Multisociety guidelines for antimicrobial prophylaxis in surgery published in 2013 provide comprehensive recommendations on prophylactic agents to use based on type of procedure. For women undergoing vaginal or abdominal hysterectomy, whether through an open or laparoscopic approach, the recommended prophylactic antibiotic regimen is a single dose of cefazolin. Alternative options include cefoxitin, cefotetan, or ampicillin-sulbactam. For patients with a beta-lactam allergy, the alternatives are combinations such as clindamycin or vancomycin with an aminoglycoside, aztreonam, or a fluoroquinolone, and metronidazole with an aminoglycoside or a fluoroquinolone. The strength of evidence supporting this prophylactic approach is rated as A, indicating strong evidence for effectiveness. [1]
The 2018 American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin presents comprehensive guidelines for the prevention of infection following gynecologic procedures. Patients undergoing various types of hysterectomy, whether vaginal, abdominal, laparoscopic, or robotic, including supracervical hysterectomy, are advised to receive single-dose antimicrobial prophylaxis to minimize postoperative infections. Currently, cefazolin is recommended as the primary prophylactic antibiotic for hysterectomies, backed by evidence from over 30 prospective randomized clinical trials and four meta-analyses. These studies demonstrate that prophylactic antibiotics effectively reduce postoperative infectious morbidity and shorten hospital stays in women undergoing these procedures. A Cochrane review identified significant reductions in postoperative infections, including abdominal wound infections, urinary tract infections, pelvic infections, and postoperative fevers, for abdominal and vaginal hysterectomies when compared to placebo. However, the review did not establish the superiority of any specific antibiotic regimen. While the panel did not provide a specific recommendation for metronidazole in this setting, it noted that a combination of metronidazole or clindamycin with gentamicin or aztreonam is generally recommended for patients with contraindications to cephalosporins. [2]
A 2017 Cochrane review assessed the effectiveness and safety of antibiotic prophylaxis in hysterectomy, incorporating 37 randomized controlled trials (RCTs) with 6,079 women, revealing varied evidence quality from very low to moderate. The review found that antibiotic prophylaxis notably reduced the risk of postoperative infections, urinary tract infections, pelvic infections, and postoperative fevers across both vaginal and abdominal hysterectomies. Head-to-head comparisons between different antibiotics, as well as single versus combined antibiotic regimens, were limited and showed no significant differences, except for fewer infections with cephalosporins compared to antiprotozoals (e.g. metronidazole, anitroimidazole) in vaginal hysterectomy. Most comparisons lacked robust evidence on adverse effects due to methodological limitations and imprecision. It was highlighted that there is insufficient evidence to determine whether prophylactic antibiotic use affects rates of adverse effects, or to identify the safest and most effective individual antibiotic, dose regimen, or route of administration. The review included studies that were 14 years old at the time of the search, suggesting that their findings may not align with current perioperative and postoperative care practices, nor do they reflect current locoregional antimicrobial resistance patterns. [3]