The Influence of Preoperative Vaginal Cleansing on Postoperative Infectious Morbidity in Abdominal Total Hysterectomy for Benign Indications: A Study From the Swedish National Register for Gynecological Surgery

Abstract

A significant complication of hysterectomy is postoperative infections. It is believed that prophylactic use of antibiotics reduces infectious morbidity in abdominal and vaginal hysterectomies and antimicrobial prophylaxis for this purpose is common. Another method used to reduce postoperative infectious morbidity after hysterectomy is preoperative vaginal cleansing, but evidence for its effectiveness is conflicting. This retrospective cohort study examined the effect of vaginal cleansing on risk of postoperative infectious morbidity after benign abdominal total hysterectomy and also analyzed associated risk factors for infection. The investigators combined data obtained from the Swedish National Register for Gynecological Surgery with information collected retrospectively from a postal survey of clinics in Sweden on routines for preoperative vaginal cleansing and other methods. The study population was comprised of 7193 women who had abdominal total hysterectomy for benign indications between 2000 and 2007. Multivariate logistic regression models were used to analyze the possible association of vaginal cleansing on the risk of occurrence of postoperative infectious morbidity and to assess the association between potential risk factors for infection. Postoperative infections were defined as infections treated with antibiotics within 6 to 8 weeks after hysterectomy. The overall postoperative infection rate requiring antibiotic treatment was 14.4% (893/6084). The data showed no significant association between occurrences of postoperative infections in women who had received prophylactic vaginal cleansing using chlorhexidine in comparison to those without vaginal cleansing. The use of a saline solution for vaginal cleansing also did not reduce risk of infection, and was, in fact, an independent risk factor for postoperative infectious morbidity. In addition to saline, other independent risk factors were age >60, obesity, smoking, preoperative injury of the urinary bladder or ureter, hospital stay exceeding 3 days, and blood transfusion. There was a significant association between the presence of a large uterus (≥500 gm) and less postoperative infectious morbidity. Interestingly, prophylactic antibiotic use was not found to be an independent risk-reducing factor for postoperative infections. These data indicate that preoperative vaginal cleansing with chlorhexidine does not reduce the risk of postoperative infectious morbidity and that vaginal cleansing with saline solution appears to be a significant risk factor for postoperative infections. The investigators believe that prevention of infection should be focused on preventable risk factors, such as smoking, obesity, and surgical techniques.