BJOG Exchange
postoperative surgical infection a much rarer thing than it currently is. Certainly it is an avenue to explore. & References 1 Brummer T, Heikkinen A, Jalkanen J, Fraser J, M€ akinen J, Tom as E, et al. Antibiotic prophylaxis for hysterectomy, a prospective cohort study: cefuroxime, metronidazole, or both? BJOG 2013;120:1269–1276. 2 Cartwright P, Pittaway D, Jones H, Entman S. The use of prophylactic antibiotics in obstetrics and gynecology. A review. Obstet Gynecol Surv 1984;39:537–554. 3 Seamon MJ, Wobb J, Gaughan JP, Kulp H, Kamel I, Dempsey DT. The effects of intraoperative hypothermia on surgical site infection: an analysis of 524 trauma laparotomies. Ann Surg 2012;255:789–795. 4 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization Study of Wound Infection and Temperature Group. N Engl J Med 1996;334:1209–1215.
MJ Dickson,a R Yakubb & K Cheungb a
Wayside, Cheshire, UK bRoyal Oldham Hospital, Oldham, Lancashire, UK
Accepted 24 September 2013. DOI: 10.1111/1471-0528.12644
Authors’ reply Sir, We thank Drs Dickson, Yacub, and Cheung for their interest in our work. In FINHYST, ‘Antibiotic prophylaxis for hysterectomy, a prospective cohort study: cefuroxime, metronidazole or both?’, our main result regarding antibiotic prophylaxis was that treatment with metronidazole in combination with cefuroxime was useless. Although anaerobes are involved at the surgical site, cefuroxime, which is secondgeneration cephalosporine is also effective against some anaerobic species. The pathogenesis of anaerobic infections involves (surgical) trauma and hypoxia, yet in order to initiate infection it seems that anaerobes require the presence of other bacteria.1 Therefore, as a prophylaxis against infections arising from the polymicrobial vaginal florae, cefuroxime
1576
seems sufficient. We must emphasise that metronidazole, or other antibiotics particularly targeted against anaerobes, do have an important place in the treatment of pelvic infections, but as a routine prophylactic agent, metronidazole seems to be a waste of money. The physiological warming balance, normally maintained by muscle work and tonus, is impaired during relaxation. Regional and general anaesthesia also cause periferic vasodilatation, resulting in redistribution that enhances hypothermia during surgery. Perioperative warming more than halves surgical-site infections.2,3 The use of forced-air blankets in Finland is very common, and is almost routine, but regarding our FINHYST study, information of coverage is lacking. The surgical site, however, must always be exposed. To our knowledge, the role of skin preps in temperature control has not been greatly discussed. Although the effect of such local wound-site cooling would appear to be temporary, and soon to be reversed, we find your results interesting. The optimal antibiotic prophylaxis tissue level should be reached by the time of contamination, i.e. when the bacteria gain access to the tissues.4 A vasoconstrictive effect on the skin might theoretically affect the tissue levels of the prophylactic antibiotics. As skin preps are essential, the beneficial effect of preoperative warming of the surgical site could more often be kept in mind.2 & References 1 McDonald PJ, O’Loughlin JA. Prophylactic antibiotics and prevention of surgical sepsis. Baillieres Clin Obstet Gynaecol 1993;7:219–36. 2 Melling AC, Ali B, Scott E, Leaper D. Effects of preoperative warming on incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 2001;358:876–80. 3 Wong PF, Kumar S, Bohra A, Whetter D, Leaper DJ. Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg 2007; 94:421–6. 4 Classen D, Evans S, Pestotnik S, Horn S, Menlove R, Burke J. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med 1992;326:281–6.
T Brummera & P H€arkkib a
Department of Gynaecology and Obstetrics, Porvoo Hospital, Porvoo, Finland b Department of Gynaecology and Obstetrics, Helsinki University Central Hospital, Helsinki, Finland Accepted 11 December 2013. DOI: 10.1111/1471-0528.12645
Effect of ethnicity on live birth rates after in vitro fertilisation or intracytoplasmic sperm injection treatment: possible explanations and further observations
Sir, Lower success rates of in vitro fertilisation (IVF) in South East Asian countries than Western countries in informal studies and surveys1 has always been considered a reflection of variations in methodology and expertise. Clearly, the recent article by Jayaprakasan et al.2 regarding the effects of ethnicity on the success rates of IVF and intracytoplasmic sperm injection (ICSI) in the UK would suggest other contributing factors. Jayaprakasan et al.2 have suggested some possible causes but full evaluation of these requires further extensive studies. We have developed a method of investigating the influence of ethnic group on prevalence, co-morbidity and other factors in a variety of conditions using completely anonymous hospital admissions data from multiple hospitals in Birmingham and Manchester, UK, using the ICD-10 and OPCS coding.3,4 According to this data set consisting of 522 223 female patients aged 18 and over, there were 44 758 (8.4%) patients from the South Asian community. From the overall female population, 8653 patients were coded for infertility, of which 1156 patients (13.4%) were of South Asian ethnicity, which is considerably higher than the proportion of the background South Asian female population. Of the 1479 patients coded for IVF procedures, the percentage of South Asian patients increased to 15.4% (233).
