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Cochrane Database of Systematic Reviews Review - Intervention

Antibiotic prophylaxis for elective hysterectomy

Authors' declarations of interest

Version published: 18 June 2017 Version history

https://doi.org/10.1002/14651858.CD004637.pub2
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Background

Elective hysterectomy is commonly performed for benign gynaecological conditions. Hysterectomy can be performed abdominally, laparoscopically, or vaginally, with or without laparoscopic assistance. Antibiotic prophylaxis consists of administration of antibiotics to reduce the rate of postoperative infection, which otherwise affects 40%‐50% of women after vaginal hysterectomy, and more than 20% after abdominal hysterectomy. No Cochrane review has systematically assessed evidence on this topic.

Objectives

To determine the effectiveness and safety of antibiotic prophylaxis in women undergoing elective hysterectomy.

Search methods

We searched electronic databases to November 2016 (including the Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Studies (CRSO), MEDLINE, Embase, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), as well as clinical trials registers, conference abstracts, and reference lists of relevant articles.

Selection criteria

All randomised controlled trials (RCTs) comparing use of antibiotics versus placebo or other antibiotics as prophylaxis in women undergoing elective hysterectomy.

Data collection and analysis

We used Cochrane standard methodological procedures.

Main results

We included in this review 37 RCTs, which performed 20 comparisons of various antibiotics versus placebo and versus one another (6079 women). The quality of the evidence ranged from very low to moderate. The main limitations of study findings were risk of bias due to poor reporting of methods, imprecision due to small samples and low event rates, and inadequate reporting of adverse effects.

Any antibiotic versus placebo

Vaginal hysterectomy

Low‐quality evidence shows that women who received antibiotic prophylaxis had fewer total postoperative infections (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.19 to 0.40; four RCTs, N = 293; I2 = 85%), less urinary tract infection (UTI) (RR 0.58, 95% CI 0.43 to 0.77; eight RCTs, N = 1473; I2 = 44%), fewer pelvic infections (RR 0.28, 95% CI 0.20 to 0.39; 11 RCTs, N = 1693; I2 = 57%), and fewer postoperative fevers (RR 0.43, 95% CI 0.34 to 0.54; nine RCTs, N = 1562; I2 = 47%) than women who did not receive such prophylaxis. This suggests that antibiotic prophylaxis reduces the average risk of postoperative infection from about 34% to 7% to 14%. Whether this treatment has led to differences in rates of other serious infection remains unclear (RR 0.20, 95% CI 0.01 to 4.10; one RCT, N = 146; very low‐quality evidence).

Data were insufficient for comparison of adverse effects.

Abdominal hysterectomy

Women who received antibiotic prophylaxis of any class had fewer total postoperative infections (RR 0.38, 95% CI 0.21 to 0.67; one RCT, N = 158; low‐quality evidence), abdominal wound infections (RR 0.51, 95% CI 0.36 to 0.73; 11 RCTs, N = 2247; I2 = 6%; moderate‐quality evidence), UTIs (RR 0.41, 95% CI 0.31 to 0.53; 11 RCTs, N = 2705; I2 = 28%; moderate‐quality evidence), pelvic infections (RR 0.50, 95% CI 0.35 to 0.71; 11 RCTs, N = 1883; I2 = 11%; moderate‐quality evidence), and postoperative fevers (RR 0.59, 95% CI 0.50 to 0.70; 11 RCTs, N = 2394; I2 = 55%; moderate‐quality evidence) than women who did not receive prophylaxis, suggesting that antibiotic prophylaxis reduces the average risk of postoperative infection from about 16% to 1% to 6%. Whether this treatment has led to differences in rates of other serious infection remains unclear (RR 0.44, 95% CI 0.12 to 1.69; two RCTs, N = 476; I2 = 29%; very low‐quality evidence).

It is unclear whether rates of adverse effects differed between groups (RR 1.80, 95% CI 0.62 to 5.18; two RCTs, N = 430; I2 = 0%; very low‐quality evidence).

Head‐to‐head comparisons between antibiotics

Vaginal hysterectomy

We identified four comparisons: cephalosporin versus penicillin (two RCTs, N = 470), cephalosporin versus tetracycline (one RCT, N = 51), antiprotozoal versus lincosamide (one RCT, N = 80), and cephalosporin versus antiprotozoal (one RCT, N = 78). Data show no evidence of differences between groups for any of the primary outcomes, except that fewer cases of total postoperative infection and postoperative fever were reported in women who received cephalosporin than in those who received antiprotozoal.

Only one comparison (cephalosporin vs penicillin; two RCTs, N = 451) yielded data on adverse effects and showed no differences between groups.

Abdominal hysterectomy

We identified only one comparison: cephalosporin versus penicillin (N = 220). Data show no evidence of differences between groups for any of the primary outcomes. Adverse effects were not reported.

Combined antibiotics versus single antibiotics

Vaginal hysterectomy

We identified three comparisons: cephalosporin plus antiprotozoal versus cephalosporin (one RCT, N = 78), cephalosporin plus antiprotozoal versus antiprotozoal (one RCT, N = 78), and penicillin plus antiprotozoal versus penicillin (one RCT, N = 18). Data were unavailable for most outcomes, including adverse effects. We found no evidence of differences between groups, except that fewer women receiving cephalosporin with antiprotozoal received a diagnosis of total postoperative infection, UTI, or postoperative fever compared with women receiving antiprotozoal.

Abdominal hysterectomy

We identified one comparison (penicillin plus antiprotozoal vs penicillin only; two RCT, N = 155). Whether differences between groups occurred was unclear. Adverse effects were not reported.

Comparison of cephalosporins in different regimens

Single small trials addressed dose comparisons and provided no data for most outcomes, including adverse effects. Whether differences between groups occurred was unclear. No trials compared route of administration.

The quality of evidence for all head‐to‐head and dose comparisons was very low owing to very serious imprecision and serious risk of bias related to poor reporting of methods.

Authors' conclusions

Antibiotic prophylaxis appears to be effective in preventing postoperative infection in women undergoing elective vaginal or abdominal hysterectomy, regardless of the dose regimen. However, evidence is insufficient to show whether use of prophylactic antibiotics influences rates of adverse effects. Similarly, evidence is insufficient to show which (if any) individual antibiotic, dose regimen, or route of administration is safest and most effective. The most recent studies included in this review were 14 years old at the time of our search. Thus findings from included studies may not reflect current practice in perioperative and postoperative care and may not show locoregional antimicrobial resistance patterns.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

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Antibiotic prophylaxis for elective hysterectomy

Review question

Are antibiotics effective and safe for preventing postoperative infection in women undergoing elective (non‐urgent) hysterectomy?

Background

Surgical operation carried out to remove the uterus (hysterectomy) is commonly performed. Most cases are performed as non‐urgent (elective) procedures for non‐cancerous (benign) conditions affecting the uterus, such as menstrual pain or abnormal bleeding patterns. Antibiotics are usually given before the operation is performed (prophylactic antibiotics, or antibiotic prophylaxis) to prevent or reduce the occurrence of infection after the procedure. Researchers in the Cochrane Collaboration reviewed the evidence on effectiveness and safety of antibiotics used to prevent infection after non‐urgent surgical operation to remove the uterus. Evidence is current to November 2016.

Study characteristics

We identified 37 randomised controlled trials (RCTs), which included a total of 6079 women and compared 20 different types of antibiotics versus placebo (an inactive pill) or versus one another.

Key results

This review found moderate‐quality evidence showing that antibiotics appear to be effective in preventing infection in women undergoing non‐urgent surgical removal of the uterus through the vagina or abdomen. This suggests that antibiotic prophylaxis reduces the average risk of postoperative infection after vaginal hysterectomy from about 62% to 12% to 25%, and after abdominal hysterectomy from about 39% to 8% to 26%.

However, evidence is insufficient to show whether use of prophylactic antibiotics influences rates of adverse effects (side effects), or whether any one antibiotic is more effective or safer than the others.

When antibiotics are compared head‐to‐head or in combination versus single antibiotics, it is unclear which individual antibiotic was more effective and safer, or whether combined antibiotics were more effective and safer than single antibiotics. The quality of the evidence for these comparisons is very low.

It is also unclear which dose regimen or route of administration of antibiotics is safest or most effective in women undergoing elective hysterectomy.

The most recent of the studies included in this review was published 14 years ago, at the time of our search. Thus findings from the included studies may not reflect current practice in perioperative and postoperative care and may not show locoregional antimicrobial resistance patterns.

Quality of the evidence

The quality of evidence for our main comparisons ranged from very low to moderate. The main limitations of this evidence are risk of bias due to poor reporting of randomisation methods, imprecision due to small sample sizes and low event rates, and inadequate reporting of adverse effects.

Authors' conclusions

Implications for practice

Antibiotic prophylaxis appears to be effective in preventing postoperative infection in women undergoing elective vaginal or abdominal hysterectomy, regardless of the dose regimen. However, evidence was insufficient to show whether their use influences rates of adverse effects. Similarly, evidence was insufficient to show which (if any) individual antibiotic, dose regimen, or route of administration is safest and most effective. In interpreting results, it is important to realise that the most recent of the included studies was published 14 years ago, at the time of our search. Thus findings from included studies might not reflect current practice in perioperative and postoperative care or might not show locoregional antimicrobial resistance patterns.

