A 28 yr old lady is undergoing laparoscopic ovarian cystectomy, for suspected mature cystic teratoma. She reports a penicillin allergy, discovered after development of laryngeal edema and hives following amoxicillin administration.
- Laparoscopy without entry into vagina or bowel
- Penicillin allergy
- No prophylaxis
- IV cefazolin
- IV clindamycin + gentamicin
- IV metronidazole + gentamicin
Infectious complications following gynecologic surgeries form a notable source of morbidity and potential mortality. Multiple factors need to be implemented to limit the risk of this complication, including sterile surgical fields, ongoing assessment of sterilization technique, and postoperative wound care.
Antibiotic prophylaxis is a practice that has become widely accepted to reduce the risk of infectious complications. Although it is generally considered to be safe, the unnecessary use of antibiotics can lead to issues such as antibiotic adverse events, added costs, or the development of antibiotic resistance. The use of an appropriate antibiotic prophylaxis protocol is therefore crucial to gaining the full benefit of this intervention, with minimal adverse events.
Laparoscopic ovarian cystectomy is a procedure that does not involve entry into neither bowel nor the vagina. It is considered a clean procedure, with a very low risk of surgical site infection. As such, the scenario does not justify the use of prophylactic antibiotics.
A clean-contaminated wound, with entry into bowel or gential tract, would warrant the use of prophylactic antibiotics prior to operation. The recommended antibiotic regimen would be single-dose IV cefazolin for patients undergoing a hysterectomy, regardless of the planned route, or a uro-gynecologic procedure.
Patients who are allergic to penicillin, with a history of an immediate hypersensitivity reaction should not receive cephalosporins, for fear of cross reactivity. In allergic patients planned for clean-contaminated procedures, and for whom prophylactic antibiotics are indicated, a combination of IV metronidazole or clindamycin plus gentamicin or aztreonam is recommended. Clindamycin or metronidazole alone have been shown to reduce rates of infection following hysterectomy, but the added spectrum coverage results in even lower rates
- Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR (William R 1948-. Guideline for the prevention of surgical site infection, 1999. Bull Am Coll Surg . Available from: https://stacks.cdc.gov/view/cdc/7160
- ACOG Practice Bulletin No. 195: Prevention of Infection After Gynecologic Procedures. Obstet Gynecol . Available from: https://pubmed.ncbi.nlm.nih.gov/29794678/
- JM B, DH J. Antibiotic prophylaxis for gynecologic cancer surgery. Taiwan J Obstet Gynecol . Available from: https://pubmed.ncbi.nlm.nih.gov/32653122/