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Antibiotic prophylaxis for radical abdominal hysterectomy
GYNECOLOGIC
ONCOLOGY
28,
201-204 (1987)
Antibiotic Prophylaxis for Radical Abdominal Hysterectomy ERIK Department
BENDVOLD,
of Gynecologic
M.D.,
Oncology,
AND KJELL
The Norwegian Norway
Received
E.
KJORSTAD,
Radium Hospital,
M.D. Montebello,
Oslo 3,
May 28, 1986
Records of 35 patients with cervical cancer Stage IB operated with radical abdominal hysterectomy and pelvic lymphadenectomy were surveyed retrospectively for incidence of febrile morbidity and site-related infections. Febrile morbidity was observed in 6 patients (17%). No surgical site-related infections were observed. It is concluded that radical abdominal hysterectomy in our hospital does not carry any significant risk of postoperative site-related infections and that prophylactic antibiotics cannot be recommended. Q 1987 Academic press, Inc.
The justification of generalized use of prophylactic antibiotics in conjunction with surgery or studies on the effectiveness of such medication must rest upon the clinical observation that the actual operation carries a significant risk of operative site-related infections. This seems to be the case in three controlled studies known to be published on this topic [l-3]. Among American gynecologic oncologists, prophylactic use of antibiotics for radical abdominal hysterectomy seems to have widespread acceptance. A recent interview indicated that 65% of the responding oncologists routinely used prophylactic antibiotics and that another 19% used it, but not routinely, for patients undergoing radical hysterectomy [I]. At The Norwegian Radium Hospital, the clinical impression has been that radical abdominal hysterectomy does not imply an elevated risk of infection compared to other gynecological surgical procedures. This is reflected by the fact that prophylactic antibiotics are hardly ever used for this operation. The present study was undertaken to establish the incidence of infectious morbidity in patients undergoing radical hysterectomy in order to evaluate the indications for prophylactic antibiotic administration. MATERIALS
AND METHODS
The study involved 45 women with cancer of the cervix Stage IB consecutively admitted to our department for radical abdominal hysterectomy from October 1984. The medical records of these patients were surveyed in retrospect. Routine clinical and laboratory evaluations required at admittance included a complete blood count and electrolyte panel, chest X-ray, and intravenous pyel201 0090-8258/87$1SO Copyright 0 1987 by Academic Press, Inc. All rights of reproduction in any form reserved.
202
BENDVOLD
AND
KJORSTAD
ography. Ten patients who received antibiotic therapy within 72 hours prior to the planned operation because of clinical or laboratory evidence of infection were excluded from the study. The remaining 35 did not receive any kind of antibiotic medication pre- or peroperatively. In 21 patients preoperative lymphography was performed. Twenty-eight patients were given intracavitary radiotherapy before the operation. Ten patients had a diagnostic conization performed preoperatively. All patients were prepared for surgery in a uniform and standardized fashion. Abdominal-perineal shave was performed the evening before the operation. Bowel preparation was confined to a l-liter saline solution enema given the evening before the operation. In the operating theater, after anesthesia, a transurethral catheter was inserted and the surgical field was prepared with Klorhexidin ethanol solution and covered with sterile dressing. Vaginal douches were not performed, and drugs for tromboembolic prophylaxis were not given. The abdomen was entered through a midline incision from the symphysis to just above the umbilicus. The abdominal cavity was then explored. A complete bilateral pelvic lymphadenectomy including the common iliac nodes was carried out. Para-aortic lymphadenectomy was not routinely performed. Radical hysterectomy was then done, with removal of 2-3 cm of the upper part of the vagina and the parametrial tissues to the lateral pelvic wall. Drains were placed along each pelvic sidewall, exited through the anterior abdominal wall bilaterally, and connected to low-pressure suction. Appendectomy was not performed in any of the patients. The medical records of each patient were analyzed for age, weight, and duration of the operation and hospital stay. Estimated blood loss during surgery was registered as well as number of days the urinary catheter and retroperitoneal drains were left in place. Morbidity was analyzed and classified according to a modification of the criteria used by Sevin et al. [l]: (1) Surgical site-related infections consisting of sepsis, pelvic abscess, pelvic cellulitis, and would infection with purulent wound breakdown; (2) nonsurgical site-related infections including urinary tract infection and respiratory infection; and (3) morbidity not related to infection, including temperature above 38.0 orally on two separate occasions postoperatively at least 6 hours apart either within the first 48 hr after surgery or more than 48 hr after the end of the procedure. The patients were aged 29-62 years (mean 42) and weighed 61.1 kg (mean value). Mean operating time was 2 hr 38 min with an average blood loss of 525 ml. The transurethral catheter was routinely left indwelling for 5 days. A positive bacteriological culture (> 100.000 bacteria/ml urine) was observed in 16 patients (46%). Retroperitoneal drains were left in place for a mean of 4 days. Total postoperative hospital stay averaged 10 days (Table I). RESULTS