Implications for research

More studies including large numbers of women and based on sound methods are needed to detect meaningful differences in efficacy between various antibiotics and to properly evaluate adverse effects associated with their use as prophylaxis for women undergoing elective hysterectomy. Also needed are more studies investigating various antibiotics in different combinations, dose regimens, and routes of administration to determine which combinations, dose regimens, and routes of administration are associated with better efficacy and fewer adverse effects. Laparoscopic hysterectomy is now commonly performed; thus future research should focus on the use of prophylaxis in laparoscopic hysterectomy (total or subtotal laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy).

In addition, trial publications should adequately report trial methods in accordance with the CONSORT statement.

Summary of findings

Open in table viewer
Summary of findings for the main comparison. Antibiotics compared with placebo for prophylaxis in elective vaginal hysterectomy

Antibiotics compared with placebo for prophylaxis in elective vaginal hysterectomy

Population: women having elective vaginal hysterectomy
Settings: hospital
Intervention: antibiotics
Comparison: placebo

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Placebo

Antibiotics

Total postoperative infections ‐ early and late

Moderatea

RR 0.28
(0.19 to 0.4)

293
(4 studies)

⊕⊕⊕⊝
lowb,c,f

618 per 1000

173 per 1000
(117 to 247)

Urinary tract infection

Moderatea

RR 0.58
(0.43 to 0.77)

1473
(8 studies)

⊕⊕⊕⊝
moderateb

127 per 1000

74 per 1000
(55 to 98)

Pelvic infection

Moderatea

RR 0.28
(0.20 to 0.39)

1693
(11 studies)

⊕⊕⊕⊝
moderateb,d

134 per 1000

38 per 1000
(27 to 52)

Other serious infections

Moderatea

RR 0.20
(0.01 to 4.10)

146
(1 study)

⊕⊝⊝⊝
very lowb,e

27 per 1000

5 per 1000
(0 to 111)

Postoperative fever

Moderatea

RR 0.43
(0.34 to 0.54)

1562
(9 studies)

⊕⊕⊕⊝
moderateb

219 per 1000

94 per 1000
(74 to 118)

Total adverse effects ‐ not reported

This outcome was not reported

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI)
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

aMedian baseline risk of control group
bDowngraded one level for serious risk of bias: sequence generation and allocation concealment assessed as "unclear" in some studies owing to poor reporting
cSubstantial heterogeneity for this comparison (I2 = 85%). The quality of the evidence was not downgraded for inconsistency, as the direction of effect was consistent and all inconsistency was attributable to a study that measured only early postoperative infection rates (to hospital discharge), whereas the other three studies measured both early and late infection
dSubstantial heterogeneity for this comparison (I2 = 57%), but the quality of the evidence was not downgraded for inconsistency, as the direction of effect was consistent
eDowngraded two levels for very serious imprecision: small sample size and effect estimate with wide confidence interval

fDowngraded two levels for serious imprecision: small sample size

Open in table viewer
Summary of findings 2. Antibiotics compared with placebo for prophylaxis in elective abdominal hysterectomy

Antibiotics compared with placebo for prophylaxis in elective abdominal hysterectomy

Population: women having elective abdominal hysterectomy
Settings: hospital
Intervention: antibiotics
Comparison: placebo

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Placebo

Antibiotics

Total postoperative infections ‐ early and late

Moderatea

RR 0.38
(0.21 to 0.67)

158
(1 study)

⊕⊕⊝⊝
lowb,c

388 per 1000

147 per 1000
(82 to 260)

Abdominal wound infection

Moderatea

RR 0.51
(0.36 to 0.73)

2247
(11 studies)

⊕⊕⊕⊝
moderateb

65 per 1000

33 per 1000
(23 to 47)

Urinary tract infection

Moderatea

RR 0.41
(0.31 to 0.53)

2705
(11 studies)

⊕⊕⊕⊝
moderateb

132 per 1000

54 per 1000
(41 to 70)

Pelvic infection

Moderatea

RR 0.50
(0.35 to 0.71)

1883
(11 studies)

⊕⊕⊕⊝
moderateb

83 per 1000

42 per 1000
(29 to 59)

Other serious infections

Moderatea

RR 0.44
(0.12 to 1.69)

476
(2 studies)

⊕⊝⊝⊝
very lowb,d,e

27 per 1000

12 per 1000
(3 to 46)

Postoperative fever

Moderatea

RR 0.59
(0.50 to 0.70)

2394
(11 studies)

⊕⊕⊕⊝
moderateb

242 per 1000

143 per 1000
(121 to 169)

Total adverse effects

Moderatea

RR 1.80
(0.62 to 5.18)

430
(2 studies)

⊕⊝⊝⊝
very lowb,e

23 per 1000

41 per 1000
(14 to 119)

*The basis for assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI)
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

aMedian baseline risk of control group
bDowngraded one level for serious risk of bias: sequence generation and/or allocation concealment assessed as "unclear" in some studies owing to poor reporting
cDowngraded one level for serious imprecision: small sample size
dSubstantial heterogeneity for this comparison (I2 = 51%), but the quality of the evidence was not downgraded for inconsistency, as the direction of effect was consistent
eDowngraded two levels for very serious imprecision: small sample size and effect estimate with wide confidence interval

Open in table viewer
Summary of findings 3. Head‐to‐head comparisons of antibiotics for prophylaxis in elective vaginal hysterectomy

Antibiotics compared with alternative antibiotics for prophylaxis in elective vaginal hysterectomy

Population: women having elective vaginal hysterectomy
Settings: hospital
Intervention: antibiotics
Comparison: alternative antibiotics

Outcomes

Illustrative comparative risks

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Antibiotics vs alternative antibiotics

  • Total postoperative infections ‐ early and late

  • Urinary tract infection

  • Pelvic infection

  • Other serious infections

  • Postoperative fever

When data were available, no evidence showed a difference between any groups compared for any of our primary outcomes, except:

  • fewer cases of total postoperative infection and postoperative fever in women who received cephalosporin than in those who received antiprotozoal

  • fewer cases of total postoperative infection, UTI, or postoperative fever in women receiving cephalosporin with antiprotozoal than in those receiving antiprotozoal only

  • cephalosporin vs penicillin (2 RCTs, 470 women)

  • cephalosporin vs tetracycline (1 RCT, 51 women)

  • cephalosporin vs antiprotozoal (1 RCT, 78 women)

  • antiprotozoal vs lincosamide (1 RCT, 80 women)

  • cephalosporin plus antiprotozoal vs cephalosporin only (1 RCT, 78 women)

  • cephalosporin plus antiprotozoal vs antiprotozoal only (1 RCT, 78 women)

  • penicillin plus antiprotozoal vs penicillin only (1 RCT, 18 women)

⊕⊝⊝⊝
very lowa,b

Total adverse effects

  • No evidence of a difference between cephalosporin and penicillin.

  • No data available for other comparisons

  • cephalosporin vs penicillin (2 RCTs, 451 women)

⊕⊝⊝⊝
very lowa,b

CI: confidence interval; RCT: randomised controlled trial

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

aDowngraded two levels for very serious imprecision with very few events and wide confidence intervals
bDowngraded one level for serious risk of bias: methods were poorly reported in most studies

Open in table viewer
Summary of findings 4. Head‐to‐head comparisons of antibiotics for prophylaxis in elective abdominal hysterectomy

Head‐to‐head comparisons of antibiotics for prophylaxis in elective abdominal hysterectomy

Population: women having elective abdominal hysterectomy
Settings: hospital
Intervention: antibiotics
Comparison: alternative antibiotics

Outcomes

Illustrative comparative risks

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Antibiotics vs alternative antibiotics

  • Total postoperative infections ‐ early and late

  • Abdominal wound infection

  • Urinary tract infection

  • Pelvic infection

  • Other serious infections

  • Postoperative fever

  • No clear evidence of differences between groups

  • cephalosporin vs penicillin (1 RCT, 220 women)

  • penicillin plus antiprotozoal vs penicillin only (2 RCT, 155 women)

⊕⊝⊝⊝
very low1,2

  • Total adverse effects

  • No data reported on adverse effects

CI: confidence interval; RCT: randomised controlled trial

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

aDowngraded two levels for very serious imprecision with very few events and wide confidence intervals
bDowngraded one level for serious risk of bias: methods were poorly reported in most studies

Background

Description of the condition

Hysterectomy is one of the most commonly performed operations, particularly in the United States, where the lifetime risk of a hysterectomy is 45% (Merrill 2013). Most hysterectomies are elective (non‐urgent) procedures for benign gynaecological conditions; the most common of these in the United States is leiomyoma (fibroids). Other common indications include endometriosis, heavy menstrual bleeding, and uterovaginal prolapse. This surgery can be performed abdominally, laparoscopically, or vaginally, with or without laparoscopic assistance (Farquhar 2002). The incidence of postoperative infection after hysterectomy was found to be 2% in a recent large cohort from the United States, in which women had surgery between 2012 and 2015 (Upall 2016). In older cohorts, this percentage is likely to be higher owing to factors such as longer hospital stay and prolonged postoperative urinary catheterisation. Some types of hysterectomy may be more susceptible to infectious complications than others, depending on the extent of the breach in body tissues and in the genital tract.

