Prevention of inflammatory postoperative complications in gynecology

Antibacterial prophylaxis of inflammatory postoperative complications in gynecology

Along with surgical (pathogenetic preoperative preparation, rational surgical tactics, active management of the postoperative period, careful attitude to the tissues during the operation, radical removal of the lesion focus, minimal operating injury and blood loss) and organizational (theoretical training, training in surgical techniques) aspects, rational antibiotic prophylaxis is important for a favorable outcome of an operative intervention. Microbial contamination of the operating wound is unavoidable, and in 80-90% of cases it is seeded. Therefore, the incidence of postoperative inflammatory complications does not tend to decrease and amounts, according to different authors, from 7 to 25%.

However, at present, many gynecological and midwifery departments of public health institutions have formed and rooted in views that do not correspond to the modern approach to this problem: from the complete ignoring of the role of antibiotics (since adherents of this view believe that postoperative complications are only defects in work surgeon) to the desire to prescribe after any operation "preventive" course of antibiotics lasting from 3 to 7 days.

A significant factor determining the effectiveness of antibiotic prophylaxis is the time of administration of the drug. It seems logical that the bactericidal concentration of the antibacterial drug in the tissues of the operating wound should be maintained throughout the entire duration of the operation until it ends (stitches).

It is not justified to prevent the introduction of antibiotics long before the surgery, since they do not provide pre-surgical sterilization of the patient, and the risk of antibiotic-resistant microorganisms is significantly increased.

It is known that the decisive for the development of postoperative infection are the first 3 hours from the moment the bacteria enter the wound.

It was shown that the appointment of an antibiotic more than 2 hours before the operation or 3 hours after it is associated with a greater risk of infection (3.8% and 3.3%, respectively) than its perioperative administration (0.5%), . The use of antibiotics after the end of the operation in most cases is superfluous and does not lead to a further reduction in the percentage of infection.

Unfortunately, the erroneous view that the prolongation of antibacterial prophylaxis for a few days after the operation is at least not harmful, but is likely to reduce the risk of infectious complications, is quite common.

Experimental and clinical data obtained as a result of multicenter randomized trials have convincingly demonstrated that the rational conduct of antibiotic prophylaxis in surgical practice reduces the incidence of postoperative complications from 40-20% to 5-1.5%.

The results of a meta-analysis conducted in the United States on the basis of literature data indicate that rational antibiotic prophylaxis allows a 50% reduction in the number of bacterial complications after abortion operations.

In general, the issue in favor of antibiotic prophylaxis was solved in the world by the end of the 1970s, and no one now questions its advantages. Today in the literature the question is not whether antibiotic prophylaxis should be prescribed, but a particular drug that should be used in terms of its clinical and pharmacoeconomic effectiveness is discussed. The use of antibacterial drugs for preventive purposes should be justified, and indications for the prophylactic use of antibiotics are differentiated and weighed.

Currently, antibiotic prophylaxis means a one- or maximum three-time perioperative administration of an antibiotic that acts on the main possible pathogens of wound and local infection.

Antibiotic therapy - a full 5-7-day course with vigorous doses of the drug acting on the main potential pathogens of purulent postoperative complications.

In surgery, four types of surgical interventions are distinguished: "clean", "conditionally clean", "contaminated" and "dirty" operations with a possible risk of infectious complications from 2 to 40%.

To standardize the risk of postoperative infections in gynecological patients, we also identified four types of surgical interventions. This classification is a working scheme and is based on the degree of risk of development of bacterial complications in the absence of prescription of antibacterial drugs.

Prevention for "clean" operations is carried out only in the presence of risk factors, which include:

• extragenital factors: age over 60 years, anemia, hypotrophy or obesity, diabetes mellitus, immunodeficiency states, chronic renal or hepatic insufficiency, circulatory insufficiency, infections of other localization (bronchopulmonary, urinary system, etc.);
• genital factors: wearing of IUD, previous operations intra-uterine interventions; the presence of chronic salpingoophoritis, infertility or chronic recurrent STIs (trichomoniasis, chlamydia, bacterial vaginosis, genital herpes, etc.);
• hospital factors: antibiotic therapy for a few days before surgery, prolonged (especially more than 5 days before surgery) or repeated hospitalization;
• intraoperative factors: duration of intervention - 2.5 hours or more, blood loss - more than 800-1000 ml, insufficient hemostasis (bleeding), hypotension during surgery; use of foreign materials, insufficient qualification of the surgeon.

