Does dual antibiotic prevention and vaginal prep decrease surgical site infections?


Based on the literature, a bundled intervention was created that included dual antibiotic prophylaxis (cefazolin and metronidazole) aimed at reducing surgical site infections for all patients undergoing hysterectomy.

A dual antibiotic infection prevention bundle achieved a 58% reduction in surgical site infections after hysterectomy, according to a retrospective study in the International Journal of Gynecological Cancer.1

The research was conducted at the Moffitt Cancer Center, which is located on the campus of the University of South Florida in Tampa.

First author Michelle Kuznicki, MD, was a resident in ob/gyn at the University of South Florida at the time of the study. “We performed a literature search and institutional assessment with the help of our Department of Infection Prevention to identify potential opportunities for quality improvement in surgical infections,” he said.

Based on the literature, a bundled intervention was created that included dual antibiotic prophylaxis (cefazolin and metronidazole) aimed at reducing surgical site infections for all patients undergoing hysterectomy.

The bundle also importantly contained the antiseptic chlorhexidine gluconate (CHG) for vaginal preparation.

“Organ space infection is not comprised of vaginal cuff infection alone and due to the bundled nature of this intervention, we cannot determine which component most strongly contributed to this observed outcome,” Dr. Kuznicki said.

The study comprised 358 women (median age 58) undergoing hysterectomy for any indication, benign or malignant, at the surgically diversegynecologic oncology practice of Moffitt Cancer Center between January 2016 and January 2017.

Indications for surgery varied widely and a mixed cohort of open and laparoscopic cases was included.

Patients were divided into two groups: those who had surgery during the 6 months prior to the intervention (pre-bundle) (n = 178) and those who had surgery during the 6 months following the intervention (post-bundle) (n = 180).

The post-bundle cohort attained a 58% reduction in rate of surgical site infection: 3.3% vs. 7.9% pre-bundle. This was mostly attributed to a reduction in organ space infection, including vaginal cuff abscesses: 0.6% vs. 4.5%, respectively.

“Although we expected to see some degree of infection reduction after hysterectomy with our bundled intervention, we were surprised at the significant 58% reduction in surgical site infection after bundle implementation,” Dr. Kuznicki told Contemporary OB/GYN.

“The bundle was associated with a reduction specifically in organ space infection, a clinically important outcome which often requires hospital admission, IV antibiotics and/or procedural intervention for resolution.”

Not only were infections averted in open surgical cases with the infection prevention bundle, but there was a reduction in infection after laparoscopic hysterectomy as well.

The study also found that mean length of stay was shorter post-bundle than pre-bundle: 2.7% vs. 3.2%. The 30-day re-admission rate was also lower: 2.2% vs. 6.7%, respectively.

“By demonstrating safety with these interventions and the associated improved outcomes, they are reasonable to implement into clinical practice,” said Dr. Kuznicki, who is currently a gynecologic oncology fellow at Cleveland Clinic in Ohio. “Surgical site infection reduction after hysterectomy is an important endpoint for patients, caregivers, and payers.”

Given the bundled nature of the intervention, the investigators were unable to identify which components most heavily contributed to infection prevention. Furthermore, the study is subject to intrinsic bias because of the non-randomized and retrospective study design.

“Reflecting on this experience, a big challenge to long-term infection prevention is maintaining team compliance with infection prevention measures over time,” Dr. Kuznicki said.

“Therefore, we encourage multidisciplinary involvement when instituting and maintaining such measures, along with interval re-education efforts. This can help to continually engage staff members and trainees who are integral to infection prevention.”

Additional data from prospective, randomized studies of dual antibiotic prophylaxis and vaginal preparation will allow clinicians to determine associated risk reduction and optimize the care of hysterectomy patients.


Dr. Kuznicki reports no relevant financial disclosures.

  1. Kuznicki M, Mallen A, McClung EC. Dual antibiotic prevention bundle is associated with decreased surgical site infections. Int J Gynecol Cancer. Published online July 29, 2020. doi:10.1136/ijgc-2020-001515
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