5 days plus Metronidazole electronic Medicines Compendium 1g PR stat 1 hour prior to procedure followed by 400mg orally three times daily for 5 days

Urogynaecology procedures, including those involving mesh

Recommended

C5

Wound & pelvic infection

 

Co-amoxiclav electronic Medicines CompendiumIV 1.2g single dose 

Teicoplanin electronic Medicines CompendiumIV 400mg IV & Gentamicin 2mg/kg IBW IV & Metronidazole electronic Medicines Compendium 500mg IV.  All single dose. 

Tension-Free Vaginal Tape (TVT)

Recommended

C5

Pelvic infection

 

Co-amoxiclav electronic Medicines Compendium IV 1.2g single dose

Teicoplanin electronic Medicines CompendiumIV 400mg IV & Gentamicin 2mg/kg IBW IV & Metronidazole electronic Medicines Compendium 500mg IV.  All single dose. 

Vaginal Termination of Pregnancy (TOP)

Recommended

C5

Pelvic infection

 

Doxycycline electronic Medicines Compendium 100mg PO and 200mg PO post-operatively.  Metronidazole electronic Medicines Compendium 1g PR stat 1 hour prior to termination followed by 400mg orally three times daily for 5 days

Doxycycline electronic Medicines Compendium 100mg PO one hour before procedure and 200mg PO post-operatively.  Metronidazole electronic Medicines Compendium 1g PR stat 1 hour prior to termination followed by 400mg orally three times daily for 5 days

Evacuation of incomplete miscarriage

Not Recommended

D

 

 

 

 

Laparoscopy (diagnostic, operative, tubal sterilization)

Considered

D

Pelvic infection

 

Doxycycline electronic Medicines Compendium 100mg PO and 200mg PO post-operatively. Metronidazole electronic Medicines Compendium 1g PR stat 1 hour prior to procedure followed by 400mg orally three times daily for 5 days

Doxycycline electronic Medicines Compendium 100mg PO and 200mg PO post-operatively. Metronidazole electronic Medicines Compendium 1g PR stat 1 hour prior to procedure followed by 400mg orally three times daily for 5 days

Laparotomy

Not recommended

C5

 

 

 

 

Hysteroscopy (diagnostic, operative, endometrial ablation, essure)

Not recommended except where a history of PID 

D

Pelvic infection

 

If PID history only: Doxycycline electronic Medicines Compendium 100mg PO and 200mg PO post-operatively. Metronidazole electronic Medicines Compendium 1g PR stat 1 hour prior to procedure followed by 400mg orally three times daily for 5 days

If PID history only:
Doxycycline electronic Medicines Compendium 100mg PO and 200mg PO post-operatively. Metronidazole electronic Medicines Compendium 1g PR stat 1 hour prior to procedure followed by 400mg orally three times daily for 5 days

Endometrial biopsy

Not recommended

C5

 

 

 

 

Urodynamics

Not recommended

C5

 

 

 

 

Intrauterine Contraceptive Device (IUD) insertion

Not recommended

C5

 

 

 

 

Assisted Conception Techniques
- Egg collections
- Embryo transfers
- IUI (intra-uterine insemination)
- Sonohysterography

Recommended for egg collection and embryo transfer.  See local guidelines flushing medium. 

D

Pelvic infection

 

Clindamycin electronic Medicines Compendium information on Clindamycin  vaginal cream starting 2 days before egg collection & 4 days before embryo transfer.

Clindamycin electronic Medicines Compendium information on Clindamycin  vaginal cream starting 2 days before egg collection & 4 days before embryo transfer.