Even with the best surgical and postoperative care, hysterectomy is unavoidably associated with high risk of infection because the procedure breaches the genital tract ‐ an area commonly colonised by a wide variety and large numbers of micro‐organisms. In addition, most women undergoing hysterectomy require an indwelling urinary catheter for the first 24 hours, which increases the risk of urinary tract infection. Common sites of infection after hysterectomy include bladder, pelvic floor, the cuff of tissue at the top of the vagina (vaginal vault), and the abdominal wound; related complications include pelvic abscess, infected haematoma (accumulation of blood from the wound), septicaemia (infection of the blood), and pneumonia (Duff 1980; Faro 2001). Such infections are usually caused by a mixture of bacteria from the woman's own vaginal or urethral tissues ‐ both Gram‐positive and Gram‐negative, and both aerobic and anaerobic (these terms refer to the staining techniques used in identification, and whether the bacteria are oxygen dependent). The individual woman's susceptibility to infection depends upon the effectiveness of her immune system, the virulence of the bacteria present, and the extent of tissue trauma and fluid collection resulting from surgery (Duff 1980).

Description of the intervention

"Antibiotic prophylaxis" refers to administration of antibiotics to prevent infection: It has been used in surgery since antibiotics were introduced in the 1950s, in an attempt to reduce the rate of postoperative infection. Such infection not only causes patient morbidity but may result in additional costs, extended hospital stay, and increased antibiotic use, which promotes the emergence of antimicrobial resistant organisms (Dellinger 1994). Antibiotic prophylaxis for hysterectomy has been extensively studied, and it has been estimated that such prophylaxis has reduced the rate of postoperative infection by more than half; otherwise, about 40% to 50% of women would develop infection after vaginal hysterectomy, and more than 20% after abdominal hysterectomy (Duff 1980; Mittendorf 1993). National guidelines now recommend this practice for all types of hysterectomy (ACOG 2009; Bratzler 2013; Dellinger 1994; Nelson 2016; RCOG 1999; SIGN 2008; Van Eyk N, van Schalkwyk J 2012), although in reality, application of such guidelines is variable (Gorecki 1999).

Although various antibiotic regimens and routes of delivery have been used, the most frequent current practice consists of a single dose of antibiotic given intravenously within two hours of the surgical incision, to facilitate optimum serum antibiotic levels during the operation (Classen 1992; DiPiro 1984; Nelson 2016). A single dose has been reported to be as effective as multiple doses, although some researchers have suggested repeat dosing if surgery is long or blood loss is high (DiPiro 1986; Tanos 1994). If prophylaxis is continued postoperatively, it is recommended that the duration of therapy should not exceed 24 hours (Dellinger 1994).

The type of antibiotic most commonly used is active against a wide range of bacteria (broad spectrum); this type includes amoxicillin/clavulanic acid (Augmentin) or a cephalosporin. Cephalosporins are grouped into generations according to their antimicrobial properties, with the oldest type referred to as "first generation". Subsequent generations of these drugs have progressively widened their antibacterial coverage against Gram‐negative organisms while showing a concurrent reduction in effectiveness against Gram‐positive organisms; moreover, wide use of very broad‐spectrum antibiotics greatly increases the risk of emergence of drug‐resistant bacteria (BNF 2002). It is generally recommended that first‐ or second‐generation cephalosporins should be used for prophylaxis, as they appear to be equally effective for this purpose, less expensive than other treatments, and less likely to favour drug resistance (Fukatsu 1997; Tanos 1994; Weed 2003).

How the intervention might work

Prophylaxis works by briefly bolstering tissue defence mechanisms to promote rapid restoration of normal immune responses after the trauma of surgery.

Why it is important to do this review

A very large body of evidence on prophylactic antibiotics for hysterectomy involves hundreds of clinical trials. However, review authors have not systematically assessed this evidence in recent times. Existing meta‐analyses conducted some years back focused mainly on abdominal hysterectomy. No meta‐analysis has focused on trials involving other routes of hysterectomy.

Several Cochrane reviews of prophylactic antibiotics for elective surgery have reported mixed findings. Two of these examined the topic of caesarean section (Gyte 2014; Nabhan 2016). Gyte 2014 evaluated different classes of prophylactic antibiotics for women undergoing caesarean section and found that cephalosporins and penicillins had similar efficacy for preventing immediate postoperative infection. Investigators provided no data on late infection, nor on outcomes for the baby. Nabhan 2016 compared routes of administration of prophylactic antibiotics and concluded that data show no clear difference between irrigation and intravenous routes in rates of post‐caesarean endometritis. A review on elective endoscopic retrograde cholangiopancreatography (Brand 2010) reported that antibiotic prophylaxis appeared to reduce rates of bacteraemia, cholangitis, and septicaemia. A review of different regimens of antibiotic prophylaxis for people undergoing orthognathic surgery (Brignardello‐Petersen 2015) found that long‐term antibiotic prophylaxis decreased the risk of skin and skin structure infection compared with short‐term prophylaxis, but comparisons between short‐term prophylaxis and a single preoperative dose were inconclusive. Reviews of antibiotic prophylaxis for elective open inguinal hernia repair (Sanchez‐Manuel 2012) or for elective laparoscopic cholecystectomy (Sanabria 2010) provided no clear evidence of benefit for the intervention group.

Objectives

To determine the effectiveness and safety of antibiotic prophylaxis in women undergoing elective hysterectomy.

Methods

Criteria for considering studies for this review

Types of studies

Randomised, controlled trials (RCTs) of women having an elective total or subtotal hysterectomy by any route and comparing prophylactic antibiotics versus placebo or versus a different type, route, or timing of antibiotic. Trials were at least double‐blinded (i.e. with participants and clinicians blinded). We did not include quasi‐randomised trials (e.g. trials that allocated treatment by date of birth, day of the week, medical record number, month of the year, or the order in which participants were enrolled in the study).

We excluded from the review studies that did not analyse at least 80% of women randomised for at least one outcome. When trials analysed at least 80% of participants for some outcomes but analysed less than 80% of participants for other outcomes, we included only those outcomes analysed for at least 80% of participants. The rationale for excluding trials with high numbers of withdrawals is that attrition was unlikely to be equally distributed between trial arms: Women who did not develop infection were more likely to be lost to follow‐up than those who did develop infection.

Types of participants

Women of any age without serious comorbidity (such as cancer) undergoing an elective total or subtotal abdominal, vaginal, laparoscopic, or laparoscopically assisted hysterectomy, with or without oophorectomy, for a benign gynaecological condition such as fibroids, endometriosis, uterovaginal prolapse, or heavy menstrual bleeding.

Types of interventions

Prophylactic antibiotics versus placebo or a different type or regimen of antibiotics.

The term "prophylactic" was defined as follows. Prophylactic: antibiotic(s) given when an individual had no signs or symptoms of infection, when no antibiotics had been taken within the previous 48 hours, and when the first dose was given up to 12 hours preoperatively and the last dose was given not more than 24 hours postoperatively.

Types of antibiotics

Antibiotics were classified into the following types.

  1. Cephalosporins.

    1. First‐generation (e.g. cefazolin, cephradine, cephazolin, cephalexin, cefadroxil).

    2. Second‐generation (e.g. cefoxitin, cefuroxime, cephamandole, cefaclor, cefprozil, loracarbef).

    3. Third‐generation (e.g. cefotaxime, cefotetan, ceftazidime, ceftriaxone, cefixime, cefpodoxime proxetil, ceftibuten, cefdinir, cephoperazone, ceftizoxime).

    4. Fourth‐generation (e.g. cefepime).

  2. Penicillins (e.g. penicillin, amoxicillin).

  3. Macrolides (e.g. erythromycin, clarithromycin, azithromycin).

  4. Fluoroquinolones (e.g. ciprofloxacin, levofloxacin, oxfloxacin).

  5. Sulfonamides (e.g. co‐trimoxazole, trimethoprim).

  6. Tetracyclines (e.g. tetracycline, doxycycline).

  7. Aminogylocosides (e.g. gentamycin, tobramycin).

  8. Glycopeptides (e.g. vancomycin).

  9. Antiprotozoals (e.g. metronidazole, anitroimidazole).

  10. Combination drugs.

    1. Augmentin (amoxicillin and clavulanic acid).

    2. Other combinations of drugs (will be considered individually).

Antibiotic regimens include the following.

  1. Route: Any systemic regimen was included, irrespective of the route of administration (e.g. intravenous, intramuscular, oral, rectal).

  2. Number of doses (e.g. single vs repeated doses).

Types of outcome measures

We considered trials if they reported any of the following clinical outcomes.

Primary outcomes

  1. Infection: measured as the proportion of women who within eight weeks of surgery developed one of the following as defined by the study.