No patient experienced surgical site-related infections. Of the 16 patients in whom a positive bacteriological culture in the urine was observed on the fifth
ANTIBIOTICS
IN
RADICAL
203
HYSTERECTOMY
TABLE 1 ANTIBIOTIC
PROPHYLAXIS IN RADICAL HYSTERECTOMY: PATIENT SURGICAL CHARACTERISTICS (N = 35) Mean
Age Weight (kg) Hours of surgery Blood loss (ml) Catheterization (days) Retroperitoneal Drainage (days) Hospitalization (days)
AND
SD
41.8 61.1 2.6 525 4.9
9.1 8.0 0.6 170 0.3
4.2 10.1
1.4 1.8
(29-62) (50-85) (1.3-4.0) (200- 1000) (4-5)
U-6) (8-16)
postoperative day, only 2 (6%) had symptoms of infection. No respiratory infections were observed. Febrile morbidity during the 48 hr following surgery was observed in six patients (17%). None of the patients fulfilled the criteria for febrile morbidity later in the postoperative course. DISCUSSION
Radical hysterectomy is an operation considered to carry a significant risk for postoperative site-related infections [ 11. In a series of 27 patients not receiving prophylactic antibiotics, Sevin et al. [l] found 52% incidence of wound infections or pelvic cellulitis. More recently, Marsden et al. [2] reported that 16% of 43 patients in an untreated control group experienced infections related to the surgical site. Under such conditions it seems logical that studies evaluating the effect of various regimes for antibiotic prophylaxis are performed. The present study does, however, fail to demonstrate that radical hysterectomy implies a severe risk of site-related infections. As no such complication was observed in our series of 35 operations, administration of prophylactic antibiotics cannot be recommended on this basis. There are a number of possible explanations for the divergence of results between the present study and the two studies cited above. The relatively short operation time along with moderate average blood loss may be important for the reduction of site-related infections. Other contributing factors may be that the infectious focus represented by the primary tumor is less noxious after preoperative intracavitary radiation, a routine procedure in our department. Our patients had a transurethral catheter in place for 5 days. An incidence of 6% symptomatic urinary infections and 40% incidence of nonsymptomatic urinary infections was observed. This is much lower than the 40% incidence of symptomatic urinary infections reported by Sevin et al. [I ] when the patients were catheterized for an average of 17 days. Urinary tract infections are, however, in our opinion,
204
BENDVOLD
AND
KJORSTAD
not a valid indication for antibiotic prophylaxis. The incidence of such infections can presumably be lowered by simpler means, such as rigorous disinfection routines before insertion of the catheter, shorter catheterization periods, or possibly postoperative suprapubic drainage instead of transurethral catheter. Of our patients, 17% experienced fevers above 38.o”C at two separate occasions more than 6 hr apart during the 48 hr following surgery. There were no indications of infections causing these febrile episodes. We consider combating febrile morbidity, not related to obvious infection, with antiphlogistic drugs a more logical approach than administration of antibiotics. In summary we conclude that radical abdominal hysterectomy does not carry a significant risk of postoperative site-related infection and that prophylactic use of antibiotics is not indicated. SYNOPSIS
In a retrospective study surveilling the records of 35 patients operated with radical hysterectomy, no surgical site-related infections were observed. In our hospital, prophylactic use of antibiotics therefore cannot be recommended. REFERENCES 1. Sevin, B. U.. Ramos, R., Lichtinger, M., et nl. Antibiotic prevention of infections complicating radical abdominal hysterectomy, Ohsret. Gq’necol. 64, 539 (1984). 2. Marsden, D. E., Cavanagh, D.. Wisniewski, B. J.. et N/. Factors affecting the incidence of infectious morbidity after radical hysterectomy. Amer. J. Obsret. Gyned. 152, 817 (1985). 3. Rosenshein, N. B., Ruth, J. C., Villar, J., ef al. A prospective randomized study of doxycycline as a prophylactic antibiotic in patients undergoing radical hysterectomy, Gynerol. On&. 15, 201 (1983).
