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 treatment of tissues during surgery, radical removal of the site of destruction, minimal surgical trauma and blood loss) and organizational (theoretical training of personnel, training in surgical technique) aspects, rational antibiotic prophylaxis is of great importance for a favorable outcome of surgical intervention. Microbial contamination of the surgical wound is inevitable, and in 80-90% of cases it becomes seeded. Therefore, the frequency of postoperative inflammatory complications does not tend to decrease and, according to various authors, ranges from 7 to 25%.

However, at present, among doctors of many gynecological and obstetric departments of practical healthcare institutions, views have formed and taken root that do not correspond to the modern approach to this problem: from a complete disregard for the role of antibiotics (since adherents of this point of view believe that postoperative complications are only defects in the surgeon’s work) to the desire to prescribe a “prophylactic” course of antibiotics lasting from 3 to 7 days after any operation.

A serious 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 surgical wound should be maintained throughout the entire duration of the operation until its completion (sutures are applied).

Prophylactic administration of antibiotics long before surgery is not justified, since they do not provide preoperative sterilization of the patient, and the risk of the emergence of antibiotic-resistant microorganisms increases significantly.

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

It has been shown that the administration of antibiotics more than 2 hours before surgery or 3 hours after surgery is associated with a higher risk of developing infection (3.8 and 3.3%, respectively) than its perioperative administration (0.5%), i.e. the use of antibiotics after surgery is in most cases unnecessary and does not lead to a further reduction in the percentage of infection.

Unfortunately, a fairly common misconception is that prolonging antibacterial prophylaxis for several days after surgery will at least not cause harm, and will most likely reduce the risk of infectious complications.

Experimental and clinical data obtained as a result of multicenter randomized studies have convincingly proven that rational 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 USA based on literature data indicate that rational antibiotic prophylaxis can reduce the incidence of bacterial complications after abortion by 50%.

In general, the question of antibiotic prophylaxis was resolved in the world by the end of the 1970s, and at present no one questions its advantages. Today, the literature does not discuss the question of whether antibiotic prophylaxis should be prescribed, but discusses a specific drug that should be used from the point of view of its clinical and pharmacoeconomic effectiveness. The use of antibacterial drugs for prophylactic purposes should be justified, and the indications for prophylactic administration of antibiotics should be differentiated and weighed.

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

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

In surgery, there are four types of surgical interventions: “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 developing bacterial complications in the absence of the prescription of antibacterial drugs.

Prevention during “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 failure, circulatory failure, infections of other localizations (bronchopulmonary, urinary system, etc.);
• genital factors: wearing an IUD, previous intrauterine interventions; presence of chronic salpingo-oophoritis, infertility or chronic recurrent STIs (trichomoniasis, chlamydia, bacterial vaginosis, genital herpes, etc.);
• hospital factors: antibiotic therapy several days before surgery, long-term (especially more than 5 days before surgery) or repeated hospitalization;
• intraoperative factors: duration of the 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 prevention should extend to the main pathogens of postoperative infections. After any operation, two main types of infectious complications may develop: firstly, it is a wound infection, mainly associated with gram-positive flora of the skin (mainly Staphylococcus aureus and Staphylococcus epidermidis), which are the cause of inflammation of the subcutaneous tissue in 70-90% of patients; secondly, it is an infection in the tissues directly related to the area of the surgical intervention. In the latter case, there is a polymicrobial spectrum of pathogens, and therefore the antibacterial drug must also be active against gram-negative bacteria and anaerobic microorganisms.

An antibiotic for prophylaxis should have a narrow spectrum of activity, aimed at the main, but not all probable pathogens of postoperative complications, while the duration of prophylaxis should be as short as possible (only one or three injections). It is not necessary, and it is impossible, to achieve complete destruction of bacteria - a decrease in their number already facilitates the work of the immune system in preventing purulent infection.

Basic requirements for antibiotics for prevention:

• the drug must be active against the main pathogens causing postoperative complications;
• the drug must be bactericidal, with minimal toxicity;
• the drug 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;
• reserve antibiotics that are used for treatment (III-IV generation cephalosporins, carbapenems, fluoroquinolones, ureidopenicillins) should not be used for prevention;
• The drug should not interact with anesthetics.

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

This is what 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.

All necessary requirements from the huge arsenal of antibacterial drugs are met primarily by protected penicillins - beta-lactamase antibiotics with fixed beta-lactamase inhibitors, for example, augmentin (a combination of amoxicillin and clavulanic acid).

In addition to the fact that 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 antibacterial prophylaxis. Based on the degree of risk, it is important to determine those situations in which the use of cephalosporins is preferable. The use of second-generation cephalosporins (bactericidal action on part of gram-positive and gram-negative flora) as a monodrug for prophylaxis is sufficient only for "clean" operations, when we mainly prevent wound infection; in other cases, their combination with antianaerobic drugs, such as metronidazole, is advisable.

Third-generation cephalosporins should not be the “standard” drugs for antibiotic prophylaxis; their use should remain a reserve for the treatment of developed bacterial complications.

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

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

We conducted a comparative study of the effectiveness of antibiotic prophylaxis and the traditional regimen of antibiotic administration: the clinical effectiveness of one- to three-time perioperative administration of antibiotics exceeded that of the traditional administration with a virtually complete absence of side effects associated with long-term use.

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

For “clean” operations, during induction of anesthesia, it is advisable to administer a single intravenous injection of 1.5 g of cefuroxime (zinacef).

Options: cefazolin 2.0 g IV.

For “conditionally clean” operations, during induction of anesthesia, it is advisable to administer a single intravenous injection of a combination of amoxicillin/clavulanic acid (Augmentin) 1.2 g.

Options: cefuroxime (zinacef) 1.5 g intravenously in combination with metronidazole (metrogil) - 0.5 g.

In “contaminated” operations, it is advisable to use a combination of amoxicillin/clavulanic acid (Augmentin) 1.2 g once during induction of anesthesia and, if necessary (the presence of two or more risk factors), another 2 injections of 1.2 g intravenously after 6 and 12 hours.

Options: cefuroxime (zinacef) 1.5 g intravenously during induction of anesthesia and additionally 0.75 g intramuscularly after 8 and 16 hours in combination with metronidazole (metrogil) - 0.5 g intravenously intraoperatively, as well as after 8 and 16 hours.

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