    1. Total postoperative infection.

    2. Abdominal wound infection (e.g. wound cellulitis, abscess, dehiscence).

    3. Pelvic infection (including vaginal cuff (vault) infection, pelvic inflammatory disease, pelvic abscess, infected haematoma).

    4. Urinary tract infection.

    5. Other serious infection or infectious complication, such as septicaemia, septic shock, distant infection (e.g. pneumonia).

  2. Postoperative fever of > 38° on at least two occasions more than four hours apart, excluding the day of surgery.

  3. Total adverse effects: morbidity (e.g. allergic reaction, diarrhoea, bacterial resistance, or as defined by the study) and mortality (infection‐related and all‐cause).

We classified primary outcomes as early (before discharge from hospital or within seven days of surgery), late (at follow‐up: within eight weeks of surgery), or total (early + late).

Secondary outcomes

  1. Need for therapeutic antibiotics ‐ early (before discharge from hospital or within seven days of surgery), late (at follow‐up: within eight weeks of surgery), or total (early + late).

  2. Length of hospital stay.

  3. Quality of life.

Search methods for identification of studies

In consultation with the Gynaecology and Fertility Group Information Specialist, we searched the following databases for all published and unpublished RCTs.

Electronic searches

We searched the following electronic databases, trial registers, and websites up to 29 November 2016.

  1. Gynaecology and Fertility Group (CGF) Specialised Register of Controlled Trials.

  2. Cochrane Central Register of Studies Online (CRSO).

  3. MEDLINE.

  4. Embase.

  5. PsycINFO.

  6. Cumulative Index to Nursing Allied Health and Literature (CINAHL).

    1. We combined the MEDLINE search with the Cochrane highly sensitive search strategy for identifying randomised trials, which appears in the Cochrane Handbook for Systematic Reviews of Interventions (Version 5.0.2, Chapter 6, 6.4.11). We combined Embase, PsycINFO, and CINAHL searches using trial filters developed by the Scottish Intercollegiate Guidelines Network (SIGN) (http://www.sign.ac.uk/methodology/filters.html#random).

  7. Other electronic sources of trials included:

    1. trial registers for ongoing and registered trials;

    2. http://www.clinicaltrials.gov (a service of the US National Institutes of Health);

    3. http://www.who.int/trialsearch/Default.aspx (World Health Organization International Clinical Trials Registry Platform search portal) (Note: it is now mandatory for Cochrane reviews to include searches of trial registers);

    4. DARE (Database of Abstracts of Reviews of Effects) in the Cochrane Library (http://onlinelibrary.wiley.com/o/cochrane/cochrane_cldare_articles_fs.html) (for reference lists from relevant non‐Cochrane reviews);

    5. Web of Knowledge (http://wokinfo.com/ ‐ another source of trials and conference abstracts);

    6. OpenGrey (http://www.opengrey.eu/ ‐ for unpublished literature from Europe);

    7. Latin American Caribbean Health Sciences Literature (LILACS database) (http://regional.bvsalud.org/php/index.php?lang=en ‐ for trials from the Portuguese‐ and Spanish‐speaking world); and

    8. PubMed and Google Scholar (for recent trials not yet indexed in MEDLINE).

For details of search strategies, see Appendix 1,Appendix 2,Appendix 3,Appendix 4,Appendix 5, and Appendix 6.

Searching other resources

We handsearched the reference lists of articles retrieved by the search and contacted experts in the field to request additional data. We also handsearched relevant journals and conference abstracts not included in the CGF register, in liaison with the Information Specialist from the CGF Group.

Data collection and analysis

Selection of studies

After an initial screen of titles and abstracts retrieved by the search, we retrieved the full texts of all potentially eligible studies. At least two review authors (of VJ, JM, and RA) independently examined these full‐text articles for compliance with the inclusion criteria and selected studies that were eligible for inclusion in the review. We contacted study investigators as required to clarify study eligibility. We resolved disagreements regarding study eligibility by discussion or by consultation with a third review author. We documented the selection process using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) flow chart.

Data extraction and management

Two review authors independently extracted data from eligible studies using a data extraction form that they had designed and pilot‐tested. We resolved disagreements by discussion or by consultation with a third review author. Data extracted included study characteristics and outcome data. When studies had multiple publications, review authors collated multiple reports of the same study, so that each study rather than each report was the unit of interest in the review, and assigned such studies a single study ID with multiple references.

We contacted study investigators to request additional data on methods and/or results, as required.

Assessment of risk of bias in included studies

Two review authors independently examined included studies for risk of bias using the Cochrane "Risk of bias" assessment tool (Higgins 2011) to assess selection (random sequence generation and allocation concealment); performance (blinding of participants and personnel); detection (blinding of outcome assessors); attrition (incomplete outcome data); reporting (selective reporting); and other bias such as differences in demographic characteristics of participants. We took care to search for within‐trial selective reporting, as seen in trials failing to report obvious outcomes, or reporting them in insufficient detail to allow inclusion. We sought published protocols and compared outcomes between the protocol and the final published study.

We resolved disagreements by discussion or by consultation with a third review author. We described all judgements fully and presented conclusions in the "Risk of bias" table; we incorporated these into the interpretation of review findings by performing sensitivity analyses (see below).

Measures of treatment effect

For dichotomous data (e.g. infection rates), we used numbers of events in control and intervention groups of each study to calculate risk ratios (RRs). For continuous data (e.g. length of hospital stay), when studies reported exactly the same outcomes, we calculated mean differences (MDs) between treatment groups. We reversed the direction of effect of individual studies, if required, to ensure consistency across trials. We intended to treat ordinal data (e.g. quality of life scores) as continuous data if any included studies reported ordinal data. We presented 95% confidence intervals (CIs) for all outcomes. We compared the magnitude and direction of effects reported by studies versus how they were presented in the review, while taking account of legitimate differences.

Unit of analysis issues

The primary analysis was per woman randomised.

Dealing with missing data

We analysed the data on an intention‐to‐treat basis as far as possible and attempted to obtain missing data from the original trialists. When these were unobtainable, we analysed only available data.

When studies reported sufficient detail for calculation of mean differences but no information on associated standard deviation (SD), we assumed the outcome to have a standard deviation equal to the highest SD from other studies within the same analysis.

Assessment of heterogeneity

We considered whether clinical and methodological characteristics of included studies were sufficiently similar for meta‐analysis to provide a clinically meaningful summary. We assessed statistical heterogeneity by using the I2 measurement. We took an I2 measurement greater than 50% to indicate substantial heterogeneity (Higgins 2003; Higgins 2011).

Assessment of reporting biases

In view of the difficulty of detecting and correcting for publication bias and other reporting biases, review authors aimed to minimise their potential impact by ensuring a comprehensive search for eligible studies and by staying alert for duplication of data. When we included 10 or more studies in an analysis, we used a funnel plot to explore the possibility of small‐study effects (the tendency for estimates of the intervention effect to be more beneficial in smaller studies).

Data synthesis

When studies were sufficiently similar, we combined the data using a fixed‐effect model.

We graphically displayed an increase in risk of a particular outcome within meta‐analyses to the right of the centre‐line, and a decrease in risk of a particular outcome to the left of the centre‐line.

We made the following comparisons.

  1. Any antibiotic versus placebo.

  2. Specific antibiotics versus placebo.

  3. Head‐to‐head comparisons of antibiotics.

  4. Comparisons of antibiotic regimens.

We subgrouped all analyses by surgical route: vaginal or abdominal. We did not pool these subgroups.

Subgroup analysis and investigation of heterogeneity

We subgrouped our main analysis according to the surgical route used (vaginal or abdominal). We did not undertake other prespecified subgroup analyses.

When we detected substantial heterogeneity (I2 > 50%), we explored possible explanations by performing sensitivity analyses. We took any statistical heterogeneity into account when interpreting results, especially if we noted any variation in the direction of effect estimates.

Sensitivity analysis

When heterogeneity was substantial (I2 > 50%), we conducted sensitivity analysis by choosing a statistical model (fixed‐effect vs random‐effects) and an effect estimate (risk ratio vs odds ratio), regardless of the number of trials included in an analysis. We planned to explore other clinical or methodological differences between studies only if data showed variation in the direction of effect.

Overall quality of the body of evidence: "Summary of findings" table

We prepared two separate "Summary of findings" tables for vaginal hysterectomy and abdominal hysterectomy based on the review's main comparison, that is, any antibiotics versus placebo. We used GRADEPRO (GRADEPro GDT 2014) and Cochrane methods (Higgins 2011) and used these tables to evaluate the overall quality of the body of evidence for main review outcomes (total postoperative infections, abdominal wound infection, urinary tract infection, pelvic infection, other serious infection, postoperative fever, and total adverse effects) by applying GRADE criteria (study limitations (i.e. risk of bias), consistency of effect, imprecision, indirectness, and publication bias). Two review authors working independently made judgements about evidence quality (high, moderate, low, or very low) and resolved disagreements by discussion. We justified, documented, and incorporated our judgements into reporting of results for each outcome.