ONCOLOGY
28,
201-204 (1987)
Antibiotic Prophylaxis for Radical Abdominal Hysterectomy ERIK Department
BENDVOLD,
of Gynecologic
M.D.,
Oncology,
AND KJELL
The Norwegian Norway
Received
E.
KJORSTAD,
Radium Hospital,
M.D. Montebello,
Oslo 3,
May 28, 1986
Records of 35 patients with cervical cancer Stage IB operated with radical abdominal hysterectomy and pelvic lymphadenectomy were surveyed retrospectively for incidence of febrile morbidity and site-related infections. Febrile morbidity was observed in 6 patients (17%). No surgical site-related infections were observed. It is concluded that radical abdominal hysterectomy in our hospital does not carry any significant risk of postoperative site-related infections and that prophylactic antibiotics cannot be recommended. Q 1987 Academic press, Inc.
The justification of generalized use of prophylactic antibiotics in conjunction with surgery or studies on the effectiveness of such medication must rest upon the clinical observation that the actual operation carries a significant risk of operative site-related infections. This seems to be the case in three controlled studies known to be published on this topic [l-3]. Among American gynecologic oncologists, prophylactic use of antibiotics for radical abdominal hysterectomy seems to have widespread acceptance. A recent interview indicated that 65% of the responding oncologists routinely used prophylactic antibiotics and that another 19% used it, but not routinely, for patients undergoing radical hysterectomy [I]. At The Norwegian Radium Hospital, the clinical impression has been that radical abdominal hysterectomy does not imply an elevated risk of infection compared to other gynecological surgical procedures. This is reflected by the fact that prophylactic antibiotics are hardly ever used for this operation. The present study was undertaken to establish the incidence of infectious morbidity in patients undergoing radical hysterectomy in order to evaluate the indications for prophylactic antibiotic administration. MATERIALS
AND METHODS
The study involved 45 women with cancer of the cervix Stage IB consecutively admitted to our department for radical abdominal hysterectomy from October 1984. The medical records of these patients were surveyed in retrospect. Routine clinical and laboratory evaluations required at admittance included a complete blood count and electrolyte panel, chest X-ray, and intravenous pyel201 0090-8258/87$1SO Copyright 0 1987 by Academic Press, Inc. All rights of reproduction in any form reserved.
202
BENDVOLD
AND
KJORSTAD
ography. Ten patients who received antibiotic therapy within 72 hours prior to the planned operation because of clinical or laboratory evidence of infection were excluded from the study. The remaining 35 did not receive any kind of antibiotic medication pre- or peroperatively. In 21 patients preoperative lymphography was performed. Twenty-eight patients were given intracavitary radiotherapy before the operation. Ten patients had a diagnostic conization performed preoperatively. All patients were prepared for surgery in a uniform and standardized fashion. Abdominal-perineal shave was performed the evening before the operation. Bowel preparation was confined to a l-liter saline solution enema given the evening before the operation. In the operating theater, after anesthesia, a transurethral catheter was inserted and the surgical field was prepared with Klorhexidin ethanol solution and covered with sterile dressing. Vaginal douches were not performed, and drugs for tromboembolic prophylaxis were not given. The abdomen was entered through a midline incision from the symphysis to just above the umbilicus. The abdominal cavity was then explored. A complete bilateral pelvic lymphadenectomy including the common iliac nodes was carried out. Para-aortic lymphadenectomy was not routinely performed. Radical hysterectomy was then done, with removal of 2-3 cm of the upper part of the vagina and the parametrial tissues to the lateral pelvic wall. Drains were placed along each pelvic sidewall, exited through the anterior abdominal wall bilaterally, and connected to low-pressure suction. Appendectomy was not performed in any of the patients. The medical records of each patient were analyzed for age, weight, and duration of the operation and hospital stay. Estimated blood loss during surgery was registered as well as number of days the urinary catheter and retroperitoneal drains were left in place. Morbidity was analyzed and classified according to a modification of the criteria used by Sevin et al. [l]: (1) Surgical site-related infections consisting of sepsis, pelvic abscess, pelvic cellulitis, and would infection with purulent wound breakdown; (2) nonsurgical site-related infections including urinary tract infection and respiratory infection; and (3) morbidity not related to infection, including temperature above 38.0 orally on two separate occasions postoperatively at least 6 hours apart either within the first 48 hr after surgery or more than 48 hr after the end of the procedure. The patients were aged 29-62 years (mean 42) and weighed 61.1 kg (mean value). Mean operating time was 2 hr 38 min with an average blood loss of 525 ml. The transurethral catheter was routinely left indwelling for 5 days. A positive bacteriological culture (> 100.000 bacteria/ml urine) was observed in 16 patients (46%). Retroperitoneal drains were left in place for a mean of 4 days. Total postoperative hospital stay averaged 10 days (Table I). RESULTS
