Infections after gynecologic surgery

Infections observed after gynecologic surgical procedures are polymicrobial and require parenteral broad-spectrum antimicrobial therapy until the patient has been afebrile 24 to 72 hours. Therapy should be tailored to the specific infection and patient response thereto. When the infections are complicated by abscess or infected hematoma, combination therapy appears to be effective in a shorter period of time, and surgical drainage is infrequently necessary other than drainage of those in the supravaginal, extraperitoneal space. Administration of antibiotics immediately before surgery to women at high risk for postoperative infection has essentially eliminated pelvic infections. These infections range from cuff cellulitis through pelvic abscess and include pelvic thrombophlebitis. Pelvic infections and those in an abdominal, perineal, or vaginal incision can occur during the immediate postoperative period or after discharge from the hospital. As many as 50 per cent of these infections may occur after the patient is discharged from the hospital. Without question, the most appropriate means of objectively identifying infection rates, appropriate and inappropriate use of antimicrobials, and trends in morbidity is with an infection control program, usually consisting of an epidemiologist or specially trained nurses. Their contribution to appropriate patient care is significant. Information uncovered may put some clinicians on the defensive. This need not happen if gynecologic surgeons participate in and define criteria to be used for various infection diagnoses and similar situations. These diagnoses must be based on physical examination evidence, not 'presumptive evidence'. Antimicrobial administration and selection has an emotional component; objective evaluation avoids this bias. Optimal and efficient patient care is the goal and these programs should be established with that as their only goal. Several synergistic polymicrobial infections involve skin, subcutaneous tissue, and perhaps fascia; these are infrequently observed but require prompt recognition and antimicrobial therapy as wll as wide surgical excision to healthy tissue to effect a cure. Clinical presentation extends to both ends of the spectrum with respect to degree of illness. These infections also occur spontaneously in gynecologic sites, and do so only in patients at high risk, such as those with diabetes, delibitating disease, advanced age, or evidence of arteriosclerotic disease. Another infection that was diagnosed and managed only surgically (that is, septic pelvic thrombophlebitis) can now be accurately diagnosed without surgery and can be adequately treated medically. As is true with all infections, prevention (when possible), prompt and accurate diagnosis, knowledge of probable pathogens, and aggressive management - medical or surgical, or both - are requirements for good patient outcome.