 

Gentamicin dosing in ADULT FEMALES (> 16 yrs)

Height

IBW (kg)

Gentamicin dose (mg)

ABW (use if less than IBW) (kg)

6’ 3”  (1.9m) +

79.5

160

78 to 82

6’ 2”  (1.88m)

77.2

 150

72 to 77

6’ 1”  (1.85m)

74.9

6’  (1.82m)

72.6

5’ 11”  (1.8m)

70.3

140

66 to 71

5’ 10”  (1.78m)

68

5’ 9”  (1.75m)

65.7

 130

60 to 65

5’ 8”  (1.72m)

63.4

5’ 7”  (1.7m)

61.1

5’ 6”  (1.67m)

58.8

 120

55 to 59

5’ 5”  (1.65m)

56.5

5’ 4”  (1.62m)

54.2

5’ 3”  (1.6m)

51.9

100

49 to 54

5’ 2”  (1.57m)

49.6

5’ 1”  (1.55m)

47.3

90

43 to 48

5’  (1.52m) or under

45

Give additional peri-operative doses if procedure >4 hours long or if patient undergoes total body volume transfusion: Co-amoxiclav electronic Medicines Compendium after 4 hours, Metronidazole electronic Medicines Compendium after 8 hours. Do not give another dose of Teicoplanin electronic Medicines Compendium.  Gentamicin dose to be repeated if patient undergoes total volume transfusion.
Teicoplanin electronic Medicines Compendium & Gentamicin are incompatible, so ALWAYS flush between administrations.  Teicoplanin electronic Medicines Compendium takes 15 minutes to reconstitute so allow time for preparation.

MRSA Risk Factors
Patients within these categories are considered at increased risk of MRSA infection:

  1. Known previous infection or colonisation with MRSA at any time.
  2. Resident of a long term care facility (nursing home, residential home or any other long term residential facility) without a negative MRSA screening result.
  3. Any history of inpatient hospital stay within the previous 6 months without a negative MRSA screening result

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2. Background information

The aim of antimicrobial prophylaxis when used in gynaecological surgery is a reduction in surgical site infection (SSI) - a potentially debilitating and occasionally life-threatening complication.

The continued presence of meticillin-resistant Staphylococcus aureus (MRSA) in the Trust and the ongoing problem of Clostridium difficile infection has prompted a review of surgical prophylaxis. It is appropriate to use a single pre-operative dose of prophylaxis in most situations to reduce the risks related to antimicrobial use while gaining maximum benefit from prophylaxis (NICE, SIGN).

These guidelines should be applicable to the majority of patients.  Where the recommendations in these guidelines do not seem appropriate for a particular patient, the surgeon is advised to discuss the case with a microbiologist.

For most surgical site infections, the source of pathogens is the endogenous flora of the patient’s skin or vagina. When the skin is incised, the exposed tissues are at risk of contamination with endogenous flora.  These organisms are usually aerobic Gram-positive cocci (e.g. Staphylococcus aureus) , but may include faecal flora (e.g. anaerobic bacteria and Gram-negative aerobes when incisions are made near the perineum or groin.  When the vagina is opened during surgery, the surgical site is exposed to a polymicrobial flora of aerobes and anaerobes.  Bacterial vaginosis, a complex alteration of the vaginal flora resulting in an increased concentration of pathogenic anaerobic bacteria is associated with an increased risk of post-hysterectomy cuff cellulitis. Staph. aureus and Staph. epidermidis may lead to abdominal incision infection.  Gynaecological procedures such as laparotomies or laparoscopies, do not breach surfaces colonised with bacteria from the vagina, and infections after these procedures result from contaminating skin bacteria only.

Procedures breaching the endocervix, such as hystosalpingogram, sonohysterography, IUD insertion, endometrial biopsy, chromotubation, and dilatation and curettage, may seed the endometrium and the fallopian tubes with microorganisms found in the upper vagina and endocervix.  However post-procedural infection is rare and tends to occur only in those patients with either a history of pelvic inflammatory disease (PID) or findings at the time of surgery suggestive of prior PID (e.g. hydrosalpinges).  When choosing an antibiotic for prevention and treatment for post-procedural infections, for either endometriosis or PID, the polymicrobial nature of these infections should be taken into consideration.

