Febrile Morbidity/Pelvic Infection Complicating Vaginal Hysterectomy Case File
Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG
Case 28
A 40-year-old G3 P3003 Caucasian woman with a body mass index (BMI) of 24 kg/m2 has dysfunctional uterine bleeding unresponsive to hormonal therapy. The patient is desirous of permanent sterilization, and opts for a total abdominal hysterectomy. She denies any symptoms of urinary or fecal incontinence. Her general physical examination is unremarkable, except that her uterus is at the upper limits of normal size and slightly tender to bimanual examination. She has adequate vaginal support of both the anterior and posterior vaginal walls. On the day of her surgery, an emergency in the adjoining OR just preceding the patient’s general anesthesia induction required a quick substitution of one anesthesiologist for another, and during the physician transfer procedure, the patient did not receive her scheduled dose of cefazolin, 1 g intravenously just prior to having general anesthesia. Her vaginal hysterectomy (VH) is complicated by an 850-cc blood loss, though no intra- or postoperative transfusion is required. On postoperative day 1, her 4:00 AM oral temperature is 101.5°F, and her 8:00 AM temperature is 101.8°F.
➤ What is the most likely diagnosis?
➤ What is your next step?
➤ What potential complications may ensue?
➤ When should the prophylactic antibiotics be administered?
ANSWERS TO CASE 28:
Febrile Morbidity/Pelvic Infection Complicating Vaginal Hysterectomy
Summary: A 40-year-old woman underwent a VH without receiving her scheduled dose of preoperative antibiotic. She has an 850-cc blood loss, and has two elevated temperatures 4 hours apart on the morning of postoperative day 1.
➤ Most likely diagnosis: Febrile morbidity/probable pelvic infection following vaginal hysterectomy.
➤ Next step: Treat the pelvic infection. Perform an examination to rule out other causes of fever, and likely start antibiotic therapy.
➤ Potential complications: Development of pelvic abscess, allergic reaction to antibiotic therapy, development of septic pelvic thrombophlebitis.
➤ Prophylactic antibiotics: Administration of antimicrobial agents usually prior to surgery or a procedure used to decrease febrile morbidity such as wound infection.
ANALYSIS
Objectives
- Know why, how, and when to use prophylactic antibiotic therapy when performing vaginal surgery.
- Be able to construct the differential diagnosis for the febrile patient following vaginal hysterectomy.
- Learn how to treat postoperative pelvic infection following vaginal surgery.
- Be able to recognize and treat pelvic abscess and septic pelvic thrombophlebitis following vaginal surgery.
Considerations
This 40-year-old Caucasian woman had a VH without receiving preoperative antibiotics, and she sustained an 850-cc blood loss at the time of surgery.1 She has febrile morbidity on postoperative day 1, with two elevated temperatures 4 hours apart. The differential diagnosis of fever following vaginal surgery depends to some extent on which postoperative day the elevated temperature occurs. On postoperative day 1, the differential should include infection at the surgical site, such as cuff cellulitis, or atelectasis, or infection at a nonsurgical site, such as the urinary tract, the respiratory tract, or at the IV site.1 A directed physical examination and appropriate laboratory and imaging studies will help to delineate the source of the fever if the patient appears significantly ill, but these workups are usually not likely to yield much useful clinical information.2,3 Febrile responses occurring later in the postoperative course suggest the possibility of a pelvic abscess or pelvic vein thrombosis.
APPROACH TO
Evaluation and Management of Fever after Vaginal Hysterectomy
DEFINITIONS
FEBRILE MORBIDITY: Temperature of 100.4°F or greater on two separate occasions at least 4 hours apart, after the first 24 hours after surgery.
VAGINAL CUFF CELLULITIS: Infection of the vaginal mucosal and submucosal tissue involving vaginal bacteria.
CLINICAL APPROACH
Prophylactic Antibiotic Usage
Febrile morbidity is the most common complication of VH, although this is less likely to occur with vaginal than with abdominal hysterectomy. A major review has shown that some of the difference in rates of febrile morbidity may relate to the increased use of prophylactic antibiotics in VH versus TAH, specifically 7.2% versus 16.8%.4 Both routes of hysterectomy experience decreased febrile morbidity if prophylaxis is used. Overall, the literature suggests that the incidence of febrile morbidity varies from 10% to 30% for all types of hysterectomy.4 This case illustrates the two major risk factors for febrile morbidity following VH: those being failure to use prophylactic antibiotics and experiencing excessive blood loss.
There is a unique circumstance that merits therapy before the day of surgery. Studies have shown that the patient with bacterial vaginosis is at increased risk for postoperative pelvic cuff cellulitis. This should be searched for and treated at a preoperative visit prior to the scheduled surgical procedure, with therapy consisting of 4 days of therapy with metronidazole.
The rationale for using a prophylactic antibiotic prior to vaginal hysterectomy rests on the premise that the vagina is a “clean contaminated” space, and that no amount of sterile preoperative preparation is going to make this a sterile operative field. Upon transcervical surgical entry into the peritoneal cavity via the vagina, the operative site is exposed to a plethora of aerobic and anaerobic bacterial organisms with the potential to cause infection. Using antibiotics preoperatively enhances the patient’s own immune response and lowers the number of bacteria at the surgical site. The efficacy of single-dose antibiotic prophylaxis does not require that the drug used be bactericidal against all of the organisms in the vagina.
