INFECTION AFTER HYSTERECTOMY are in the lateral pelvic tissues and inaccessible to drainage from the cuff, percutaneous CT-guided drainage may be necessary, but usually is not. There rarely may be a requirement for laparotomy. Rupture of an abscess in(to) the peritoneal cavity is an event that requires immediate surgical therapy. Many abdominal incision margins normally may have a minimal amount of erythema while healing. If the patient develops wound pain with advancing erythema, fever, and tenderness, asound infection is present. These typically develop 4 or 5 days after surgery. Purulent exudate is usually found in vary- ing volumes; it is also possible to have a positive wound culture in the absence of purulent material in an infected wound. Given time, purulent secre- tions would be present. Seromas and hematomas are not included in the infection category. The patient may develop an operative site he- matoma which is asymptomatic, but which serves as an excellent growth medium for inoculated flora. This may become an infected hematoma, and can be located either centrally or laterally in the extraperi- toneal spaces or in an abdominal incision. A hema- toma is not usually associated with symptoms ini- tially, and is neither palpable nor tender. The only indication of its presence is an unexplained drop in hemoglobin. Even if temperature elevation devel- ops, patients are usually asymptomatic and the he- matoma is not palpable in the pelvis at bimanual examination, but vaginal probe sonography is an effective means for detection. Temperature elevation is the first sign of in- fected hematoma, and does not occur until the 4th postoperative day or later, now a time when pa- tients are at home. Without treatment, and after several days of fever, pain develops and the in- fected hematoma is detectable at bimanual exami- nation as a tender mass. It is important therefore to diagnose a hematoma before the patient is dis- charged. Parenteral antibiotic therapy is indicated for an infected hematoma. Studies have not been performed to determine whether oral antibiotic would prevent clinical infection in an uninfected hematoma. When located in an abdominal incision, a hematoma is more clinically obvious and acces- sible and is therefore diagnosed and treated (evacu- ation) before infection develops. Wound infection definitions were recently re- viewed by the Centers for Disease Control and Prevention (CDC)s and constitute another and 54 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY TABLE 2. Specific organ/space SSI HEMSELL Sinusitis Disc space Vaginal cuff Ear, mastoid Endometritis Endocarditis Mediastinitis Osteomyelitis Joint or bursa Gastrointestinal tract Meningitis or ventriculitis Myocarditis or pericarditis Breast abscess or mastitis Arterial or venous infection Eye, other than conjunctivitis Spinal abscess without meningitis Intracranial, brain abscess, or dura Upper respiratory tract, pharyngitis Other infections of the urinary tract Oral cavity (mouth, tongue, or gums) Other male or female reproductive tract Intra-abdominal, not specified elsewhere Other infections of the lower respiratory tract more general set of definitions. In their classifica- tion, surgical site infections (SSI) are divided into 1) organ or space infection and 2) incisional infec- tions. Organ or space infections are defined as those that develop in surgical sites other than the abdominal incision that was opened during the operative pro- cedure. An example would be pelvic infection after hysterectomy. Table 2 lists the specific organ/space surgical infection sites included in their definitions. These infections must occur within 30 days of the hysterectomy and must be accompanied by at least one of the following: 1) purulent drainage from a drain placed through a stab wound into the organ/ space; 2) organisms isolated from an aseptically ob- tained culture of fluid or tissue in the organ/space; 3) an abscess or other evidence of infection involv- ing the organ/space identified during reoperation or by radiologic or histopathologic examination; or 4) diagnosis of a SSI by a surgeon or, attending phy- sician. Because of the difficulty in the ability to asep- tically obtain a culture from a pelvic infection site, most infections are diagnosed clinically based on patient symptoms, vital signs, and physical findings at examination. Radiologic examination may be useful in diagnosing an infected hematoma or an abscess, however. Urine culture, complete blood count (CBC) with differential count, blood cul- tures, and chest X-ray are seldom necessary, but hemoglobin should be monitored and an unex- plained decrease should be investigated. It must be remembered that a patient may also develop non-surgical site infections after elective pelvic surgery. For that reason, a complete exami-