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3. Special antimicrobial prophylaxis recommendations

Endocarditis prophylaxis
Routine endocarditis prophylaxis is no longer recommended for patients undergoing urological or gynaecological procedures3. Both AHA and NICE, having reviewed the evidence, concluded that there was insufficient evidence to support prophylaxis against IE for these procedures.

However, the use of appropriate antimicrobial therapy is recommended for patients at increased risk of developing endocarditis who have known or suspected infection at the site of a procedure/operation3.  Patients at risk of endocarditis include those with valve replacement, acquired valvular heart disease with stenosis or regurgitation, structural congenital heart disease (including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect, fully repaired patent ductus arteriosus and closure devices considered to be epithelialised), hypertrophic cardiomyopathy or a previous episode of infective endocarditis.  The important consideration in this setting is ensuring anti-enterococcal activity which is provided by Co-amoxiclav electronic Medicines Compendium in these guidelines.

If a procedure for which routine prophylaxis is not recommended in these guidelines is undertaken in a patient with endocarditis risk factors and there may be infection at the site of the operation e.g hysteroscopy for potential pyometra or chronic endometritis then prophylaxis would be appropriate.  Please call microbiology to discuss on a case-by-case basis.

Pelvis surgery
Abdominal hysterectomy
One systematic review was identified. A systematic review4 (17 trials, n = 2752 participants) investigated wound infections in abdominal hysterectomy following randomisation to antibiotic prophylaxis or placebo. It was unclear which trials had contributed to the comparison ‘antibiotic versus placebo or no antibiotic’ and no quality assessment of methodology is provided. The group treated with cephalosporin showed a statistically significantly lower infection rate compared with the control group (9.8% versus 23.4%; OR 0.35, 95% CI 0.30 to 0.40, P < 0.0001).

Hysterectomy5
Patients undergoing vaginal hysterectomy or abdominal hysterectomy should receive single-dose antimicrobial prophylaxis. A recent report noted that as many as one half of women undergoing hysterectomy receive either inappropriately timed prophylaxis or no antibiotic prophylaxis. Hospital policies can significantly increase the appropriate use of prophylactic preoperative antibiotics.  More than 30 prospective randomized clinical trials and two meta-analyses support the use of prophylactic antibiotics to substantially reduce postoperative infectious morbidity and decrease length of hospitalization in women undergoing hysterectomy. Most studies show no particular antibiotic regimen to be superior to all others. Although no trials have been conducted in patients undergoing laparoscopically assisted hysterectomy, laparoscopic supracervical hysterectomy, or laparoscopic total hysterectomy, antibiotic prophylaxis seems reasonable for these procedures. Patients included in the reports concerning the safety and effectiveness of these laparoscopic approaches all received antibiotic prophylaxis.

Bacterial vaginosis is a known risk factor for surgical site infection after hysterectomy. Preoperative treatment and postoperative treatment of bacterial vaginosis with Metronidazole electronic Medicines Compendium for at least 4 days beginning just before surgery significantly reduces vaginal cuff infection among women with abnormal flora.

Laparoscopy and Laparotomy5
No data are available to recommend antibiotic prophylaxis in clean surgery not involving vaginal operations or intestinal operations. A single placebo-controlled, randomized clinical trial failed to show benefit of cephalosporin prophylaxis in women undergoing laparoscopy. Antibiotic prophylaxis is not recommended in patients undergoing diagnostic laparoscopy or exploratory laparotomy.

Hysterosalpingography, Chromotubation, Sonohysterography, and Hysteroscopy
Hysterosalpingography (HSG) is a commonly performed procedure to evaluate infertile couples for tubal factor infertility. Post-HSG PID is an uncommon (1.4–3.4%) but potentially serious complication in this patient population. Patients with dilated fallopian tubes at the time of HSG have a higher rate (11%) of post-HSG PID. The possibility of lower genital tract infection with chlamydia should be considered before performing this procedure. In a retrospective review, investigators observed no cases of post-HSG PID in patients with nondilated fallopian tubes (0/398). In patients with no history of pelvic infection, HSG can be performed without prophylactic antibiotics. If HSG demonstrates dilated fallopian tubes, Doxycycline electronic Medicines Compendium, 100 mg twice daily for 5 days, should be given to reduce the incidence of post-HSG PID.