Conceptually, prophylactic antibiotic usage requires that the drug used be relatively inexpensive, safe, and effective. A detailed analysis of the drugs available for use for this purpose is available elsewhere in American College of Obstetricians and Gynecologists publications.5 and different hospitals may have unique pathogens, which require modification of any blanket recommendations. Also, efficacy and sensitivity patterns are subject to change, so hospital infection control committees should monitor the patterns of prophylaxis usage and benefit for their particular environment and make specific drug recommendations accordingly. Given the overwhelming evidence regarding the effectiveness of prophylactic antibiotic usage, hospital quality committees should enforce their usage as a routine preoperative protocol for indicated surgical procedures, unless there is some compelling reason for the surgeon to cancel this order.
Within that context, current studies suggest that a single dose of a cephalosporin, usually cefazolin, 1 or 2 g IV is the drug of choice for prophylaxis, especially for vaginal and abdominal hysterectomy. The drug is low cost, has a long (1.8 hours) half-life, a low incidence of allergic reactions, and is relatively free of side effects. Antibiotics significantly more expensive than cefazolin will decrease the theoretical cost-benefit ratio implicit in supporting the prophylaxis concept. Cefazolin is also similar in its profile of effectiveness against anaerobes to other cephalosporins. Anaphylaxis with cephalosporins occurs less than 0.02% of the time, and this is only slightly increased in patients with known penicillin allergy. Of the four types of immunopathologic responses to β-lactam antibiotics, only the immediate hypersensitivity-type reaction to penicillin should preclude the use of a cephalosporin for prophylaxis. For those patient that have significant allergy to beta lactam agents, other choices include:
- Clindamycin 600 mg IV and Gentamicin 1.5 mg/kg IV
- Metronidazole 500 mg IV and Gentamicin 1.5 mg/kg IV
Timing of administration of antibiotic therapy preoperatively is important. Most studies demonstrate that the antibiotic should reach therapeutic tissue levels prior to the initial incision, and this is best accomplished by administering antibiotic 30 to 60 minutes prior to the initial incision, which effectively means that the antibiotic should be given just prior to the induction of general anesthesia. While the strongest evidence is for the use of a single dose of antibiotic prior to the onset of VH, there are other recommendations in the literature for the use of more than one dose. Some experts suggest that the object of the preventative therapy is to have therapeutic drug levels on board for the duration of the operative procedure and, therefore, if the case is exceptionally long, that is, greater than 2 hours, a subsequent dose of prophylactic antibiotic can be considered at sequences of one to two times the drug’s half-life.5 Given that excess blood loss is also a major risk factor for infection, another antibiotic dose at the conclusion of the case is a consideration. Different studies have suggested that blood loss amounts of 750 to 1500 cc may prompt additional antibiotic dosing. Bacterial resistance is a risk factor for more than routine prophylactic antibiotic usage, so the use of more than a single dose should be approached with caution.
Treatment of Infection/Pelvic Cellulitis
As the ptient case demonstrates, febrile morbidity may occur following VH. When used appropriately, antibiotic prophylaxis has reduced postoperative infection rates from 5% to 10% to about 4% for most gynecologic procedures, infection may result. Pelvic cellulitis is the most likely diagnosis in the illustrative case report. The patient may complain of pelvic pain and a slight increase in vaginal discharge, but neither pelvic examination nor imaging procedures are likely to demonstrate a mass within 24 hours of surgery. Laboratory results may likely demonstrate an elevated white blood (cell) count (WBC) of greater than 13,000/mm3, with a left shift to greater than 90% bands and polymorphonuclear leucocytes. The value of an extensive fever workup for febrile morbidity following gynecologic procedures has been questioned.3 Comparing groups of patients with postoperative infection did not demonstrate the value of multiple laboratory or imaging studies, and the approach to the patient with fever following VH should be specific to the individual situation. The therapy of choice is a single agent IV antibiotic, usually not the drug used for prophylaxis.
Again, knowledge of hospital antibiotic resistance patterns is important, but in general, single agent cephalosporin therapy is indicated, such as cefotetan, cefotaxime, cefoxitin, or ceftriaxone. Other choices include ampicillin/sulbactam, piperacillin, mezlocillin, or ticarcillin/clavulanic acid.
Treatment of Infection/Infected Hematoma and Pelvic Abscess
Febrile responses persisting beyond 48 to 72 hours of antibiotic suggest the presence of an abscess or an infected hematoma, and imaging studies such as ultrasound or CT may show a mass.6 These abscesses usually require surgical drainage, usually in the OR with sedation or anesthesia to allow for transvaginal access to the mass, bluntly opening the cuff enough to facilitate drainage. If imaging studies suggest that the hematoma or abscess is not accessible via the vaginal route, ultrasound- or CT-guided needle or catheter drainage is a consideration. IV antibiotic therapy must continue until the patient becomes afebrile for 24 to 48 hours. The concept of continuing prolonged oral antibiotic therapy for several days after the patient is afebrile is no longer viable and only serves to increase antibiotic resistance.
