背景:手术部位感染(SSI)是妇科癌症手术最常见的并发症之一。目前的指南建议在手术前使用头孢唑啉,以降低接受清洁污染手术如子宫切除术的患者的SSI率。
目的:评估在综合癌症中心接受妇科手术的妇女中,在头孢唑啉中加入甲硝唑预防抗生素的质量改进项目对SSI发生率的影响。
方法:本回顾性研究,单中心,队列研究纳入了2017年5月至2023年6月在妇科肿瘤科接受手术的患者.青霉素过敏的患者和进行伴随肠切除术和/或关节病例的患者被排除。干预前的组患者于2017年5月至2022年4月进行手术,干预后的组患者于2022年4月至2023年6月进行手术。主要结果是30天SSI率。进行敏感性分析以比较基于实际接受的抗生素和子宫切除术患者的SSI率。使用调整混杂变量的多变量逻辑回归模型确定与SSI独立相关的因素。
结果:在3343名患者中,2572(76.9%)和771(23.1%)在干预前后组,分别。大多数患者(74.7%)进行了子宫切除术。34%的病例是非肿瘤(良性)适应症。干预前患者更有可能接受适当的术前抗生素(95.6%vs90.7%;p<0.001)。干预前的整体SSI率为4.7%,干预后为2.6%(p=0.010)。所有接受子宫切除术的患者的SSI率为4.9%(干预前)与2.8%(干预后)(p=0.036);良性病例的趋势相似(4.4%vs2.4%;p=0.159)。在多变量分析中,与干预前相比,术后组的SSI比值比为0.49(95%CI0.38-0.63)(p<0.001).在敏感性分析(n=3087)中,单独接受头孢唑林的患者的SSI率为4.5%,而接受头孢唑林加甲硝唑的患者为2.3%,头孢唑林加甲硝唑组的SSI几率显着降低(校正OR0.40,95%CI0.30-0.53;p<0.001)。只有那些做了子宫切除术的人,干预后患者发生SSI的几率显著降低(校正OR0.63,95%CI0.47~0.86;p=0.003).
结论:妇科手术前在头孢唑啉中添加甲硝唑可使SSI率降低一半,即使在考虑了其他已知的SSI预测因素和随着时间的推移实践模式的差异之后。提供者应在接受妇科手术的女性中考虑这种联合治疗方案,尤其是涉及子宫切除术的病例。
BACKGROUND: Surgical site infection is one of the most common complications of gynecologic cancer surgery. Current guidelines recommend the administration of cefazolin preoperatively to reduce surgical site infection rates for patients undergoing clean-contaminated surgeries such as hysterectomy.
OBJECTIVE: To evaluate the impact of a quality improvement project adding metronidazole to cefazolin for antibiotic prophylaxis on surgical site infection rate for women undergoing gynecologic surgery at a comprehensive cancer center.
METHODS: This retrospective, single-center cohort study included patients who underwent surgery in the gynecologic oncology department from May 2017 to June 2023. Patients with penicillin allergies and those undergoing concomitant bowel resections and/or joint cases were excluded. The preintervention group patients had surgery from May 2017 to April 2022, and the postintervention group patients had surgery from April 2022 to June 2023. The primary outcome was a 30-day surgical site infection rate. Sensitivity analyses were performed to compare surgical site infection rates on the basis of actual antibiotics received and for those who had a hysterectomy. Factors independently associated with surgical site infection were identified using a multivariable logistic regression model adjusting for confounding variables.
RESULTS: Of 3343 patients, 2572 (76.9%) and 771 (23.1%) were in the pre-post intervention groups, respectively. Most patients (74.7%) had a hysterectomy performed. Thirty-four percent of cases were for nononcologic (benign) indications. Preintervention patients were more likely to receive appropriate preoperative antibiotics (95.6% vs 90.7%; P<.001). The overall surgical site infection rate before the intervention was 4.7% compared with 2.6% after (P=.010). The surgical site infection rate for all patients who underwent hysterectomy was 4.9% (preintervention) vs 2.8% (postintervention) (P=.036); a similar trend was seen for benign cases (4.4% vs 2.4%; P=.159). On multivariable analysis, the odds ratio for surgical site infection was 0.49 (95% confidence interval, 0.38-0.63) for the postintervention compared with the preintervention group (P<.001). In a sensitivity analysis (n=3087), the surgical site infection rate was 4.5% for those who received cefazolin alone compared with 2.3% for those who received cefazolin plus metronidazole, with significantly decreased odds of surgical site infection for the cefazolin plus metronidazole group (adjusted odds ratio, 0.40 [95% confidence interval, 0.30-0.53]; P<.001). Among only those who had a hysterectomy performed, the odds of surgical site infection were significantly reduced for those in the postintervention group (adjusted odds ratio, 0.63 [95% confidence interval, 0.47-0.86]; P=.003).
CONCLUSIONS: The addition of metronidazole to cefazolin before gynecologic surgery decreased the surgical site infection rate by half, even after accounting for other known predictors of surgical site infection and differences in practice patterns over time. Providers should consider this combination regimen in women undergoing gynecologic surgery, especially for cases involving hysterectomy.