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Practice bulletins > #195 Prevention of Infection after Gynecologic Procedures > Flashcards

#195 Prevention of Infection after Gynecologic Procedures Flashcards

1
Q

What is the definition of a superficial incisional surgical site infection?

A

Occurs within 30d postop. Involves only skin or subcutaneous tissue. At least one of the following: purulent drainage from superficial incision; organisms isolated from aseptically obtained culture of fluid or tissue from superficial incision; pain or tenderness, localized swelling, redness, or heat, and incision opened and is culture-pos or not cultured; diagnosis of superficial incisional surgical site infection by surgeon or attending physician

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2
Q

What is the definition of deep incisional surgical site infection?

A

Within 30d post op if no implant, or within 1 year if implant is in place. Involves deep soft tissues (eg fascial and muscle layers). At least one of the following: purulent drainage from deep incision, but not from organ/space component; deep incision spontaneously dehisces or is deliberately opened by surgeon and is culture-pos or not cultured w/ one of the following symptoms: fever (>38oC), localized pain or tenderness, abscess or evidence of deep infection; diagnosis of deep incisional SSI by surgeon or attending physician

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3
Q

What is the definition of organ/space surgical site infection?

A

Involves any part of the body, excluding skin incision, fascia or muscle layers, that is opened or manipulated during operation. Occur within 30d in no implants, 1 yr if implants and affection appears related to surgery. At least one of the following: purulent drainage from a drain in organ/space; organisms isolated from aseptically obtained culture of fluid or tissue in organ/space; abscess or other infection involving organ/space; diagnosis of organ/space SSI by a surgeon or attending physician

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4
Q

What is the rate of superficial incisional infection after total and supracervical abdominal hysterectomy? After laparoscopic hysterectomy?

A

2.3-2.6% after abdominal hyst. 0.6-0.8% after laparoscopic.

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5
Q

What type of surgical site infection is a vaginal cuff cellulitis?

A

Organ/space infection

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6
Q

What is the rate of deep incisional and organ/space infection after women having hysterectomy by any route?

A

0.5-1.2%

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7
Q

True or false, use of foreign material increases risk of infection?

A

True

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8
Q

For gynecologic surgery, where do most pathogens arise from?

A

Skin or vaginal flora

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9
Q

What types of organisms causes surgical site infections on abdominal incisions?

A

usually aerobic gram-pos cocci (eg, staphylococci)

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10
Q

What types of organisms causes surgical site infections on perineal or groin incisions?

A

Aerobic gram-pos cocci, but may include fecal flora (eg, anaerobic bacteria and gram-neg aerobes)

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11
Q

Does the presence of bacterial vaginosis affect the risk of infection after hysterectomy?

A

Prior to use of routine antibiotics it was associated with an increased risk of posthyst cuff cellulitis. BV has alteration of vaginal flora resulting in an increased concentration of potentially pathogenic anaerobic bacteria.

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12
Q

What is surgical wound classification Class I/Clean?

A

Uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or urinary tracts are not entered.

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13
Q

What is surgical wound classification Class II/Clean-contaminated?

A

Operative wounds in which respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination.

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14
Q

What is surgical wound classification Class III/Contaminated?

A

Open, fresh, accidental wounds. Operation with major breaks in sterile technique or gross spillage from GI tract, and incisions in which acute, nonpurulent inflammation is encountered, including necrotic tissue w/o evidence of purulent drainage

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15
Q

What is surgical wound classification Class IV/Dirty or infected?

A

Includes old traumatic wound with retained devitalized tissue and htose that involve existing clinical infection or perforated viscera.

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16
Q

What surgical wound classification does IUD insertion fall under?

A

Clean-contaminated (Class II), as it breaches the endocervix

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17
Q

What surgical wound classification does sonohysterography insertion fall under?

A

Clean-contaminated (Class II), as it breaches the endocervix

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18
Q

Does hysterosalpingography require antibiotics?

A

Depends. Postoperative PID or endometritis is a risk in cases with hx of PID or abnormal tubal architecture noted on HSG, warrent periop antimicrobial prophylaxis

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19
Q

What are risk to antibiotic prophylaxis for surgery?

A

Pseudomembranous colitis (caused by C diff), induction of bacterial resistance, allergic reactions

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20
Q

What are the three categories of variables that have proven to be reliable predictors of surgical site infection risk?

A
  1. Those that estimate the intrinsic degree of microbial contamination of surgical site
  2. The type and duration of surgery
  3. Those that serve as markers for host susceptibility
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21
Q

What are patient risk factors for surgical site infection?

