Antibiotic Prophylaxis in Pelvic Floor Surgery

Purpose of Review: The goal of this review is to summarize the current recommendations and evidence for the use of antibiotic prophylaxis in pelvic floor surgery. We provide a historical perspective on antimicrobial prophylaxis, review bacteria associated with pelvic floor surgery by site, and current antimicrobial prophylaxis recommendations from the American Urological Association (AUA) and American College of Obstetrics and Gynecology (ACOG). Recent Findings: ACOG published updated recommendations for perioperative prophylaxis in June 2018 and the AUA in June 2019. There has been a complete de-emphasis on the use of fluoroquinolones; the preferred antimicrobials, when indicated, are first and second generation Cephalosporins alone for nearly all pelvic floor procedures via a vaginal or abdominal approach. Aside from allergy considerations, exceptions include reconstruction with use of large bowel, for which additional anaerobic coverage and mechanical and antibiotic bowel prep is recommended, and for select diagnostic and therapeutic procedures of the lower urinary tract, for which trimethoprim-sulfamethoxazole is recommended. Summary: Pelvic floor surgery is unique due to its variable surgical approaches and the range of potential infectious sources to be considered (i.e., the skin, vagina, bladder, intestine). Urinary tract infection is the most common infectious complication across nearly all procedures, although its prevention is not simply related to antibiotic selection and duration. Antibiotic stewardship calls for judicious use, including non-use when risks are low. Although updated societal guidelines provide the foundation on which most perioperative antimicrobial recommendations should be based, surgeons must consider patient-specific factors (e.g., multidrug -resistant bacteriuria) and local antibiograms. Input from colleagues in pharmacy and infectious diseases may optimize antibiotic selection, dosing, and duration, particularly when non-guideline antibiosis appears to be indicated.