Antimicrobial prophylaxis for gynecologic and obstetric surgery in adults*

Procedure	ACOG preferred regimen^¶^[1,2]	Dose	Alternative regimens^Δ^[3,4]	Dose
Hysterectomy (abdominal, including supracervical, vaginal, laparoscopic, or robotic) Pelvic reconstruction procedures, including colporrhaphy or those involving mesh or vaginal sling placement	Cefazolin, cefoxitin or cefotetan	Cefazolin: <120 kg: 2 g IV ≥120 kg: 3 g IV Cefoxitin or cefotetan: 2 g IV	Regimen:
			Ampicillin-sulbactam	3 g IV
			Regimen:
			Clindamycin OR	900 mg IV^◊
			Vancomycin^¶	15 mg/kg IV (not to exceed 2 g per dose)
			PLUS one of the following:
			Gentamicin OR	5 mg/kg IV (if overweight or obese, based on adjusted body weight)^§
			Aztreonam OR	2 g IV
			Fluoroquinolone^¶^¥
			Regimen:
			Metronidazole	500 mg IV
			PLUS one of the following:
			Gentamicin OR	5 mg/kg IV (if overweight or obese, based on adjusted body weight)^§
			Fluoroquinolone^¶^¥
Cesarean delivery (intact membranes, not in labor)	Cefazolin	<120 kg: 2 g IV ≥120 kg: 3 g IV	Clindamycin	900 mg IV^◊
			PLUS
			Gentamicin	5 mg/kg IV (if overweight or obese, based on adjusted body weight)^§
Cesarean delivery (in labor, ruptured membrane)	Cefazolin	<120 kg: 2 g IV >120 kg: 3 g IV	Clindamycin	900 mg IV
	PLUS		PLUS
	Azithromycin	500 mg IV	Gentamicin	5 mg/kg IV (if overweight, or obese, based on adjusted body weight)
			PLUS
			Azithromycin	500 mg IV
Uterine evacuation (including surgical abortion, suction D&C, and D&E)	Doxycycline	200 mg orally
Hysterosalpingogram, including chromotubation or saline infusion sonography	Not recommended^‡
Laparotomy without entry into bowel or vagina	Consider cefazolin	<120 kg: 2 g IV ≥120 kg: 3 g IV
Laparoscopy (diagnostic, tubal sterilization, operative except for hysterectomy) Other transcervical procedures: Cystoscopy^† Hysteroscopy (diagnostic or operative) Intrauterine device insertion Endometrial biopsy Oocyte retrieval D&C for non-pregnancy indication Cervical tissue biopsy, including LEEP or endocervical curettage	Not recommended

ACOG: American College of Obstetricians and Gynecologists; IV: intravenous; D&C: dilation and curettage; D&E: dilation and evacuation; LEEP: loop electrosurgical excision procedure; IDSA: Infectious Diseases Society of America; ASHP: American Society of Health-System Pharmacists; HSG: hysterosalpingogram; PID: pelvic inflammatory disease.
* Common pathogens: Enteric gram-negative bacilli, anaerobes, group B Streptococcus, enterococci.
¶ Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure. If vancomycin or a fluoroquinolone is used, the infusion should be given over 60 to 90 minutes and started within 60 to 120 minutes before the initial incision.
Δ An alternative regimen should be used in women with history of immediate hypersensitivity to beta-lactam agents. Due to increasing resistance of Escherichia coli to ampicillin-sulbactam and fluoroquinolones, local sensitivity profiles should be reviewed prior to use.
◊ When clindamycin prophylaxis is warranted, UpToDate authors prefer a single dose of 900 mg based upon pharmacokinetic considerations according to 2013 IDSA/ASHP surgical antibiotic prophylaxis guidelines.^[3] However, a 600 mg dose consistent with ACOG guidance may be sufficient.^[1,2]
§ Gentamicin use for surgical antibiotic prophylaxis should be limited to a single dose given preoperatively. Based on evidence from colorectal procedures, a single dose of approximately 5 mg/kg gentamicin appears more effective for the prevention of surgical site infection than multiple doses of gentamicin 1.5 mg/kg every 8 hours.^[4] For overweight and obese patients (ie, actual weight is >125% of ideal body weight), a dosing weight should be used. A calculator to determine ideal body weight and dosing weight is available in UpToDate.
¥ Ciprofloxacin 400 mg IV OR levofloxacin 500 mg IV OR moxifloxacin 400 mg IV. Fluoroquinolones are contraindicated in pregnancy and in women who are breastfeeding.
‡ Antimicrobial prophylaxis is recommended for women undergoing HSG or chromotubation with a history of PID or abnormal tubes noted on HSG or laparoscopy. For these women, an antibiotic prophylaxis regimen of doxycycline, 100 mg twice daily for 5 days, can be considered to reduce the incidence of post-procedural PID.^[5,6] For women undergoing chromotubation, a single preoperative 2 gram dose of intravenous cefazolin is recommended, and the patient can be discharged on the same doxycycline regimen recommended for abnormal HSG.
† Most clinicians exclude urinary tract infection with a urinalysis before cystoscopy, with subsequent urine culture performed to confirm findings suggestive of infection. Patients with positive test results should be given antibiotic treatment.

References:

ACOG practice bulletin No. 195: Prevention of infection after gynecologic procedures. Obstet Gynecol 2018; 131:e172.
ACOG practice bulletin No. 199: Use of prophylactic antibiotics in labor and delivery. Obstet Gynecol 2018; 132:e103.
Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
Zelenitsky SA, Silverman RE, Duckworth H, Harding GK. A prospective, randomized, double-blind study of single high dose versus multiple standard dose gentamicin both in combination with metronidazole for colorectal surgical prophylaxis. J Hosp Infect 2000; 46:135.
Pittaway DE, Winfield AC, Maxson W, et al. Antibiotic prophylaxis for gynecologic procedures prior to and during the utilization of assisted reproductive technologies: a systematic review. Am J Obstet Gynecol 1983; 147:623.
Pereira N, Hutchinson AP, Lekovich JP, et al. Antibiotic prophylaxis for gynecologic procedures prior to and during the utilization of assisted reproductive technologies: a systematic review. J Pathog 2016; 2016:4698314.

Adapted from: Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.

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Antimicrobial prophylaxis for gynecologic and obstetric surgery in adults*