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Antibiotic prophylaxis in female pelvic surgery
Prof. Elisabetta Costantini Department of Medicine and Surgery Chief of Andrological and Urogynaecological Unit, Terni Hospital University of Perugia Perugia (IT)
The primary rationale for antimicrobial prophylaxis is to decrease the incidence of surgical site infection and other preventable periprocedural infections, with the secondary goal of reducing antibiotic overuse. [1]
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The choice of a correct pre-operative antibiotic prophylaxis is of primary importance in female pelvic surgery, especially when meshes are implanted and this is even more if the mesh is positioned by the vaginal route.
Postoperative infectious complications related to the prosthesis have been recorded, [2] wound infection (3-6%), urinary tract infection (UTI) (3.5-31%) mesh infections (1%), vaginal infections (0-18.4%), and pelvic abscess (1-2%). On these bases and taking into consideration that approximately one third of urogynecological surgical procedures for pelvic organ prolapse (POP) or stress urinary incontinence are performed using a mesh material, antibiotic prophylaxis is recommended [3] and the choice of a correct regimen is of paramount interest.
Effective prophylaxis Shapiro in 2017 [4] demonstrated that gynecologic surgeons overuse antibiotics for surgical prophylaxis without adhering to the American College of Obstetricians and Gynecologists (ACOG) and many surgeons indiscriminately use antibiotic prophylaxis for all surgeries even when evidence-based medicine indicates otherwise. Indiscriminate antibiotic prophylaxis can lead to multidrug resistant (MDR) pathogens, higher medical expenses and unnecessary exposure to adverse reactions or toxicities. [5-6]
There are four major rules to obtain an effective prophylaxis: (1) correct antibiotic selection, (2) timing of administration, (3) dosing, and (4) redosing. Goede reported that 75% of cases were missing correct application of at least one of these four components. [7]
Antibiotic selection should consider the most likely infectious organisms associated with the site(s) of surgery (the lower urinary tract, skin, vagina, and intestine) and with the local antibiotic resistance patterns.
The optimal duration of antibiotics prophylaxis in female pelvic surgery is not known. Studies comparing single dose to multi-dose antibiotic prophylaxis regimens in patient undergoing prolapse surgery with mesh are lacking [8] and it is unclear if these women have any additional benefit. The correct timing is the administration within two hours prior to the incision.
To make the best choice also in accordance with Antibiotic Stewardship it is useful to create multidisciplinary round tables and make a joint decision between surgeons, infectious disease specialists, and pharmacists.
The American Urological Association (AUA) and The American College of Obstetrics and Gynecology (ACOG) published their guidelines on the use of antibiotic prophylaxis in POP surgery taking into consideration some differences between abdominal and vaginal surgery. Female pelvic surgery is considered clean-contaminated procedure and we should consider that vagina could favour the spread of germs with the need of additional anaerobic coverage. (Table 1) Both in abdominal sacrocolpopexy and vaginal approach the most common infectious complication is UTI (9.2% in abdominal approach; 6-34.7% in vaginal approach) [9-10] while the rates of superficial surgical site infections are quite low (1.8%-3.9% in abdominal approach and 0.4-5% in vaginal approach). [9-11] In abdominal approach, mesh infection is uncommon, especially if the procedure is performed with laparoscopic or robotic approach, possibly due to the lack of contact of the prosthesis with the vagina (except in the case of total hysterectomy) and the extreme biocompatibility of the most-used monofilament macroporous polypropylene materials. [12-13]
Also in vaginal anti-incontinence procedures which involve the use of mesh the rate of UTI is high (5.9-10.4%) while the rates of superficial surgical site infections are rare (1%). [14-18]
Swartz [19] showed that after anti-incontinence surgery there are non-significant differences in UTI rate between women undergoing pre-treatment antibiotic prophylaxis (in according to the AUA and ACOG recommendation), and patients who additionally received 3 days of postoperative antibiotics. Nevertheless in the second group there was increased risk of adverse events (7.8% vs. 0.9%). Therefore it was advisable to carry out only prophylaxis.
