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 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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