The activity of the antibacterial drug used for prophylaxis should extend to the main pathogens of postoperative infections. After any operation, two main types of infectious complications are possible: first, wound infection, mainly associated with the gram-positive flora of the skin (mainly golden and epidermal staphylococci), which cause inflammation of the subcutaneous tissue in 70-90% of patients; secondly, it is an infection in the tissues directly related to the zone of surgical intervention. In the latter case, there is a polymicrobial spectrum of pathogens, and therefore the antibacterial drug is required to show activity also against gram-negative bacteria and anaerobic microorganisms.

Antibiotic for prophylaxis should have a narrow spectrum of activity aimed at the main, but not all likely causative agents of postoperative complications, and the duration of prevention should be as short as possible (only one or three injections). It should not, and it is impossible to achieve complete destruction of bacteria - reducing their number already makes it easier for the immune system to prevent purulent infection.

Basic requirements for antibiotics for prevention:

• the drug should be active against the main pathogens of postoperative complications;
• the drug should be bactericidal, with minimal toxicity;
• the preparation must penetrate well into the tissues;
• antibiotics with bacteriostatic action (tetracyclines, chloramphenicol, sulfonamides) should not be used;
• the drug should not increase the risk of bleeding;
• for the prevention should not be used reserve antibiotics, which are used for treatment (cephalosporins III-IV generation, carbapenems, fluoroquinolones, ureidopenicillins);
• the drug should not interact with anesthetics.

The choice of the safest antibiotic for prophylactic purposes is much more important than for treatment, since in this case the drug is prescribed for almost all patients being referred for surgical treatment.

This makes it unreasonable to use aminoglycosides, whose nephro- and ototoxic effects can lead to serious consequences. In addition, aminoglycosides due to their pharmacodynamic interaction with muscle relaxants can lead to neuromuscular blockade.

First of all, protected penicillins - beta-lactam antibiotics with fixed inhibitors of beta-lactamases, for example, augmentin (a combination of amoxicillin and clavulonic acid) satisfy all the necessary requirements from a huge arsenal of antibacterial drugs.

In addition to the fact that the drugs of this group have a bactericidal effect on gram-positive and gram-negative flora, their advantage also lies in the fact that they are active against anaerobes and enterococci.

Cephalosporins are the most widely used drugs for antibiotic prophylaxis. Based on the degree of risk, it is important to determine those situations in which the appointment of cephalosporins is preferable. The use of cephalosporins of the second generation (bactericidal action on a part of Gram-positive and Gram-negative flora) in the form of a monopreparation for prophylaxis is sufficient only for "pure" operations, when we mainly prevent wound infection, in other cases, their combination with anti-anaerobic drugs such as metronidazole is appropriate.

Cephalosporins of the third generation should not be "standard" drugs for antibiotic prophylaxis, their use should remain a reserve for treatment of the developed bacterial complication.

Antibiotic prophylaxis should be individual, its choice should depend not only on the type of operation, but also on the presence of risk factors, the presence and nature of which changes the direction of prevention and in some cases transfers it from prevention to therapy, which has an undeniable advantage over traditional "late" therapy due to the powerful perioperative protection.

The widespread use of antibiotic prophylaxis (78% of all patients) did not increase the number of complications and significantly reduced the need for antibiotics.

We conducted a comparative study of the efficacy of antibiotic prophylaxis and the traditional antibiotic prescribing scheme: the clinical efficacy of a one to three-time perioperative administration of an antibiotic exceeded that of traditional administration, with almost no side effects associated with prolonged use.

It is recommended to carry out antibiotic prophylaxis according to the following schemes:

In "clean" operations during the initial anesthesia, a single intravenous injection of 1.5 g of cefuroxime (zinaceph) is advisable.

Variants: cefazolin 2.0 g IV.

At "conditionally clean" operations during the introductory anesthesia, a single intravenous administration of a combination of amoxicillin / clavulonic acid (augmentin) of 1.2 g is advisable.

Variants: cefuroxime (zinacef) 1,5 g IV in combination with metronidazole (metrogil) - 0,5 g.

In case of "contaminated" operations, it is advisable to use a combination of amoxicillin / clavulonic acid (augmentin) 1,2 g once during the initial anesthesia and, if necessary (two or more risk factors), 2 injections of 1.2 g IV at 6 and 12 h.

Variants: cefuroxime (zinacef) 1.5 g IV during induction anesthesia and additionally at 0.75 g IM at 8 and 16 h in combination with metronidazole (metrogil) - 0.5 g IV intraoperatively, and also at 8 and 16 h.

[1], [2], [3], [4], [5], [6], [7]