Results

Description of studies

Results of the search

The search produced a total of 940 titles and abstracts after duplicates were removed; we considered 149 full‐text articles for further assessment. Thirty‐seven trials in 42 reports met the eligibility criteria for inclusion, and we excluded 107 full‐text articles. See Characteristics of included studies and Characteristics of excluded studies tables. The PRISMA flow chart in Figure 1 illustrates the flow of literature throughout the search and assessment process.

Figure 1
PRISMA flow chart.

PRISMA flow chart.

Included studies

Study design and setting

We included 37 studies in this review (Benigno 1986; Boodt 1990; Chongsomchai 2002; Crosthwaite 1985; Davi 1985; Dhar 1993; Dhar 1993a; Duff 1982; Egarter 1988; Eron 1989; Faro 1988; Gall 1983; Hager 1989; Hedican 1976; Hemsell 1980; Hemsell 1983; Hemsell 1984; Hemsell 1985; Hemsell 1985a; Hemsell 1987; Hemsell 1989; Henriksson 1998; Holman 1978; Houang 1984; Houang 1984a; Jaffe 1985; Janssens 1982; Kauer 1990; Ledger 1973; Mathews 1977; Mathews 1979; Mendelson 1979; Polk 1980; Schepers 1981; Smith 1984; Stage 1982; Vincelette 1983).

The most recent study was Chongsomchai 2002, which was already 14 years old at the time of our search.

All included studies were parallel, double‐blinded, randomised controlled trials (RCTs). Twenty‐nine studies were two‐arm RCTs (Boodt 1990; Crosthwaite 1985; Davi 1985; Dhar 1993; Dhar 1993a; Duff 1982; Faro 1988; Gall 1983; Hager 1989; Hedican 1976; Hemsell 1980; Hemsell 1983; Hemsell 1984; Hemsell 1985a; Hemsell 1989; Henriksson 1998; Holman 1978; Houang 1984a; Jaffe 1985; Janssens 1982; Ledger 1973; Mathews 1977; Mathews 1979; Mendelson 1979; Polk 1980; Schepers 1981; Smith 1984; Stage 1982; Vincelette 1983). Eight studies were three‐arm RCTs (Benigno 1986; Chongsomchai 2002; Egarter 1988; Eron 1989; Hemsell 1985; Hemsell 1987; Houang 1984; Kauer 1990).

Seventeen studies were conducted in the United States (Benigno 1986; Duff 1982; Eron 1989; Gall 1983; Hager 1989; Hedican 1976; Hemsell 1980; Hemsell 1983; Hemsell 1984; Hemsell 1985; Hemsell 1985a; Hemsell 1987; Hemsell 1989; Holman 1978; Ledger 1973; Polk 1980; Stage 1982); five studies were conducted in the United Kingdom (Houang 1984; Houang 1984a; Mathews 1977; Mathews 1979; Smith 1984); two were conducted in Canada (Mendelson 1979; Vincelette 1983); and three in the Netherlands (Boodt 1990; Kauer 1990; Schepers 1981). Two studies each were conducted in Australia (Crosthwaite 1985; Egarter 1988) and India (Chandigarth) (Dhar 1993; Dhar 1993a); one study each was conducted in Belgium (Janssens 1982), Israel (Jaffe 1985), Sweden (Henriksson 1998), and Thailand (Chongsomchai 2002). The remaining two studies did not provide information on the countries in which they were conducted (Davi 1985; Faro 1988).

Six of the included studies were conducted at more than one centre: 14 centres (Stage 1982), four centres (Benigno 1986), three centres (Hager 1989; Henriksson 1998), and two centres (Chongsomchai 2002; Eron 1989); five studies did not report the number of centres (Davi 1985; Egarter 1988; Faro 1988; Hemsell 1985; Schepers 1981); and each of the remaining 26 studies was conducted at a single centre (Boodt 1990; Crosthwaite 1985; Dhar 1993; Dhar 1993a; Duff 1982; Gall 1983; Hedican 1976; Hemsell 1980; Hemsell 1983; Hemsell 1984; Hemsell 1985a; Hemsell 1987; Hemsell 1989; Holman 1978; Houang 1984; Houang 1984a; Jaffe 1985; Janssens 1982; Kauer 1990; Ledger 1973; Mathews 1977; Mathews 1979; Mendelson 1979; Polk 1980; Smith 1984; Vincelette 1983).

Participants

The 37 included studies enrolled a total of 6079 women. Seventeen studies randomised or analysed a total of 100 or fewer women (Crosthwaite 1985; Dhar 1993; Dhar 1993a; Duff 1982; Gall 1983; Hager 1989; Hedican 1976; Hemsell 1980; Hemsell 1985a; Houang 1984a; Jaffe 1985; Kauer 1990; Ledger 1973; Mathews 1977; Mathews 1979; Mendelson 1979; Smith 1984); eight studies randomised or analysed a total of 101 to 200 women (Egarter 1988; Faro 1988; Hemsell 1983; Hemsell 1984; Hemsell 1985; Janssens 1982; Schepers 1981; Vincelette 1983); five studies randomised or analysed a total of 201 to 300 women (Eron 1989; Hemsell 1987; Hemsell 1989; Holman 1978; Stage 1982); five studies randomised or analysed a total of 301 to 400 women (Benigno 1986; Chongsomchai 2002; Davi 1985; Henriksson 1998; Houang 1984); one study randomised a total of 403 women (Boodt 1990); and another randomised a total of 557 women (Polk 1980).

A common inclusion criterion was that women had to be scheduled for elective abdominal hysterectomy, vaginal hysterectomy, or both types of hysterectomy for a benign condition. Thirteeen studies included women scheduled for abdominal hysterectomy (Boodt 1990; Chongsomchai 2002; Davi 1985; Dhar 1993a; Duff 1982; Gall 1983; Hemsell 1983; Hemsell 1985; Houang 1984a; Jaffe 1985; Mathews 1977; Schepers 1981; Smith 1984); 14 studies included women scheduled for elective vaginal hysterectomy (Benigno 1986; Dhar 1993; Egarter 1988; Faro 1988; Hager 1989; Hedican 1976; Hemsell 1980; Hemsell 1984; Hemsell 1985a; Hemsell 1987; Kauer 1990; Ledger 1973; Mathews 1979; Mendelson 1979); nine studies included women scheduled for either abdominal or vaginal hysterectomy (Crosthwaite 1985; Eron 1989; Hemsell 1989; Holman 1978; Houang 1984; Janssens 1982; Polk 1980; Stage 1982; Vincelette 1983); and one study did not report the type of hysterectomy for which women were scheduled (Henriksson 1998).

No included studies focused on antibiotic prophylaxis in participants undergoing laparoscopically performed hysterectomy.

Common exclusion criteria were emergency hysterectomy; pregnancy‐related hysterectomy; hypersensitivity to antibiotics such as cephalosporin, penicillin, amoxicillin, etc.; and use of antibiotics within two to seven days before surgery.

Interventions

Included studies compared different classes of antibiotics with placebo or with each other. Included studies identified the following treatment groups.

  1. Any antibiotic versus placebo (Boodt 1990; Chongsomchai 2002; Crosthwaite 1985; Davi 1985; Dhar 1993; Dhar 1993a; Duff 1982; Egarter 1988; Gall 1983; Hedican 1976; Hemsell 1980; Hemsell 1983; Henriksson 1998; Holman 1978; Houang 1984; Jaffe 1985; Janssens 1982; Ledger 1973; Mathews 1977; Mathews 1979; Mendelson 1979; Polk 1980; Smith 1984; Vincelette 1983).

  2. Cephalosporin versus placebo (Chongsomchai 2002; Davi 1985; Duff 1982; Gall 1983; Hedican 1976; Hemsell 1980; Hemsell 1983; Holman 1978; Ledger 1973; Mendelson 1979; Polk 1980; Stage 1982).

  3. Penicillin versus placebo (Chongsomchai 2002; Houang 1984).

  4. Antiprotozoal versus placebo (Crosthwaite 1985; Dhar 1993; Dhar 1993a; Egarter 1988; Hemsell 1983; Henriksson 1998; Janssens 1982; Vincelette 1983).

  5. Sulphonamides versus placebo (Jaffe 1985; Mathews 1977; Mathews 1979; Smith 1984).

  6. Cephalosporin plus antiprotozoal versus placebo (Boodt 1990).

  7. Penicillin plus antiprotozoal versus placebo (Houang 1984).

  8. Lincosamide versus placebo (Egarter 1988).

  9. Cephalosporin versus penicillin (Benigno 1986; Chongsomchai 2002; Faro 1988; Hager 1989).

  10. Cephalosporin versus tetracycline (Hemsell 1985a).

  11. Cephalosporin versus antiprotozoal (Kauer 1990).

  12. Antiprotozoal versus lincosamide (Egarter 1988).

  13. Cephalosporin plus antiprotozoal versus cephalosporin only (Kauer 1990).

  14. Cephalosporin plus antiprotozoal versus antiprotozoal only (Kauer 1990).

  15. Penicillin plus antiprotozoal versus penicillin only (Houang 1984; Houang 1984a).

  16. Cephalosporin early administration versus usual timing (both single dose) (Eron 1989).

  17. Cephalosporin one dose versus two doses (Hemsell 1985).

  18. Cephalosporin one dose versus three doses (Hemsell 1984; Hemsell 1985).

  19. Cephalosporin one dose versus multiple doses (Mendelson 1979).

  20. Cephalosporin one gram versus two grams (Hemsell 1987).

Included studies administered antibiotics through the following routes.

