INFECTION AFTER HYSTERECTOMY nation designed to detect an infection in any loca- tion must be performed when evaluating the pa- tient for operative site infection after hysterec- tomy. Incisional surgical site infections are subdivided in the CDC definitions into superficial and deep in- fections. Superficial infection must occur within 30 days and involve only the skin or skin and subcu- taneous tissues. Either organisms isolated from an aseptically obtained culture, or purulent drainage must be present in the incision. One of these also must be accompanied by at least one of the follow- ing symptoms or signs: 1) redness or heat; 2) local- ized swelling; 3) pain or tenderness; 4) deliberate opening of incision by a surgeon (unless culture negative); or 5) diagnosis by the surgeon or attend- ing physician. These definitions do not include stitch abscesses. Deep incisiona/ surgical site infections must occur within 30 days after hysterectomy. The diagnosis is confirmed by at least one of the following: 1) pu- rulent drainage from a deep incision, but not the organ or space component of the surgical site; or 2) a deep incision that is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: 1) temperature >38C; 2) an abscess or other evidence of infection found at reoperation, by radiologic examination, or at rcoperation by histopathologic diagnosis; or 3) if the diagnosis is made by the surgeon or attending physician. This diagnosis can also be made if a deep incision dehisces spontaneously. When symptomatic cuff cellulitis develops, the non-penicillin allergic patient often can be treated with an oral broad spectrum regimen such as amoxicillin with sodium clavulanate (Augmcntin(R) 250-500 nag every 8 h. Clindamycin 450 mg orally every 6 h is an alternative for the penicillin allergic patient. For most women with pelvic infections other than cuff cellulitis, parcnteral antibiotic therapy is necessary, and women usually promptly respond to parenteral antimicrobial therapy. Paren- teral antibiotics should not be administered to women given the diagnosis of presumed pelvic in- fection without a pelvic examination. Table 3 lists alphabetically several tested and reported regimens that have been effective in the treatment of women who develop operative site pelvic infections after hysterectomy. Parenteral HEMSELL TABLE 3. Tested and reported regimens that have been effective in the treatment of women with operative site infections after hysterectomy Ampicillin/sulbactarn (Unasyn(R)) 3 g q 6 h Cefotaxime (Claforan(R)) g q 8 h Cefotetan (Cefotan(R)) 2 g q 12 h Cefoxitin (Mefoxin(R)) 2 g q 6 h Imipenem/cilastatin (Primaxin(R)) 500 mg q 8 h Meropenem (Merem(R)) 500 mg q 8 h Piperacillin (Piperacil(R)) 4 g q 6 h Piperacillin and tazobactam (Zosyn(R)) 3.375 g q 6 h therapy is continued until the patient has been afe- brile 24-36 h. Oral antibiotic therapy is unneces- sary after successful parenteral therapy.6 The most important consideration in antibiotic selection is predictable efficacy. Infections are polymicrobial, and a broad spectrum of antibacte- rial activity is necessary. The regimens listed in Table 3 have comparable clinical efficacy in re- ported trials. If regimens are comparable in effi- cacy, then safety profile considerations are impor- tant. If efficacy and safety profiles are similar, then cost considerations become important. Without doubt, combination antimicrobial therapy is also ef- fective in the treatment of women with operative site infection following hysterectomy. No compara- tive trials have shown combination therapy to be significantly more effective than single-agent therapy, however, and multiple antibiotic regimens are usually more expensive and always more labor intensive for nurses. Clindamycin resistance is in- creasingly reported, and we have observed an in- creasing percentage of operative site infections that were not cured until metronidazole was substituted for clindamycin. Patients that have a true type I hypersensitivity reaction to penicillin antibiotics should not be ad- ministered penicillins, cephalosporins, pcnems, etc. Women who do not have a type I hypersensi- tivity reaction to penicillin but develop a rash, etc., can be administered a cephalosporin. If a patient has a type hypersensitivity reaction to penicillin, then therapy should be combination and will con- tain an anti-anaerobic antibiotic such as clindarny- cin, 900 nag every 8 h or metronidazole at a loading dose of 15 mg/kg, and then a maintenance dose of 7.5 mg/kg every 6 h. Either should bc combined with an aminoglycoside, an antibiotic family effcc- INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 55