A 
Periop hyperglycemia (>180-200mg/dL)
Smoking
Obesity
Nutritional status
Depth of subcu tissue
Coexistent infection at remote body site
Vaginal colonization with microorganisms
American Society of Anesthesiologist Physical Status (ASA)
Immunodeficiency
MRSA status
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22
Q

What is the recommendation regarding performing elective surgery on a patient with a remote infection (eg, lower leg cellulitis)?

A

All remote infections should be identified and treated before elective operation and postponed until infection has resolved

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23
Q

How should hair around a planned surgical site be managed?

A

Any necessary hair removal should be done immediately before the operation with electric clippers. A razor should not be used. Instruct patients to not shave themselves as shaving with a razor increases risk of infection

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24
Q

What is the target periop glucose level to help decrease risk of infection?

A

<180-200mg/dL

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25
Q

For patients coming in from home for surgery, what should you advise them on how they can decrease their risk of infection?

A

Do not shave surgical area. Advise patient to shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or antiseptic agent at least the night before abdominal surgery. Studies support using hexachlorophene and chlorhexidine.

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26
Q

How does chlorhexidine compare to povidone-iodine as a surgical site skin preparation agent?

A

Chlorhexidine appears to achieve greater reductions in skin microflora and has greater residual activity after application as it is not inactivated by blood or serum proteins (in contrast to povidone-iodine). Chlorhexidine is superior, 44% lower odds of developing a SSI compared with povidone-iodine.

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27
Q

What are the requirements for prepping with povidone-iodine (scrub time, dry time, etc)?

A

Recommended scrub time can be as long as 5 mins (see manufacturers instructions), solution should be removed with towel, then pain with topical povidone-iodine solution, which should be allowed to dry for 2 minutes before draping.

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28
Q

What are the requirements for prepping with chlorhexidine-alcohol preparations (scrub time, dry time, etc)?

A

Scrub time (gentle, repeated back-and-forth strokes) should last for 2 mins for moist sites (inguinal fold and vulva) and 30 seconds for dry sites (abdomen), and allowed to dry for 3 minutes

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29
Q

Is vaginal cleansing recommended prior to hysterectomy?

A

Yes

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30
Q

What agents should be used to cleanse vagina prior to hysterectomy or vaginal surgery?

A

Either 4% chlorhexidine gluconate (only 4% isopropyl alcohol, not 70% used on skin) or povidone-iodine. Currently only povidone-iodine are FDA approved

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31
Q

Does the number of the times the OR door is opened during surgery affect the risk of infection?

A

Yes, increased OR traffic is associated with increased risk of infection

32
Q

Does a wound seroma increase the risk of infection?

A

Yes

33
Q

Does hypothermia of tissues increase or decrease risk of infection?

A

Increases risk

34
Q

Does drain placement decrease risk of post op surgical site infection after cesarean section?

A

No

35
Q

Does subcutaneous dead space closure decrease risk of surgical site infections during cesarean section?

A

Yes

36
Q

When should pre op antimicrobial prophylaxis be administered?

A

Initiated within 1 hour before a procedure begins. If using quinolones or vancomycin, up to 2 hours is allowable.

37
Q

What antibiotics are recommended for hysterectomy? Does it change depending on route or total vs supracervical?

A

Cefazolin. 2g, 3g IV if patient weighs >120kg. Does not change based on route or total vs supracervical.

38
Q

What antibiotics are recommended for suction D+C (pregnancy)?

A

200mg doxycycline IV or PO

39
Q

What antibiotics are recommended for D+E?

A

200mg doxycycline IV or PO

40
Q

What antibiotics are recommended for suction colporrhaphy?

A

Cefazolin. 2g, 3g IV if patient weighs >120kg

41
Q

What antibiotics are recommended for vaginal sling placement?

A

Cefazolin. 2g, 3g IV if patient weighs >120kg

42
Q

What antibiotics are recommended for laparotomy without entry into bowel or vagina?

A

Consider Cefazolin. 2g, 3g IV if patient weighs >120kg

43
Q

What antibiotics are recommended for LEEP, cervical biopsy, endocervical curettage?

A

Not recommended

44
Q

What antibiotics are recommended for cystoscopy?

A

Not recommended, unless patient with positive urine culture should be given abx treatment

45
Q

What antibiotics are recommended for endometrial biopsy?

A

Not recommended

46
Q

What antibiotics are recommended for Laparoscopic procedures without entry into bowel or vagina?

A

Not recommended

47
Q

What antibiotics are recommended for hysterosalpingogram?

A

Not recommended. UNLESS hx of PID or abnormal tubes are noted on HSG or laparoscopy. For these women, give doxycycline 100mg BID for 5d

48
Q

What antibiotics are recommended for chromopertubation?

A

Not recommended. UNLESS hx of PID or abnormal tubes are noted on HSG or laparoscopy give 2g dose cefazolin. For these women, give doxycycline 100mg BID for 5d

49
Q

What antibiotics are recommended for IUD insertion?