In patients with a history of pelvic infection, Doxycycline electronic Medicines Compendium can be administered before the procedure and continued if dilated fallopian tubes are found. Because chromotubation at the time of diagnostic laparoscopy is similar to HSG, the recommendation for administering Doxycycline electronic Medicines Compendium if abnormal fallopian tubes are visualized is the same. However, there currently are no data to support this recommendation. In patients thought to have an active pelvic infection, neither HSG nor chromotubation should be performed.

No data are available on which to base a recommendation for prophylaxis in patients undergoing sonohysterography, but reported rates of postprocedure infection are negligible (0/300 in one series). Prophylaxis should be based on the individual patient’s risk of PID; routine use of antibiotic prophylaxis is not recommended.

Infectious complications after hysteroscopic surgery are uncommon and estimated to occur in 0.18–1.5% of cases. A prospective study of 2,116 surgical hysteroscopies (782 myoma resections, 422 polyp resections, 623 endometrial resections, 90 septectomies, and 199 lysis of synechiae) were performed without antibiotic prophylaxis. Only 18 (0.85%) cases of endometritis were noted postoperatively. A single prospective study has evaluated the usefulness of amoxicillin and clavulanate antibiotic prophylaxis in preventing bacteremia associated with hysteroscopic endometrial laser ablation or endometrial resection. Although the incidence of bacteremia was lower in the antibiotic group than in the placebo group (2% versus 16%), most of the microorganisms isolated were of dubious clinical significance (anaerobic staphylococci) and may have resulted from contamination. Postoperative fever was noted twice as often in the patients receiving antimicrobial prophylaxis.  Postoperative infection requiring antibiotic therapy was not significantly different between the two groups: 11.4% and 9% of patients required antibiotics in the placebo group and antibiotic group, respectively.

Other retrospective case series evaluating endometrial ablation reported similar low rates of infection. In a series of 568 patients treated without antimicrobial prophylaxis, one woman (0.18%) developed endometritis. In a second series of 600 women, two (0.3%) developed mild pelvic infections, of whom one received antimicrobial prophylaxis (1/495) and one did not (1/105). However, in a series of 200 women undergoing operative hysteroscopy without prophylactic antibiotics, investigators reported three cases of severe pelvic infection, although all three of these women had a history of PID. Given the low risk of infection and lack of evidence of efficacy, routine antibiotic prophylaxis is not recommended for the general patient population undergoing these procedures. However, as with other transcervical procedures such as HSG, chromotubation, and sonohysterography, prophylaxis may be considered in those patients with a history of PID or tubal damage noted at the time of the procedure.

Intrauterine Device (IUD) Insertion and Endometrial Biopsy5
The IUD is a highly effective contraceptive, but concerns about the perceived risk of PID limits its use. Most of the risk of IUD-related infection occurs in the first few weeks to months after insertion, suggesting that contamination of the endometrial cavity at the time of insertion is the infecting mechanism rather than the IUD or string itself.  Four randomized clinical trials have now been performed using Doxycycline electronic Medicines Compendium or azithromycin as antibiotic prophylaxis. Pelvic inflammatory disease occurred uncommonly with or without the use of antibiotic prophylaxis, and so prophylaxis is not indicated at the time of IUD insertion. A Cochrane Collaboration review concluded that either Doxycycline electronic Medicines Compendium or azithromycin before IUD insertion confers little benefit.  When the results of the four studies were combined, a reduction in unscheduled visits to the health care provider was seen, but not in the only trial performed in the United States. In the U.S. trial, however, all patients were screened for gonorrhoea and chlamydia, and some with positive test results were excluded from the study. The cost effectiveness of screening for sexually transmitted diseases before IUD insertion remains unclear because of limited data. The only randomized controlled trial performed in the United States concluded that in women screened for sexually transmitted diseases before IUD insertion, prophylactic antibiotics provide no benefit.

