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ACOG Guidance on Preventing Gynecologic Post-Procedure Infection


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


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