  1. Intravenous (IV) (Benigno 1986; Boodt 1990; Chongsomchai 2002; Duff 1982; Egarter 1988; Faro 1988; Gall 1983; Hager 1989; Hemsell 1985; Hemsell 1985a; Hemsell 1989; Henriksson 1998; Jaffe 1985; Kauer 1990; Mathews 1979; Mendelson 1979; Polk 1980; Schepers 1981; Stage 1982; Vincelette 1983).

  2. Intramuscular (IM) (Davi 1985; Hemsell 1980; Hemsell 1983; Hemsell 1987; Smith 1984).

  3. IV and IM (Eron 1989; Hedican 1976; Hemsell 1984; Holman 1978).

  4. Oral (Crosthwaite 1985; Dhar 1993; Dhar 1993a; Janssens 1982).

  5. IV and rectal (Houang 1984; Houang 1984a).

One of the included studies did not state the route used for administration of antibiotics (Ledger 1973).

Investigators administered antibiotics as a single dose, as multiple doses, or as single versus multiple doses in the following studies.

  1. Single dose (Boodt 1990; Chongsomchai 2002; Crosthwaite 1985; Dhar 1993; Dhar 1993a; Duff 1982; Hager 1989; Hemsell 1987; Janssens 1982; Ledger 1973; Mathews 1977; Mathews 1979).

  2. Multiple doses (Boodt 1990; Davi 1985; Egarter 1988; Faro 1988; Gall 1983; Hedican 1976; Hemsell 1980; Hemsell 1983; Hemsell 1984; Henriksson 1998; Holman 1978; Houang 1984; Houang 1984a; Ledger 1973; Polk 1980; Schepers 1981; Stage 1982; Vincelette 1983).

  3. Single dose versus multiple doses (Eron 1989; Hemsell 1985; Hemsell 1985a; Hemsell 1989; Janssens 1982; Mendelson 1979).

Timing and duration of administration varied in the included studies. However, none of the included studies administered the first dose of antibiotics more than 12 hours before surgery and the last dose more than 24 hours after surgery.

Outcomes

Primary outcome measures of this review were presence of postoperative infection (total postoperative infections, abdominal wound infection, pelvic infection, urinary tract infection (UTI), other serious infection (such as pneumonia, septicaemia, septic shock), and postoperative fever), total adverse effects such as morbidity (e.g. diarrhoea, allergic reactions), and mortality. Thirty‐six included studies reported data on at least one of the review's primary outcome measures (Benigno 1986; Boodt 1990; Chongsomchai 2002; Crosthwaite 1985; Davi 1985; Dhar 1993; Dhar 1993a; Duff 1982; Egarter 1988; Eron 1989; Faro 1988; Gall 1983; Hager 1989; Hedican 1976; Hemsell 1980; Hemsell 1983; Hemsell 1984; Hemsell 1985; Hemsell 1985a; Hemsell 1987; Hemsell 1989; Henriksson 1998; Holman 1978; Houang 1984; Houang 1984a; Jaffe 1985; Janssens 1982; Kauer 1990; Ledger 1973; Mathews 1977; Mathews 1979; Polk 1980; Schepers 1981; Smith 1984; Stage 1982; Vincelette 1983); and one of the included studies did not report data on any of the review's primary outcomes (Mendelson 1979). Twenty‐five included studies reported data on adverse effects, most in narrative form (Benigno 1986; Chongsomchai 2002; Crosthwaite 1985; Davi 1985; Dhar 1993; Dhar 1993a; Duff 1982; Eron 1989; Gall 1983; Hager 1989; Hemsell 1980; Hemsell 1984; Hemsell 1985a; Hemsell 1987; Hemsell 1989; Henriksson 1998; Jaffe 1985; Kauer 1990; Mathews 1977; Mathews 1979; Polk 1980; Schepers 1981; Smith 1984; Stage 1982; Vincelette 1983). Common adverse effects included allergy reactions and diarrhoea. None of the included studies reported any incident of mortality.

Secondary outcome measures included any requirement for therapeutic antibiotics, length of hospital stay, and quality of life following surgery. Twenty‐seven included studies reported on at least one of the secondary outcome measures (Benigno 1986; Boodt 1990; Chongsomchai 2002; Dhar 1993; Dhar 1993a; Duff 1982; Egarter 1988; Eron 1989; Faro 1988; Gall 1983; Hager 1989; Hemsell 1980; Hemsell 1983; Hemsell 1984; Hemsell 1985; Hemsell 1985a; Hemsell 1987; Hemsell 1989; Holman 1978; Jaffe 1985; Kauer 1990; Ledger 1973; Mathews 1977; Mathews 1979; Polk 1980; Stage 1982; Vincelette 1983). Secondary outcome measures commonly reported were need for therapeutic antibiotics and length of hospital stay; no studies provided data on quality of life. The remaining 10 studies did not report on any of the secondary outcome measures (Crosthwaite 1985; Davi 1985; Hedican 1976; Henriksson 1998; Houang 1984; Houang 1984a; Janssens 1982; Mendelson 1979; Schepers 1981; Smith 1984).

Excluded studies

Review authors determined that 107 studies were not eligible for inclusion in this review. Common reasons for exclusion were administration of antibiotics more than 12 hours before surgery or for more than 24 hours after surgery and non‐blinding of participants and personnel. For further details on reasons for exclusion of studies, see Characteristics of excluded studies table.

Risk of bias in included studies

See Figure 2 and Figure 3.

Figure 2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Allocation

Random sequence generation

We considered processes used in sequence generation to be adequate in 10 of the included studies because they involved the use of computers (Benigno 1986; Chongsomchai 2002; Faro 1988; Hemsell 1984; Hemsell 1987; Hemsell 1989) or random number tables (Hemsell 1983; Holman 1978; Kauer 1990; Ledger 1973). We therefore rated these studies as having low risk of bias with respect to random sequence generation. The remaining 27 studies provided insufficient information to permit conclusive judgements on the process involved in sequence generation; thus we rated them as having unclear risk of bias.

Allocation concealment

We rated 17 studies as having low risk of bias with respect to allocation concealment (Benigno 1986; Chongsomchai 2002; Dhar 1993a; Duff 1982; Hager 1989; Hedican 1976; Hemsell 1980; Hemsell 1983; Hemsell 1987; Henriksson 1998; Holman 1978; Kauer 1990; Ledger 1973; Mathews 1977; Mathews 1979; Smith 1984; Stage 1982). We considered the processes involved in concealing allocations in these studies to be adequate; these included remote or central allocation through the hospital pharmacy and use of sealed opaque envelopes. We assessed the remaining 20 studies as having unclear risk because information was insufficient to allow conclusive judgements with respect to allocation concealment.

Blinding

We considered that blinding was likely to influence findings for both primary and secondary review outcomes. Although we considered all included studies to be adequate with regard to blinding of both participants and physicians, most did not provide adequate information on how participants were evaluated postoperatively. Only 16 studies reported sufficient information on outcome assessment and/or participant follow‐up; we thus rated these studies as having low risk with respect to performance and detection bias (Benigno 1986; Boodt 1990; Chongsomchai 2002; Eron 1989; Hemsell 1980; Hemsell 1983; Hemsell 1985a; Henriksson 1998; Holman 1978; Houang 1984; Houang 1984a; Janssens 1982; Kauer 1990; Ledger 1973; Polk 1980; Stage 1982). The remaining 21 studies did not provide sufficient information on whether outcome assessors were blinded; we therefore rated these studies as having unclear risk with respect to performance and detection bias (Crosthwaite 1985; Davi 1985; Dhar 1993; Dhar 1993a; Duff 1982; Egarter 1988; Faro 1988; Gall 1983; Hager 1989; Hedican 1976; Hemsell 1984; Hemsell 1985; Hemsell 1987; Hemsell 1989; Jaffe 1985; Mathews 1977; Mathews 1979; Mendelson 1979; Schepers 1981; Smith 1984; Vincelette 1983).