No data are available on infectious complications of endometrial biopsy. The incidence is presumed to be negligible. It is recommended that this procedure be performed without the use of antimicrobial prophylaxis.

Surgical Abortion5
Eleven of 15 randomized clinical trials support the use of antibiotic prophylaxis at the time of suction curettage for elective abortion. In a meta-analysis of 11 placebocontrolled, blinded clinical trials, the overall summary relative risk (RR) estimate for developing postabortal infection of the upper genital tract in women receiving antibiotic therapy compared with those receiving placebo was 0.58 (95% confidence interval [CI], 0.47–0.71). Of high-risk women, those with a history of PID had a summary RR of 0.56 (CI, 0.37–0.84); women with a positive chlamydia culture at abortion had a summary RR of 0.38 (CI, 0.15–0.92). Of low-risk women, those with no reported history of PID had a summary RR of 0.65 (CI, 0.47–0.90); in women with a negative Chlamydia culture, the RR was 0.63 (CI, 0.42–0.97). The overall 42% decreased risk of infection in women given periabortal antibiotics confirms that prophylactic antibiotics are effective for these women, regardless of risk. The risk of infection after suction curettage for missed abortion should be similar to that after suction curettage for elective abortion. Therefore, despite the lack of data, antibiotic prophylaxis should also be considered for these patients.

The optimal antibiotic and dosage regimens remain unclear. Both tetracyclines and Metronidazole electronic Medicines Compendium provide significant and comparable protection against postabortal PID. One of the most effective and inexpensive regimens reported in a meta-analysis was Doxycycline electronic Medicines Compendium, 100 mg orally 1 hour before the abortion followed by 200 mg after the procedure. It is estimated that the cost of treating a single case of postabortal PID as an outpatient far exceeds the cost of Doxycycline electronic Medicines Compendium prophylaxis. In a prospective, randomized trial, antibiotic prophylaxis showed no benefit before treatment of incomplete abortion.

Assisted Conception Techniques
At SJUH, all couples are screened for GU infections once before they start treatment. They also have hepatitis B & C, HIV and syphilis screening before an IVF cycle but not other treatments. Vaginal clindamycin (Dalacin) cream is used starting 2 days before the egg collection and 4 days before the embryo transfer. Flushing medium is used for the follicles which contains Gentamicin during the egg collection for the protection of the gametes and also the patient. These patients by nature have an increased risk as 30% would have had PID and tubal disease, 10-15% would have endometriosis and further 30% would have partners with oligo-asthenospermia largely due to past infections. The IUI patient is different in that she has a normal pelvis and patent tubes. The professionally manufactured IUI medium contains penicillin and streptomycin for the protection of both gametes and the patient. No other prophylaxis is used in these patients.

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus (no national guidelines exist, guidelines from different learned bodies   contradict each other, or no evidence exists)

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Provenance

Record: 1739
Objective:

The aim of antimicrobial prophylaxis when used in gynaecological surgery is a reduction in surgical site infection (SSI) - a potentially debilitating and occasionally life-threatening complication.

Clinical condition:

Gynaecological surgery & procedures in adults

Target patient group: All patients undergoing gynaecological surgery
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

  1. Gemmell CG, Edwards DI, Fraise AP, Gould FK, Ridgway GL, Warren RE, et al. Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the UK. 2006. p. 589-608
  2. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Ed Leaper D, Collier M, Evans D, Farrington M, Gibbs E, Gould K, et al.
  3. NICE Clinical Guideline 74: Surgical site infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor.: Royal College of Obstetrics and Gynaecology, Press; 2008.
  4. Tanos V, Rojansky N. Prophylactic antibiotics in abdominal hysterectomy. Journal of the AmericanCollege of Surgeons 1994;179:593–600.
  5. ACOG Practice Bulletin No 104, May 2009 Antibiotic prophylaxis for Gynecologic procedures. Obstetrics & Gynaecology 113; 2009: 1180-89

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Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

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