No patient experienced surgical site-related infections. Of the 16 patients in whom a positive bacteriological culture in the urine was observed on the fifth
ANTIBIOTICS
IN
RADICAL
203
HYSTERECTOMY
TABLE 1 ANTIBIOTIC
PROPHYLAXIS IN RADICAL HYSTERECTOMY: PATIENT SURGICAL CHARACTERISTICS (N = 35) Mean
Age Weight (kg) Hours of surgery Blood loss (ml) Catheterization (days) Retroperitoneal Drainage (days) Hospitalization (days)
AND
SD
41.8 61.1 2.6 525 4.9
9.1 8.0 0.6 170 0.3
4.2 10.1
1.4 1.8
(29-62) (50-85) (1.3-4.0) (200- 1000) (4-5)
U-6) (8-16)
postoperative day, only 2 (6%) had symptoms of infection. No respiratory infections were observed. Febrile morbidity during the 48 hr following surgery was observed in six patients (17%). None of the patients fulfilled the criteria for febrile morbidity later in the postoperative course. DISCUSSION
Radical hysterectomy is an operation considered to carry a significant risk for postoperative site-related infections [ 11. In a series of 27 patients not receiving prophylactic antibiotics, Sevin et al. [l] found 52% incidence of wound infections or pelvic cellulitis. More recently, Marsden et al. [2] reported that 16% of 43 patients in an untreated control group experienced infections related to the surgical site. Under such conditions it seems logical that studies evaluating the effect of various regimes for antibiotic prophylaxis are performed. The present study does, however, fail to demonstrate that radical hysterectomy implies a severe risk of site-related infections. As no such complication was observed in our series of 35 operations, administration of prophylactic antibiotics cannot be recommended on this basis. There are a number of possible explanations for the divergence of results between the present study and the two studies cited above. The relatively short operation time along with moderate average blood loss may be important for the reduction of site-related infections. Other contributing factors may be that the infectious focus represented by the primary tumor is less noxious after preoperative intracavitary radiation, a routine procedure in our department. Our patients had a transurethral catheter in place for 5 days. An incidence of 6% symptomatic urinary infections and 40% incidence of nonsymptomatic urinary infections was observed. This is much lower than the 40% incidence of symptomatic urinary infections reported by Sevin et al. [I ] when the patients were catheterized for an average of 17 days. Urinary tract infections are, however, in our opinion,
204
BENDVOLD
AND
KJORSTAD
not a valid indication for antibiotic prophylaxis. The incidence of such infections can presumably be lowered by simpler means, such as rigorous disinfection routines before insertion of the catheter, shorter catheterization periods, or possibly postoperative suprapubic drainage instead of transurethral catheter. Of our patients, 17% experienced fevers above 38.o”C at two separate occasions more than 6 hr apart during the 48 hr following surgery. There were no indications of infections causing these febrile episodes. We consider combating febrile morbidity, not related to obvious infection, with antiphlogistic drugs a more logical approach than administration of antibiotics. In summary we conclude that radical abdominal hysterectomy does not carry a significant risk of postoperative site-related infection and that prophylactic use of antibiotics is not indicated. SYNOPSIS
In a retrospective study surveilling the records of 35 patients operated with radical hysterectomy, no surgical site-related infections were observed. In our hospital, prophylactic use of antibiotics therefore cannot be recommended. REFERENCES 1. Sevin, B. U.. Ramos, R., Lichtinger, M., et nl. Antibiotic prevention of infections complicating radical abdominal hysterectomy, Ohsret. Gq’necol. 64, 539 (1984). 2. Marsden, D. E., Cavanagh, D.. Wisniewski, B. J.. et N/. Factors affecting the incidence of infectious morbidity after radical hysterectomy. Amer. J. Obsret. Gyned. 152, 817 (1985). 3. Rosenshein, N. B., Ruth, J. C., Villar, J., ef al. A prospective randomized study of doxycycline as a prophylactic antibiotic in patients undergoing radical hysterectomy, Gynerol. On&. 15, 201 (1983).