ª 2014 Royal College of Obstetricians and Gynaecologists
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
postoperative surgical infection a much rarer thing than it currently is. Certainly it is an avenue to explore. & References 1 Brummer T, Heikkinen A, Jalkanen J, Fraser J, M€ akinen J, Tom as E, et al. Antibiotic prophylaxis for hysterectomy, a prospective cohort study: cefuroxime, metronidazole, or both? BJOG 2013;120:1269–1276. 2 Cartwright P, Pittaway D, Jones H, Entman S. The use of prophylactic antibiotics in obstetrics and gynecology. A review. Obstet Gynecol Surv 1984;39:537–554. 3 Seamon MJ, Wobb J, Gaughan JP, Kulp H, Kamel I, Dempsey DT. The effects of intraoperative hypothermia on surgical site infection: an analysis of 524 trauma laparotomies. Ann Surg 2012;255:789–795. 4 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization Study of Wound Infection and Temperature Group. N Engl J Med 1996;334:1209–1215.
MJ Dickson,a R Yakubb & K Cheungb a
Wayside, Cheshire, UK bRoyal Oldham Hospital, Oldham, Lancashire, UK
Accepted 24 September 2013. DOI: 10.1111/1471-0528.12644
Authors’ reply Sir, We thank Drs Dickson, Yacub, and Cheung for their interest in our work. In FINHYST, ‘Antibiotic prophylaxis for hysterectomy, a prospective cohort study: cefuroxime, metronidazole or both?’, our main result regarding antibiotic prophylaxis was that treatment with metronidazole in combination with cefuroxime was useless. Although anaerobes are involved at the surgical site, cefuroxime, which is secondgeneration cephalosporine is also effective against some anaerobic species. The pathogenesis of anaerobic infections involves (surgical) trauma and hypoxia, yet in order to initiate infection it seems that anaerobes require the presence of other bacteria.1 Therefore, as a prophylaxis against infections arising from the polymicrobial vaginal florae, cefuroxime
1576
seems sufficient. We must emphasise that metronidazole, or other antibiotics particularly targeted against anaerobes, do have an important place in the treatment of pelvic infections, but as a routine prophylactic agent, metronidazole seems to be a waste of money. The physiological warming balance, normally maintained by muscle work and tonus, is impaired during relaxation. Regional and general anaesthesia also cause periferic vasodilatation, resulting in redistribution that enhances hypothermia during surgery. Perioperative warming more than halves surgical-site infections.2,3 The use of forced-air blankets in Finland is very common, and is almost routine, but regarding our FINHYST study, information of coverage is lacking. The surgical site, however, must always be exposed. To our knowledge, the role of skin preps in temperature control has not been greatly discussed. Although the effect of such local wound-site cooling would appear to be temporary, and soon to be reversed, we find your results interesting. The optimal antibiotic prophylaxis tissue level should be reached by the time of contamination, i.e. when the bacteria gain access to the tissues.4 A vasoconstrictive effect on the skin might theoretically affect the tissue levels of the prophylactic antibiotics. As skin preps are essential, the beneficial effect of preoperative warming of the surgical site could more often be kept in mind.2 & References 1 McDonald PJ, O’Loughlin JA. Prophylactic antibiotics and prevention of surgical sepsis. Baillieres Clin Obstet Gynaecol 1993;7:219–36. 2 Melling AC, Ali B, Scott E, Leaper D. Effects of preoperative warming on incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 2001;358:876–80. 3 Wong PF, Kumar S, Bohra A, Whetter D, Leaper DJ. Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg 2007; 94:421–6. 4 Classen D, Evans S, Pestotnik S, Horn S, Menlove R, Burke J. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med 1992;326:281–6.
T Brummera & P H€arkkib a
Department of Gynaecology and Obstetrics, Porvoo Hospital, Porvoo, Finland b Department of Gynaecology and Obstetrics, Helsinki University Central Hospital, Helsinki, Finland Accepted 11 December 2013. DOI: 10.1111/1471-0528.12645
Effect of ethnicity on live birth rates after in vitro fertilisation or intracytoplasmic sperm injection treatment: possible explanations and further observations
Sir, Lower success rates of in vitro fertilisation (IVF) in South East Asian countries than Western countries in informal studies and surveys1 has always been considered a reflection of variations in methodology and expertise. Clearly, the recent article by Jayaprakasan et al.2 regarding the effects of ethnicity on the success rates of IVF and intracytoplasmic sperm injection (ICSI) in the UK would suggest other contributing factors. Jayaprakasan et al.2 have suggested some possible causes but full evaluation of these requires further extensive studies. We have developed a method of investigating the influence of ethnic group on prevalence, co-morbidity and other factors in a variety of conditions using completely anonymous hospital admissions data from multiple hospitals in Birmingham and Manchester, UK, using the ICD-10 and OPCS coding.3,4 According to this data set consisting of 522 223 female patients aged 18 and over, there were 44 758 (8.4%) patients from the South Asian community. From the overall female population, 8653 patients were coded for infertility, of which 1156 patients (13.4%) were of South Asian ethnicity, which is considerably higher than the proportion of the background South Asian female population. Of the 1479 patients coded for IVF procedures, the percentage of South Asian patients increased to 15.4% (233).
ª 2014 Royal College of Obstetricians and Gynaecologists
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
