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CMECNECPE

ACOG Guidance on Preventing Gynecologic Post-Procedure Infection

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. List the important measures that be taken preoperatively to reduce gynecologic surgical site infections
2. Apply the correct antibiotic prophylactic regimen based on gynecologic procedure

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from June 4 2018 through June 4 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Pharmacy Education

Postgraduate Institute for Medicine designates this continuing education activity for 0.25 contact hour(s) (0.25 CEUs) of the Accreditation Council for Pharmacy Education. (Universal Activity Number – JA4008162-9999-18-160-H01-P)

Type of Activity: Knowledge

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

SUMMARY:  

The ACOG Practice Bulletin on the prevention of infection following gynecologic procedures incorporates many of the CDC 2017 recommendations for the prevention of surgical site infection, (see ‘Learn More – Primary Sources’ section below).

    • Preop Prophylaxis
    • Intraop Prophylaxis
    • Procedure-Based Antibiotic Regimens
    • History of MRSA Colonization or Infection
    • Penicillin Allergy

The key highlights of the ACOG document include the following:

Preop Prophylaxis  

  • Treat remote infections prior to elective surgeries (e.g., UTIs) 
  • Do not shave the incision site unless there is concern about interference with the procedure  
    • Clippers preferable  
    • Do not use a razor  
  • Glycemic control  
    • Target <200 mg/dL with or without diabetes (CDC guidance) 
    • Screen women pre-operatively for diabetes if at high risk  
  • Shower or full body bath 
    • CDC recommendation does not specify a particular soap or antiseptic, but ACOG states that chlorhexidine “is a reasonable choice based on limited evidence that suggests increased efficacy compared with soap or placebo” 
  • Preop surgical skin prep with alcohol-based agent unless contraindicated (CDC) 
    • ACOG states “Chlorhexidine–alcohol is an appropriate choice” and that while iodophors also have broad spectrum coverage, they tend to be aqueous and not alcohol based  
    • Povidone-iodine: For abdominal surgery, scrub time may be as long as 5 minutes, followed with towel removal and then painting with topical povidone-iodine solution; dry for 2 minutes prior to draping  
    • Chlorhexidine–alcohol: Scrub for 2 minutes for moist sites (inguinal fold and vulva) and 30 seconds for dry sites (abdomen); dry for 3 minutes prior to draping  
  • Vaginal cleansing prior to hysterectomy or vaginal surgery 
    • Use 4% chlorhexidine gluconate or povidone–iodine  
      • Only povidone–iodine FDA approved for vaginal prep  
    • High alcohol concentration (70% isopropyl alcohol) chlorhexidine gluconate is contraindicated for vaginal prep due to risk of irritation  
      • 4% chlorhexidine gluconate soap (4% alcohol) is well tolerated and an alternative to iodine-based preparations in cases of allergy or when surgeon preference  
    • Maintain aseptic technique by all members of scrubbed staff  
    • Minimize traffic in the OR  

Intraop Prophylaxis  

  • Minimize wound disruption and use excellent surgical technique (e.g., hemostatis, gentle tissue handling, avoidance of hypothermia etc.)   
    • Data lacking as to whether there is benefit in closure of subcutaneous dead space in gyn surgery  
  • Appropriate use of antimicrobial prophylaxis (see detail in ‘Key Points’ below)  
    • Administer within 1 hour prior to procedure  
    • Obesity: Increase dosing based on weight   
    • Long procedure: Redose cefazolin 4 hours from the preoperative dose (not from start of procedure)  
    • Excessive blood loss: Additional dose of cefazolin if blood loss >1,500 mL  
  • Preop screening for bacterial vaginosis  
    • Screening and initiation of therapy with metronidazole or one of the other CDC-recommended treatment regimens “can be considered”
    • If the therapy duration of 5–7 days encroaches on the scheduled time for surgery, it would be reasonable to continue therapy perioperatively for at least 4 days

KEY POINTS:  

Procedure-Based Antibiotic Regimens  

  • Hysterectomy (vaginal/abdominal/laparoscopic/robotic) 
    • ≤120 kg: 2 g IV cefazolin 
    • >120 kg: 3 g IV cefazolin 
  • Uterine evacuation (suction D&C/D&E) 
    • 200 mg doxycycline (equally effective IV or orally) 
    • Metronidazole is an appropriate 2nd line agent  
  • Colporrhaphy 
    • ≤120 kg: 2 g IV cefazolin 
    • >120 kg: 3 g IV cefazolin 
  • Vaginal sling 
    • ≤120 kg: 2 g IV cefazolin 
    • >120 kg: 3 g IV cefazolin 
  • Laparotomy (no entry into bowel or vagina) 
    • May “consider” cefazolin  
    • ≤120 kg: 2 g IV cefazolin 
    • >120 kg: 3 g IV cefazolin 
  • Cervical tissue excision procedures (LEEP/biopsy/ECC) 
    • Not recommended 
  • Cystoscopy 
    • Not recommended 
    • If UTI identified, treat appropriately  
  • Endometrial biopsy 
    • Not recommended 
  • Laparoscopic procedures (no entry into bowel or vagina) 
    • Not recommended 
  • HSG (chromotubation/saline infusion sonography) 
    • Not recommended  
  • Hysteroscopy (operative/diagnostic) 
    • Not recommended 
  • Endometrial ablation  
    • Not recommended  
  • IUD insertion 
    • Not recommended 
  • Oocyte retrieval and embryo transfer  
    • Not recommended 
  • D&C for nonpregnancy indications 
    • Not recommended 
  • Urodynamics 
    • If UTI identified, treat appropriately

History of MRSA Colonization or Infection 

  • The following is recommended 
    • Hospital-recommended MRSA antibiotic prophylaxis protocol OR  
    • Adjustment of the preoperative prophylactic antibiotic regimen to include a single preoperative intravenous dose of vancomycin is recommended 
  • Joint guidelines of the American Society of Health-System Pharmacists, Infectious Diseases Society of America, Surgical Infection Society, and the Society for Healthcare Epidemiology of America recommend Vancomycin 15 mg/kg for prophylaxis

Penicillin Allergy  

No immediate hypersensitivity reaction (anaphylaxis, urticaria, bronchospasm) 

  • Can use cephalosporin  
  • Cephalosporin allergy: Clindamycin 900 mg or metronidazole 500 mg PLUS Gentamicin 5mg/kg or aztreonam 2 g  

Immediate hypersensitivity reaction or Stevens-Johnson syndrome 

  • Cephalosporin allergy: Clindamycin 900 mg or metronidazole 500 mg PLUS Gentamicin 5mg/kg or aztreonam 2 g  

Additional Notes

  • Interval to repeat  
    • Clindamycin: 6 hours 
    • Aztreonam: 4 hours  
  • First generation cephalosporins may provide better prophylaxis than second line agents  
    • Therefore, important to obtain an accurate allergy history to not inadvertently limit access to first generation cephalosporins

Learn More – Primary Sources:

ACOG Practice Bulletin 195: Prevention of Infection After Gynecologic Procedures 

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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