A

Not recommended

50
Q

What antibiotics are recommended for oocyte retrieval?

A

Not recommended

51
Q

What antibiotics are recommended for D+C for non pregnancy indications?

A

Not recommended

52
Q

What antibiotics are recommended for urodynamics?

A

Not recommended

53
Q

How often should antibiotics be repeated intra op?

A

For lengthy procedures, additional intraop doses of an antibiotic should be given at intervals of 2x the half-life of the drug from initiation of pre op dose.

54
Q

How often should cefazolin be redosed intra op?

A

Every 4 hours from preoperative dose

55
Q

Should additional antibiotics be given intra op after a certain amount of blood loss?

A

Yes. Most guidelines do not specifically define “excessive,” however a pharmacokinetic study suggests additional dose of cefazolin after EBL 1500cc

56
Q

Should screening for vaginal infections be performed prior to hysterectomy?

A

Peri op screening for BV can be considered with treatment for 5-7d. If this treatment encroaches on scheduled time for surgery, it would be reasonable to continue therapy perioperatively for at least 4 days

57
Q

What is the risk of pelvic inflammatory disease after HSG? What is the risk of PID after HSG in patients with dilated fallopian tubes?

A

1.4-3.4%. 11% if dilated fallopian tubes

58
Q

What is the risk (%) of infectious complications after hysteroscopic surgery?

A

1-2%

59
Q

What antibiotics are recommended for hysteroscopic procedures?

A

Not recommended

60
Q

What antibiotics are recommended for endometrial ablation?

A

Not recommended

61
Q

What is the risk of infectious complications after endometrial ablation (endometritis, myometritis, PID, pelvic abscess)?

A

Endometritis 1.4-2%
Myometritis 0-0.9%
PID 1.1%
Pelvic abscess 0-1.1%

62
Q

What is the second line choice of antibiotic for uterine evacuation for pregnancy indication?

A

Metronidazole (doxycycline is first line)

63
Q

What antibiotics are recommended for short-term catheterization? Long-term catheterization?

A

Not indicated, including postsurgical patients because of concerns about selection of antimicrobial resistance

64
Q

What is the infection rate after radical and modified vulvectomies performed for treatment of vulvar cancer?

A

58%

65
Q

Has administration of antibiotic prophylaxis decreased risk of wound infection with radical and modified vulvectomies?

A

No. Infection rate 58%

66
Q

What antibiotics are recommended for vulvectomy?

A

The role of antibiotic prophylaxis for vulvectomy is not clear, but can consider cefazolin

67
Q

What is the infection rate after egg retrieval?

A

0.4%

68
Q

What is the appropriate antibiotic prophylaxis for patients with a history of MRSA colonization or infection undergoing surgery with skin incision? What is recommended dosage?

A

Pre op antibiotic regimen should include single preop IV dose of vancomycin (recommended dose 15mg/kg)

69
Q

Can patients with a penicillin allergy receive a cephalosporin for antimicrobial prophylaxis prior to surgery?

A

Depends. If they have a history of immediate hypersensitivity reaction (anaphylaxis, urticarial, bronchospasm) or exfoliative dermatitis (Stevens-Johnson syndrome, toxic epidermal necrolysis) to PCN, no.

70
Q

What is the alternate pre op abx regimen for a patient with severe PCN allergy who would otherwise receive cefazolin?

A

Combination of metronidazole or clindamycin plus gentamicin or aztreonam

71
Q

Patients with a penicillin allergy are at increased risk of allergy to which generation of cephalosporin?

A

First generation. No increased risk with second or third generation cephalosporins.

72
Q

What is the dose of clindamycin that should be used for pre op prophylaxis, what is the half life, how often should it be repeated intraop?

A

900mg
Half life 2-4h
Interval to repeat: 6h

73
Q

What is the dose of metronidazole that should be used for pre op prophylaxis, what is the half life, how often should it be repeated intraop?

A

500mg
Half life: 6-8h
Interval to repeat: N/A, no repeat admin needed

74
Q

What is the dose of gentamicin that should be used for pre op prophylaxis, what is the half life, how often should it be repeated intraop?

A

5mg/kg
Half life: 2-3h
Interval to repeat: N/A, no repeat admin needed

75
Q

What is the dose of aztreonam that should be used for pre op prophylaxis, what is the half life, how often should it be repeated intraop?

A

2g
Half life: 1.3-2.4h
Interval to repeat: 4h

76
Q

Are the second line antibiotics used for surgical prophylaxis for hysterectomy (in setting of PCN allergy), as effective as cefazolin at preventing infection?

A

No. Cefazolin is better, make sure to accurately identify allergies

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