Incomplete outcome data

We judged 16 studies as having low risk with respect to incomplete outcome data or attrition bias (Chongsomchai 2002; Dhar 1993; Dhar 1993a; Duff 1982; Egarter 1988; Hager 1989; Hemsell 1985a; Hemsell 1987; Henriksson 1998; Kauer 1990; Ledger 1973; Mathews 1977; Polk 1980; Smith 1984; Stage 1982; Vincelette 1983). Proportions of withdrawals/losses to follow‐up and reasons for withdrawal in these studies were fairly well balanced or similar across treatment groups, or outcome data were analysed on an intention‐to‐treat (ITT) basis by including all randomised women in data analyses. Nineteen studies provided insufficient information on the number of withdrawals/losses to follow‐up and/or on reasons for withdrawal, and data were not analysed on the basis of ITT (Benigno 1986; Boodt 1990; Crosthwaite 1985; Davi 1985; Faro 1988; Gall 1983; Hedican 1976; Hemsell 1980; Hemsell 1983; Hemsell 1984; Hemsell 1985; Hemsell 1989; Houang 1984a; Janssens 1982; Mathews 1979; Mendelson 1979; Schepers 1981). We thus rated these studies as having unclear risk with respect to attrition bias. We rated the remaining two studies as having high risk of bias: In one of these studies, proportions of withdrawals were not balanced between groups and data were not analysed on the basis of ITT (Eron 1989); in the other study, proportions of withdrawals and reasons for withdrawal were not balanced across treatment groups (Jaffe 1985).

Selective reporting

Protocols were not available for any of the included studies, and review authors could not determine whether outcomes were selectively reported. Therefore, the process of detecting selective reporting bias in included studies involved careful assessment of methods sections to determine which outcomes were prespecified and whether data were reported on all prespecified outcomes. Thirteen studies provided data on all outcomes prespecified in the methods sections; we rated these as having low risk with respect to selective reporting (within‐trial selective reporting) (Benigno 1986; Chongsomchai 2002; Duff 1982; Hager 1989; Hemsell 1980; Henriksson 1998; Jaffe 1985; Mathews 1977; Mathews 1979; Polk 1980; Smith 1984; Stage 1982; Vincelette 1983). Twenty‐three studies provided insufficient information to allow conclusive judgements with respect to selective reporting; therefore, we rated these studies as having unclear risk of selective reporting bias (Boodt 1990; Crosthwaite 1985; Davi 1985; Dhar 1993; Dhar 1993a; Egarter 1988; Eron 1989; Faro 1988; Gall 1983; Hedican 1976; Hemsell 1983; Hemsell 1984; Hemsell 1985; Hemsell 1985a; Hemsell 1987; Hemsell 1989; Holman 1978; Houang 1984; Houang 1984a; Janssens 1982; Kauer 1990; Ledger 1973; Mendelson 1979). We rated the only remaining study as having high risk of selective reporting because evidence showed selective reporting, with no data reported on some of the outcomes prespecified in the methods section (Schepers 1981).

Other potential sources of bias

We assessed other potential sources of bias with respect to whether data showed significant differences between treatment groups in terms of baseline demographic characteristics of participants, such as age and body mass index (BMI). In 28 studies, baseline demographic characteristics were similar between treatment groups; thus we rated these studies as having low risk with respect to other potential sources of bias (Boodt 1990; Chongsomchai 2002; Crosthwaite 1985; Dhar 1993; Dhar 1993a; Duff 1982; Egarter 1988; Eron 1989; Gall 1983; Hager 1989; Hemsell 1980; Hemsell 1983; Hemsell 1984; Hemsell 1987; Henriksson 1998; Holman 1978; Houang 1984; Houang 1984a; Jaffe 1985; Kauer 1990; Ledger 1973; Mathews 1977; Mathews 1979; Mendelson 1979; Polk 1980; Smith 1984; Stage 1982; Vincelette 1983). The remaining nine studies provided insufficient information to allow conclusive judgements with respect to whether significant differences in baseline demographic characteristics were evident between treatment groups; we thus rated these studies as having unclear risk with respect to other sources of bias (Benigno 1986; Davi 1985; Faro 1988; Hedican 1976; Hemsell 1985; Hemsell 1985a; Hemsell 1989; Janssens 1982; Schepers 1981).

Effects of interventions

See: Summary of findings for the main comparison Antibiotics compared with placebo for prophylaxis in elective vaginal hysterectomy; Summary of findings 2 Antibiotics compared with placebo for prophylaxis in elective abdominal hysterectomy; Summary of findings 3 Head‐to‐head comparisons of antibiotics for prophylaxis in elective vaginal hysterectomy; Summary of findings 4 Head‐to‐head comparisons of antibiotics for prophylaxis in elective abdominal hysterectomy

1. Any antibiotics versus placebo

Primary outcomes
1.1 Total postoperative infections ‐ early and late

See Analysis 1.1; Figure 4

Figure 4
Forest plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.1 Total postoperative infections ‐ early and late.

Forest plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.1 Total postoperative infections ‐ early and late.

1.1.1 Vaginal hysterectomy

The rate of postoperative infection (early or late) was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.28, 95% CI 0.19 to 0.40; four RCTs, N = 293; I2 = 85%; low‐quality evidence; Analysis 1.1). Evidence suggests that if the average risk of infection with placebo is assumed to be 62%, the risk following antibiotic prophylaxis would be between 12% and 25%. Although heterogeneity for this comparison was substantial (I2 = 85%), we did not downgrade the quality of evidence for inconsistency because the direction of effect was consistent and all inconsistency was attributable to Ledger 1973, which measured only early postoperative infection rates (to hospital discharge). The other three studies in this comparison measured both early and late infections.

On sensitivity analysis, observed evidence of a difference in the incidence of total postoperative infections between the two groups remained whether odds ratio (OR) (OR 0.13, 95% CI 0.08 to 0.23) or a random‐effects (RE) model (RR 0.19, 95% CI 0.06 to 0.67) was used.

1.1.2 Abdominal hysterectomy

The rate of postoperative infection was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.38, 95% CI 0.21 to 0.67; one RCT, N = 158; low‐quality evidence; Analysis 1.1). Evidence suggests that if the average risk of infection with placebo is assumed to be 39%, risk following antibiotic prophylaxis would be between 8% and 26%.

1.2 Abdominal wound infection

1.2.1 Abdominal hysterectomy

The rate of abdominal wound infection in women who received prophylactic antibiotics was lower than in those given placebo (RR 0.51, 95% CI 0.36 to 0.73; 11 RCTs, N = 2247; I2 = 6%; moderate‐quality evidence; Analysis 1.2). Evidence suggests that if the average risk of infection with placebo is assumed to be 7%, risk following antibiotic prophylaxis would be between 2% and 5%.

1.3 Urinary tract infection

1.3.1 Vaginal hysterectomy

The rate of urinary tract infection (UTI) in women who received prophylactic antibiotics was lower than in those given placebo (RR 0.58, 95% CI 0.43 to 0.77; eight RCTs, N = 1473; I2 = 44%; moderate‐quality evidence; Analysis 1.3). Evidence suggests that if the average risk of infection with placebo is assumed to be 13%, risk following antibiotic prophylaxis would be between 6% and 10%.

1.3.2 Abdominal hysterectomy

The rate of UTI was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.41, 95% CI 0.31 to 0.53; 11 RCTs, N = 2705; I2 = 28%; moderate‐quality evidence; Analysis 1.3). Evidence suggests that if the average risk of infection with placebo is assumed to be 13%, risk following antibiotic prophylaxis would be between 4% and 7%.

1.4 Pelvic infection

1.4.1 Vaginal hysterectomy

The rate of pelvic infection in women who received prophylactic antibiotics was lower than in those given placebo (RR 0.28, 95% CI 0.20 to 0.39; 11 RCTs, N = 1693; I2 = 57%; moderate‐quality evidence; Analysis 1.4). Evidence suggests that if the average risk of infection with placebo is assumed to be 13%, risk following antibiotic prophylaxis would be between 3% and 5%. Heterogeneity for this comparison was substantial (I2 = 57%), but we did not downgrade the quality of the evidence for inconsistency, as the direction of effect was consistent. Evidence of a difference in reported cases of pelvic infection persisted whether sensitivity analysis was based on OR (OR 0.17, 95% CI 0.11 to 0.27) or on an RE model (RR 0.22, 95% CI 0.11 to 0.46).

1.4.2 Abdominal hysterectomy

The rate of pelvic infection in women who received prophylactic antibiotics was lower than in those given placebo (RR 0.50, 95% CI 0.35 to 0.71; 11 RCTs, N = 1883; I2 = 11%; moderate‐quality evidence; Analysis 1.4). Evidence suggests that if the average risk of infection with placebo is assumed to be 8%, risk following antibiotic prophylaxis would be between 3% and 6%.

1.5 Other serious infection

1.5.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups in the rate of other serious infection (RR 0.20, 95% CI 0.01 to 4.10; one RCT, N = 146; very low‐quality evidence; Analysis 1.5). Evidence suggests that if the average risk of infection with placebo is assumed to be 3%, risk following antibiotic prophylaxis would be between 0% and 11%.

1.5.2 Abdominal hysterectomy

It is unclear whether data showed a difference between groups in the rate of other serious infection (RR 0.44, 95% CI 0.12 to 1.69; two RCTs, N = 476; I2 = 29%; very low‐quality evidence; Analysis 1.5). Evidence suggests that if the risk of other serious infection with placebo is assumed to be 3%, risk following antibiotic prophylaxis would be between 0% and 5%.