Illiano [20] demonstrated that perioperative prophylaxis using a single dose of antibiotic, clindamycin and gentamycin, is sufficient in women who underwent prolapse surgery using mesh, regardless of the surgical approach used (laparoscopic or transvaginal). (Fig. 1)
Besides infections, another problem of vaginal prosthetic surgery is vaginal mesh exposure. No correlation was found between the type or duration of antibiotic prophylaxis and mesh exposure [19]. Svenningsen emphasized that the antibiotic prophylaxis prevented the developing postoperative infections or prolonged postoperative pain after anti incontinence surgery, but did not offer protection against tape exposure. [21]
Illiano confirmed that the vaginal mesh exposure may not be related to the type of antibiotic therapy, but rather to technical problems. [20] When a polypropylene mesh is implanted, a complex series of foreign body reactions occurs, until it is covered with fibrous tissue. Its presence may further induce local immunosuppression and improve the survival of any bacteria near the mesh. Bacteria form a biofilm on the surface of the mesh, difficult to eradicate. [22-23] The characteristics of the mesh are therefore important to reduce biofilm formation. Meshes with pore size diameter greater than 75 mm, which permit fibroblasts, macrophages, polymorphonuclear leukocytes to penetrate the mesh, are associated with reduced incidence of mesh infections compared with the use of mesh with small pores (<10 mm).
Conclusion In conclusion, the practice of correct antibiotic prophylaxis, the choice of the right material and the expertise of the surgeon are the fundamental elements for a surgical procedure with few complications.
The principles to be considered are the patient’s susceptibility to the infection, the surgical procedure with the different likelihood of bacterial invasion at the operative site, i.e for vaginal procedures consider additional anaerobic coverage especially when hysterectomy is performed, the potential morbidity of any subsequent infection, the morbidity and adverse events due to the use of antimicrobials other than the risk of multidrug resistance. Patient-specific factors and local antimicrobial susceptibilities, as reflected in local antibiograms, should also influence the choice of the agent. Due to emerging MDR, all the recommendations remain in flux; clinicians are urged to consult their local antibiograms and local infectious disease experts where needed. We all know the tremendous variability of bacteria susceptibility in clinical practice, with variation from hospital to hospital and provider to provider. The absence of strong evidence to support such variations, lead to rapid changing paradigms in periprocedural prophylaxis in different setting.
Finally, high-level evidence in the choice of the right prophylaxis and regimen is still lacking and the recommendations are subject to changes.
Figure 1 : Post-operative complications (vaginal vs abdominal approach). Protocol A: multidose group pre and post-surgery; Protocol B: double dose group pre and post-surgery; Protocol C: single-dose group [20]
References
1. American Urological Association. Best practice policy statement on urologic surgery antimicrobial prophylaxis
American urologic association; 2008. 2. Food and Drug Administration. Surgical mesh for treatment of women with pelvic organ prolapse and stress urinary incontinence.Silver Spring, MD: Food and
Drug Administration; 2011. 3. American College of Obstetricians and Gynecologists.
Antibiotic Prophylaxis for Gynecologic Procedures.
Washington, DC: American College of Obstetrician and
Gynecologists; 2009. 4. Shapiro R, Laignel R, Kowcheck C, White V, Hashmi M.
Modifying pre-operative antibiotic overuse in gynecologic surgery. Int J Health Care Qual Assur. 2018;31(5):400–5. 5. Lightner DJ, Wymer K, Sanchez J, Kavoussi L. Best practice statement on urologic procedures and antimicrobial prophylaxis. J Urol.2020;203(2):351 – 6 6. ACOG Practice Bulletin No. 195: Prevention of infection after gynecologic procedures. Obstet Gynecol. 2018;131(6):e172–e89 7. Goede WJ, Lovely JK, Thompson RL, Cima RR. Assessment of prophylactic antibiotic use in patients with surgical site infections.Hosp Pharm. 2013;48(7):560–7 8. Andy UU, Harvie HS, Ackenbom MF, Arya LA (2014) Single versus multi-dose antibiotic prophylaxis for pelvic organ prolapse surgery with graft/mesh. Eur J Obstet Gynecol
Reprod Biol 181:37–40 9. Nguyen JN, Yang ST. Perioperative outcomes after robotic versus vaginal surgery for pelvic organ prolapse. J Robot
Surg.2020;14(3):415–21. 10. Altman D, Falconer C. Perioperative morbidity using transvaginal mesh in pelvic organ prolapse repair. Obstet
Gynecol. 2007;109(2Pt 1):303–8.
Due to space constraints, the entire reference list can be made available to interested readers upon request by sending an email to: communications@ uroweb.org.
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Table 1: American Urological Association (AUA) and American College of Obstetrics and Gynaecology (ACOG) recommendations
Abdominal or vaginal pelvic organ prolapse surgery Anti-incontinence surgery AUA RECOMMENDATIONS ACOG RECOMMENDATIONS Cefazolin or 2nd generation Cephalosporins (Cefoxitin/Cefotetan) ALTERNATIVES Ampicillin-Sulbactam Aminoglycoside + Metronidazole, Clindamycin Cefazolin
