ACOG Guidance on Preventing Gynecologic Post-Procedure Infection

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).

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