In general, cultures for anaerobic organisms are costly and not done routinely. Additionally, the antibiotic choices must be made long before the culture results are available. If the fever persists despite therapy for 48 to 72 hours, reevaluation of the cultures and antibiotic choices is in order, and consultation with the infectious disease service is a consideration. Another study of febrile morbidity in patients following VH or TAH has shown that blood cultures were not cost-effective, and that none demonstrated bacteremia in febrile patients.
“Drug fever,” as indicated by persistent temperature elevation in the patient with no sign of infection after an exhaustive evaluation, and eosinophilia on the complete blood (cell) count (CBC) should be entertained as a diagnosis.
Treatment of Infection/Septic Thrombophlebitis
If the febrile response continues in spite of 72 hours of antibiotic therapy, the diagnosis of septic pelvic thrombophlebitis should be considered. Physical examination signs are variable and may include pelvic tenderness and pain over the upper thigh along with edema, suggesting ileofemoral vein involvement. Imaging studies such as CT or MRI may show the involved region, with the radiographic criteria for diagnosis, including (1) venous enlargement, (2) the vessel wall having a low-density lumen, and (3) contrast media enhancing a sharply defined vessel wall.6 Medical therapy is indicated for this problem, not another surgical procedure. Some practitioners will add heparin therapy to the antibiotic regimen. Prolonged therapy is often required for adequate response. Oral anticoagulants are not required following defervescence.
Comprehension Questions
28.1 Which of the following classes of antibiotics is usually the first choice for use as a prophylactic antibiotic in vaginal surgery?
A. Cephalosporins
B. Penicillins
C. Quinolones
D. Tetracyclines
28.2 When pelvic cellulitis is suspected following vaginal hysterectomy, which of the following therapeutic measures should constitute your initial approach?
A. Consult the infectious disease service.
B. Begin therapy with heparin.
C. Begin triple antibiotic therapy with ampicillin, gentamycin, and metronidazole.
D. Begin single-drug therapy with a drug not used for prophylaxis.
28.3 Once the patient described in question 28.2 has responded to IV antibiotic therapy with a normal temperature and no longer appears ill, which of the following is the best next step?
A. Oral antibiotic therapy should commence and continue for another 5 to 7 days.
B. Blood cultures should be obtained to be sure that the patient is well.
C. Antifungal agents should be begun.
D. Antibiotic therapy may end 24 hours following the last elevated temperature.
ANSWERS
28.1 A. The cephalosporins, as a class, are generally preferred for antibiotic prophylaxis in vaginal surgery. They are effective, relatively inexpensive, and safe, rarely causing anaphylaxis.
28.2 D. Therapy for straightforward pelvic cellulitis should begin with single agent antibiotic therapy. The other treatment options listed should be reserved for infectious problems that do not resolve easily.
28.3 D. Continuing antibiotic therapy either IV or orally, after the patient is well, only serves to increase the potential for bacterial resistance and to cause drug fever.
Clinical Pearls
See Table 1-2 for definition of level of evidence and strength of recommendation
➤ Timing is critical in using prophylactic antibiotics—have the anesthesia service administer your antibiotic of choice before the initiation of general anesthesia, usually within the hour prior to your incision (Level A).
➤ Keep blood loss to a minimum—the greater the blood loss, the greater the chance for infection (Level B).
➤ Work quickly and efficiently.The longer the case, the greater the potential for infection. If the case is obviously going to last significantly longer than 2 hours, consider a second dose of prophylactic antibiotic at the 2-hour mark (Level B).
➤ Consider doing VH without electrocautery. Cauterized tissue provides a nidus for infection, and meticulous surgical technique combined with a lidocaine/epinephrine mixture injected at the vaginal cuff prior to the initial incision significantly reduces blood loss (Level B).
REFERENCES
1. Culligan P, Heit M, Blackwell L, Murphy M, Graham C, Snyder J. Bacterial colony counts curing vaginal surgery. Inf Dis Obstet Gynecol. 2003;11:161-165.
2. Swisher E, Kahleifeh B, Pohl J. Blood cultures in febrile patients after hysterectomy. J Reprod Med. 1997;42:547-550.
3. Schey D, Salom E, Papadia A, Penalver M. Extensive fever workup produces low yield in determining infectious etiology. Am J Obstet Gynecol. 2005;192:1729-1734.
4. Peipert J, Weitzen S, Cruickshank C, Story E, Ethridge D, Lapane K. Risk factors for febrile morbidity after hysterectomy. Obstet Gynecol. 2004;103:86-91.
5. American College of Obstetricians and Gynecologists. Antibiotic prophylaxis for gynecologic procedures. ACOG Practice Bulletin No. 74. Obstet Gynecol. 2006;108:225-234.
6. Brown C, Lowe T, Cunningham F, Weinreb J. Puerperal pelvic thrombophlebitis: impact on diagnosis and treatment using x-ray computed tomography and magnetic resonance imaging. Obstet Gynecol. 1986;68:789-794.
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