Am Fam Physician. 2004 Oct 1;70(7):1367-1368.
Approximately 7 percent of women develop significant fever following elective vaginal hysterectomy for benign conditions compared with about 17 percent of those who undergo abdominal hysterectomy. Meta-analysis has attributed much of this difference to more frequent use of prophylactic antibiotics in vaginal procedures. The latter led to the widespread use of prophylactic antibiotics for hysterectomy because patients at increased risk could not be easily identified among all patients undergoing the procedure. Peipert and colleagues conducted a retrospective cohort study of nearly 700 women undergoing hysterectomy at a university medical center to better understand risk factors for fever following surgery. They aimed to use the data from this study to develop clinical algorithms to improve the quality of care for women undergoing hysterectomy.
They studied data on all women undergoing hysterectomy for benign conditions during a nine-month period. The research assistants abstracting the demographic and clinical data were not aware of the research hypothesis.
During the study, 408 (60 percent) women underwent abdominal hysterectomy, 90 (13 percent) had laparoscopic-assisted vaginal hysterectomy, and 188 (27 percent) had vaginal hysterectomies. The women ranged in age from 25 to 83 years, about 65 percent were white, and more than 80 percent had private insurance or were members of a health maintenance organization. Women who had abdominal procedures tended to be younger, have higher body mass indexes, be nulliparous, and have private health insurance. Otherwise, the women did not differ significantly by surgical approach. The lowest blood loss was associated with vaginal hysterectomy. Operating times were similar for abdominal and vaginal hysterectomies, but laparoscopic-assisted vaginal hysterectomy had the longest surgical times. More than one half of women undergoing the latter procedure had operating times longer than two hours.
Overall, 96 (14 percent) women developed significant postoperative fever. The risk was significantly higher in abdominal cases (18 percent) than with laparoscopic-assisted vaginal approaches (9 percent) or vaginal surgeries (8 percent). Overall, one half of the women received prophylactic antibiotics. Forty-five percent of women with abdominal approaches, 53 percent of those with laparoscopic-assisted vaginal procedures, and 59 percent of those with vaginal hysterectomies received antibiotics. Cefazolin was the most common agent used. In statistical analysis, only surgical approach and estimated blood loss predicted febrile morbidity. After controlling for age, body mass index, operative time, and prophylactic antibiotic use, the odds ratio was 2.5 for febrile morbidity with the abdominal approach and 3.7 for an operative blood loss of 750 mL or more.
The authors conclude that the risk of postoperative fever is doubled in abdominal hysterectomy and significantly increased with excessive blood loss. These results correlate with data from other studies. The excess risk in abdominal surgeries may be attributable in part to the less frequent use of prophylactic antibiotics. Inconsistencies in the timing of antibiotic administration also could contribute to suboptimal prevention of postoperative fever. They suggest that febrile morbidity could be reduced by more frequent use of vaginal surgical approaches, by taking precautions for reducing blood loss during surgery, and by greater use of appropriately timed prophylactic antibiotics.
Peipert JF, et al. Risk factors for febrile morbidity after hysterectomy. Obstet Gynecol. January 2004;103:86–91.
Copyright © 2004 by the American Academy of Family Physicians.
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