Objective
Surgical site infections (SSIs) occur within 30 days of an operation, either superficially at the incision site, deeply at the incision site, or in the organ and deep spaces accessed during the operation. SSIs are the most common complications of gynecologic surgeries and can result in significant morbidity. , Specifically, hysterectomies have an SSI complication rate of 1%–2%, with most pathogens arising from the endogenous microbes of the skin, vagina, and gastrointestinal tract. Here, we characterize the bacterial composition of gynecologic SSIs to help inform prophylactic antibiotic choices.
Study Design
We retrospectively reviewed all microbiological cultures from patients with SSIs as part of a quality improvement departmental initiative. We used an institutional infection control database that includes data about all gynecologic surgeries for benign and malignant indications at an academic tertiary care center during 2010 to 2020.
Results
Among 10,495 gynecologic surgeries performed during the ten-year span, 192 (1.8%) SSIs were diagnosed. Of the 192 SSIs, 142 (74%) cases involved hysterectomies (8 vaginal, 134 abdominal), and 157 cases (82%) of the SSIs occurred among patients with suspected preoperative gynecologic malignancies. Of all the gynecologic surgeries, 4818 (46%) involved hysterectomies, with 141 (2.9%) complicated by SSIs. For all gynecologic cases, the median surgery duration was 2.15 hours (interquartile range [IQR], 2.43], whereas for cases involving hysterectomies, it was 3.15 hours (IQR, 1.7). For cases with SSIs, the median surgery duration was 4.1 hours (IQR, 2.27) with a median time to infection of 13 days (IQR, 8).
Preoperative antibiotics were administered to 186 (97%) patients who developed SSIs, including cefoxitin (44%), cefazolin (19%), cefazolin and metronidazole (10%), and non-beta-lactam regimens (22%). Preoperative antibiotics were administered to 78% of patients who did not develop SSIs; these included cefoxitin (48%), cefazolin (23%), cefazolin and metronidazole (12%), and non-beta-lactam regimens (14%). All patients who developed an SSI received preoperative surgical site skin preparation with either chlorohexidine (76%) or iodine-based preparations (24%) in the operating room.
The Table shows the classification of microbiological results by SSI location type. Strict anaerobic species were isolated from a total of 52 SSIs (27.0%), primarily from organ/space SSIs (67%). These included Anaerococcus, Arcanobacterium pyogenes, Bacteroides fragilis and other Bacteroides sp., Clostridium sp., Eggerthella lenta , Fusobacterium sp., Peptostreptococcus sp., Peptoniphilus sp., Prevotella sp., Porphyromonas sp., Propionebacterium avidum , Ruminococcus gnavus , and Veillonella sp.
| Characteristic | Organ/space (intra-abdominal) SSI N=84 n (%) | Deep incisional SSI N=18 n (%) | Superficial SSI N=90 n (%) |
|---|---|---|---|
| Skin bacteria a | 5 (6.0) | 4 (22.2) | 26 (28.9) |
| Skin and intestinal or vaginal bacteria | 13 (15.4) | 3 (16.7) | 12 (13.3) |
| Intestinal or vaginal bacteria b | 51 (60.7) | 10 (55.5) | 28 (31.1) |
| Other c and intestinal or vaginal bacteria b | 4 (4.8) | 0 (0) | 1 (1.1) |
| Other c | 2 (2.4) | 0 (0) | 3 (3.3) |
| Not cultured | 9 (10.7) | 1 (5.6) | 20 (22.3) |
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