Should Cefazolin Be the First-line Antimicrobial Prophylaxis Choice in Patients Undergoing Hysterectomy? A Systematic Review and Meta-analysis

BACKGROUND: Current practice guidelines non-preferentially recommend cefazolin, cefoxitin, cefotetan, or ampicillin-sulbactam as first line choices for antibiotic prophylaxis in hysterectomy. We undertook a systematic review to determine whether cefazolin, with no anti-anaerobic activity, is as effective as β-lactam antibiotics with anti-anaerobic activity at preventing surgical site-infection (SSI) after abdominal or vaginal hysterectomy. METHODS: We searched PubMed, Scopus, Web of Science, Cochrane Central, and conference proceedings for randomized controlled trials (RCT) in any language up to May 16, 2016. Main search terms included cephalosporins, antibiotic prophylaxis, hysterectomy, surgical wound infection, clinical trials, and random allocation. We included only RCT that measured SSI – our primary outcome – defined as superficial, deep, or organ space. We excluded trials of β-lactams no longer in clinical use. We used predefined data extraction templates, including bias assessment indicators, and performed meta-analyses with random-effects models. RESULTS: Fourteen RCTs met inclusion criteria. There were 98 (5%) SSI among 1,903 patients in the cefazolin group, and 78 (4%) SSI among 1,772 patients in the comparator β-lactam (cefoxitin, cefotetan, cefotaxime, ceftriaxone, ampicillin, amoxicillin/clavulanate, or penicillin) group. The summary estimate showed no significant benefit for cefazolin vs. other β-lactam in reducing SSI (Risk Ratio 1.19; 95% CI 0.88 – 1.62, P = 0.23). Cefazolin had a higher SSI risk when compared with cefoxitin or cefotetan (Risk Ratio 1.67; 95% CI 1.03–2.72, P = 0.04), and a trend for higher SSI risk when compared with cefoxitin, cefotetan, or amoxicillin/clavulanate (Risk Ratio 1.56; 95% CI 0.99–2.49, P = 0.06). Most studies were limited to hysterectomies for benign indications, had variability in prophylaxis duration (single vs. multiple doses) and had unclear or high risk of bias. CONCLUSION: Β-lactam antibiotics with good anti-anaerobic spectrum may be preferable to cefazolin for SSI prevention post-abdominal or vaginal hysterectomy. Antimicrobial prophylaxis for hysterectomy in the setting of advanced malignancy deserves further study. DISCLOSURES: All authors: No reported disclosures.