Preventing Infections Associated With Pelvic Sling Placement


ST. LOUIS — Infections associated with pelvic sling placement can be prevented with presurgical screening and treatment of skin and vaginal infections, according to Sebastian Faro, M.D.

Cystitis is the most common infection reported in the literature in association with transvaginal tape (TVT) placement. Superficial skin infections also have been reported, as well as abscesses in the periurethral space and the labia majora. In addition, there have been two case reports of necrotizing fasciitis after TVT placement, he said at the 14th International Pelvic Reconstructive and Vaginal Surgery Conference.

The risk factors associated with the placement of TVT, as well as transobturator slings (TOS), include placement of a foreign body; bacterial entrance to deep tissues during and after the procedure via incisions in both the skin and the anterior vaginal wall; the close proximity of the rectum, which can result in fecal flora such as bacteroides, enterococcus, and Escherichia coli, contaminating the vagina; bacterial colonization of the sling; and collection of blood and serum, which can encourage abscess formation, said Dr. Faro of the University of Texas, Houston.

In a review of his experience with 37 TVT cases and 12 TOS cases during the course of 1 year, he reported no infections in the TOS patients and 2 cases each of cystitis and pelvic cellulitis in the TVT patients.

Dr. Faro recommended screening all sling patients for bacterial vaginosis (BV) 2 weeks before surgery and treating them with vaginal metronidazole or clindamycin if they are positive. He also recommended a urinalysis and culture at the same time, and, if necessary, treatment with 100-mg nitrofurantoin twice daily for 7 days.

“I also screen for nasal carriage of Staphylococcus aureus, and if [the screenings] are positive, I start treatment 3 days before the procedure,” he said at the meeting, which was sponsored by the Society of Pelvic Reconstructive Surgeons and Emory University.

Nasal treatment is with 2% mupirocin calcium ointment 0.5 g in each nares twice daily for 5 days.

For patients undergoing a sling procedure alone—without hysterectomy or pelvic repair procedures—antibiotic prophylaxis on the day of surgery is not necessary, he said. Otherwise, checking the color and smell of vaginal discharge when the patient is in the operating room can be very valuable.

“If the discharge is dirty gray with a fishy or foul odor, suspect BV,” Dr. Faro said, recommending one 50-mg dose of metronidazole and one 500-mg dose of levofloxacin intravenously. A creamy or green discharge with no odor could be group B streptococcus or E. coli, he said, recommending one 2-g dose of cefazolin or one 500-mg dose of levofloxacin intravenously. These treatments should be started within the hour after the start of surgery.