One should keep in mind that all disinfection procedures reduce only the amount of germs on the surface, and that a considerable number of microbes will recolonize the skin within a short time (hours).

The removal of hairs before surgical interventions has to take place immediately before the surgery. This is achieved either by wet shaving or a hair removal cream. Shaving of the surgical area on the day before surgery is not permitted as this would increase the number of germs and, hence, the risk of infection.

Wound Drainage

After abdominal or vaginal hysterectomy, the vaginal stump should not be closed completely. Insertion of a T-tube for 24 hours permits the drainage of wound secretion without increasing the risk of ascending microbes. The insertion of a gauze strip (tamponade) promotes the multiplication of germs more than insertion of a drainage tube.

The tamponade should not remain in place for more than 24 hours, preferably less.

Any subfascial Redon drainage should stay in place as short as possible, normally not longer than 24 hours, preferably less.

If the drainage needs to remain for a longer period in the abdominal cavity or in the tissue, the drainage opening should be carefully covered with sterile material, and it should be repeatedly disinfected. It is also important to make sure that there is no backflow of secretion. At the first signs of an infection, early antibiotic treatment with a drug effective against staphylococci is advised, and the drainage tube should be removed soon.

Wound Care

After vaginal hysterectomy and vaginoplasty, it is not uncommon that the high numbers of bacteria present in the vagina lead to superficial infection of the wound area, which is further promoted by necrotic tissue and wound secretion. Early rinsing of the wound with a 1:100 dilution of the polyvidone–iodine solution reduces the number of germs and promotes healing.

Sitting baths are largely obsolete and only suitable for superficial wounds. Because of the macerating effect, the duration of a sitting bath should be short. Astringent bath additives, such as tanning agents (Tannolact), yield better results.

Skin infections (e.g., at the suprapubic incision) should be opened early and, depending on the pathogen, rinsed once or twice daily with polyvidone–iodine (Staphylococcus aureus) or with hydrogen peroxide (anaerobic bacteria).

The germ-reducing effect of these procedures lasts only for a few hours.

Urinary Diversion

Ascending infections due to an indwelling transurethral catheter are very common. After eight days, about 70–90 % of catheterized women exhibit bacteriuria. This may turn into symptomatic cystitis and may also cause bacteria to ascend further. If urinary diversion is supposed to last for more than three days, one should always attempt suprapubic catheterization. The rate of bacteriuria is much lower here, namely, only about 20% after five days. Even after 10 days, the rate increases only to about 30% if the site of the cutaneous incision is being cared for properly.

Approach:

Prophylaxis of Bacterial Infections

The introduction of antibiotic prophylaxis for patients undergoing hysterectomy and cesarean section has reduced the infection risk by a factor of three to four.

Objective for antibiotic prophylaxis. Whether or not antibiotic prophylaxis should be used depends also on the frequency of infections in the individual clinic.

When deciding whether or not to use antibiotics for preventing infections, one should be guided by the type of intervention as well as the patient’s condition. Patients who suffer from several systemic diseases—such as diabetes mellitus, obesity, and suspected immunodeficiency (age, cancer, AIDS, condition after transplantation)—should always receive antibiotics even if the intervention is minor.

In principle, it is safer to use antibiotic prophylaxis. Of course, it may not prevent all infections, particularly not late infections.

In addition to preventing the more common but mild infections, which nevertheless may bother the patient, the main purpose is to reduce the rare but serious infectious complications that occasionally lead to death and occur almost exclusively in patients who have undergone surgery without antibiotic prophylaxis. These cases then tend to be called “fateful events.”

The type of the antibiotic used as well as the duration of prophylaxis are of secondary importance, the purpose of prophylaxis being to reduce the germs in the surgical area to such an extent that no infection will occur in the deeper regions.

The antibiotic used does not need to be effective against all potential microbes, since it is frequently the synergism between aerobic and anaerobic microbes that leads to wound infection and, finally, sepsis.

Thus, a considerable reduction in postoperative infections has also been achieved by using substances effective only against aerobes, or those effective only against anaerobes.

The duration of prophylaxis is also of secondary importance. In today’s view, a high level of antibiotic at the time of surgery is all that is required. Antibiotic prophylaxis for more than 24 hours, or even for three or five days, has been abandoned because it does not yield better results and, apart from higher costs, carries the risk of microbial selection.

Likewise, the half-life of the antibiotic used is of secondary importance. Nevertheless, there is a slight difference in the frequency of, for example, urinary tract infections. The rate is lower for an antibiotic with a long half-life (e.g., ceftriaxone) than for an antibiotic with a comparable spectrum but a half-life of only one hour (e.g., cefotiam).