1.6. Postoperative fever

1.6.1 Vaginal hysterectomy

The rate of postoperative fever in women who received prophylactic antibiotics was lower than in those given placebo (RR 0.43, 95% CI 0.34 to 0.54; nine RCTs, N = 1562; I2 = 47%; moderate‐quality evidence; Analysis 1.6). Evidence suggests that if the average risk of postoperative fever with placebo is assumed to be 22%, risk following antibiotic prophylaxis would be between 7% and 12%.

1.6.2 Abdominal hysterectomy

The rate of postoperative fever in women who received prophylactic antibiotics was lower than in those given placebo (RR 0.59, 95% CI 0.50 to 0.70; 11 RCTs, N = 2394; I2 = 55%; moderate‐quality evidence; Analysis 1.6; Figure 5). Evidence suggests that if the average risk of postoperative fever with placebo is assumed to be 24%, risk following antibiotic prophylaxis would be between 12% and 17%. Heterogeneity for this comparison was substantial (I2 = 55%), but we did not downgrade the quality of the evidence for inconsistency, as the direction of effect was consistent. Evidence of a difference in reported cases of postoperative fever persisted whether sensitivity analysis was based on OR (OR 0.50, 95% CI 0.40 to 0.62) or on an RE model (RR 0.55, 95% CI 0.42 to 0.72).

Figure 5
Forest plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.6 Postoperative fever.

Forest plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.6 Postoperative fever.

1.7 Total adverse effects

See Analysis 1.7; Figure 6

Figure 6
Forest plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.7 Total adverse effects.

Forest plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.7 Total adverse effects.

1.7.1 Vaginal hysterectomy

Investigators provided no data for this outcome.

1.7.2 Abdominal hysterectomy

It is unclear whether results showed a difference between groups in the rate of total adverse effects (RR 1.80, 95% CI 0.62 to 5.18; two RCTs, N = 430; I2 = 0%; very low‐quality evidence; Analysis 1.7). Evidence suggests that if the average risk of total adverse effects with placebo is assumed to be 2%, risk following antibiotic prophylaxis would be between 1% and 12%.

Secondary outcomes
1.8 Need for therapeutic antibiotics

1.8.1 Vaginal hysterectomy

The rate of need for therapeutic antibiotics was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.51, 95% CI 0.37 to 0.68; six RCTs, N = 1309; I2 = 30%; Analysis 1.8).

1.8.2 Abdominal hysterectomy

The rate of need for therapeutic antibiotics was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.74, 95% CI 0.59 to 0.93; six RCTs, N = 1359; I2 = 34%; Analysis 1.8).

1.9 Length of hospital stay

1.9.1 Vaginal hysterectomy

Mean length of hospital stay was shorter in women who received prophylactic antibiotics than in those given placebo (MD ‐1.35 days, 95% CI ‐1.78 to ‐0.92; four RCTs, N = 853; I2 = 0%; Analysis 1.9).

1.9.2 Abdominal hysterectomy

Mean length of hospital stay was shorter in women who received prophylactic antibiotics than in those given placebo (MD ‐0.59 days, 95% CI ‐0.76 to ‐0.43; seven RCTs, N = 1510; I2 = 87%; Analysis 1.9). We explored the presence of significant heterogeneity.

2. Cephalosporin versus placebo

Primary outcomes
2.1 Total postoperative infections ‐ early and late

2.1.1 Vaginal hysterectomy

The total postoperative infection rate was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.29, 95% CI 0.20 to 0.42; three RCTs, N = 265; I2 = 89%; Analysis 2.1; Figure 7). Although heterogeneity among studies was substantial, the directions of effect estimates for individual studies were consistent. In addition, we examined the presence of heterogeneity using sensitivity analysis. The observed difference in outcomes between the two groups remained whether sensitivity analysis was based on OR (OR 0.14, 95% CI 0.08 to 0.24) or on an RE model (RR 0.19, 95% CI 0.04 to 0.88), and more cases of total postoperative infection were reported in women in the placebo group in both analyses.

Figure 7
Forest plot of comparison: 2 Cephalosporin versus placebo, outcome: 2.1 Total postoperative infections ‐ early and late.

Forest plot of comparison: 2 Cephalosporin versus placebo, outcome: 2.1 Total postoperative infections ‐ early and late.

2.2 Abdominal wound infection

2.2.1 Abdominal hysterectomy

The rate of abdominal wound infection was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.41, 95% CI 0.25 to 0.66; seven RCTs, N = 1528; I2 = 0%; Analysis 2.2).

2.3 Urinary tract infection

2.3.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups in the rate of UTI (RR 0.71, 95% CI 0.46 to 1.08; five RCTs, N = 499; I2 = 31%; Analysis 2.3).

2.3.2 Abdominal hysterectomy

The rate of UTI was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.42, 95% CI 0.31 to 0.58; six RCTs, N = 1668; I2 = 25%; Analysis 2.3).

2.4 Pelvic infection

2.4.1 Vaginal hysterectomy

The rate of pelvic infection was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.15, 95% CI 0.09 to 0.28; six RCTs, N = 1281; I2 = 8%; Analysis 2.4).

2.4.2 Abdominal hysterectomy

The rate of pelvic infection was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.60, 95% CI 0.39 to 0.93; seven RCTs, N = 1528; I2 = 3%; Analysis 2.4).

2.5 Other serious infection

2.5.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups in the rate of other serious infection (RR 0.20, 95% CI 0.01 to 4.12; one RCT, N = 206; Analysis 2.5).

2.5.2 Abdominal hysterectomy

It is unclear whether data showed a difference between groups in the rate of other serious infection (RR 0.33, 95% CI 0.04 to 3.16; one RCT, N = 220; Analysis 2.5).

2.6 Postoperative fever

2.6.1 Vaginal hysterectomy

The rate of postoperative fever was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.37, 95% CI 0.25 to 0.54; five RCTs, N = 1028; I2 = 71%; Analysis 2.6; Figure 8). Direction of effect estimates in all five studies were consistent. We investigated the presence of significant heterogeneity using sensitivity analysis. The observed difference in outcomes between the two groups persisted whether sensitivity analysis was based on OR (OR 0.29, 95% CI 0.18 to 0.47) or on an RE model (RR 0.34, 95% CI 0.15 to 0.78), and more women in the placebo group were given the diagnosis of postoperative fever.

Figure 8
Forest plot of comparison: 2 Cephalosporin versus placebo, outcome: 2.6 Postoperative fever.

Forest plot of comparison: 2 Cephalosporin versus placebo, outcome: 2.6 Postoperative fever.

2.6.2 Abdominal hysterectomy

The rate of postoperative fever was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.62, 95% CI 0.49 to 0.77; six RCTs, N = 1463; I2 = 43%; Analysis 2.6).

2.7 Total adverse effects

2.7.1 Abdominal hysterectomy

It is unclear whether results showed a difference between groups in the rate of adverse effects (RR 1.00, 95% CI 0.06 to 15.83; one RCT, N = 284; Analysis 2.7).

Secondary outcomes
2.8 Need for therapeutic antibiotics

2.8.1 Vaginal hysterectomy

The rate of need for therapeutic antibiotics in women who received prophylactic antibiotics was lower than in those given placebo (RR 0.55, 95% CI 0.37 to 0.81; three RCTs, N = 863; I2 = 36%; Analysis 2.8).

2.8.2 Abdominal hysterectomy

We found no conclusive evidence of a difference between groups in the number of women requiring therapeutic antibiotics, although data suggest benefit for the antibiotic prophylaxis group (RR 0.79, 95% CI 0.61 to 1.01; four RCTs, N = 1138; I2 = 0%; Analysis 2.8).

2.9 Length of hospital stay

2.9.1 Vaginal hysterectomy

Mean length of hospital stay was shorter in women who received prophylactic antibiotics than in those given placebo (MD ‐1.30 days, 95% CI ‐1.88 to ‐0.72; two RCTs, N = 657; I2 = 0%; Analysis 2.9).

2.9.2 Abdominal hysterectomy

Mean length of hospital stay was shorter in women who received prophylactic antibiotics than in those given placebo (MD ‐0.43 days, 95% CI ‐0.67 to ‐0.19; four RCTs, N = 818; I2 = 63%; Analysis 2.9). Four studies showed consistency in direction of effect estimates. In addition, we found evidence that a difference in length of hospital stay between the two groups persisted when we subjected the evidence to sensitivity analysis based on an RE model (MD ‐0.54, 95% CI ‐1.04 to ‐0.05), and that women in the placebo group stayed longer in hospital than those in the cephalosporin group.

3. Penicillin versus placebo

Primary outcomes
3.1 Total postoperative infections ‐ early and late

3.1.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups in the incidence of total postoperative infections (early and late) (RR 0.20, 95% CI 0.03 to 1.42; one RCT, N = 20; Analysis 3.1).

3.1.2 Abdominal hysterectomy

The total infection rate was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.30, 95% CI 0.13 to 0.70; one RCT, N = 100; Analysis 3.1).

3.2 Abdominal wound infection

3.2.1 Abdominal hysterectomy

The rate of abdominal wound infection was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.16, 95% CI 0.05 to 0.53; two RCTs, N = 320; I2 = 0%; Analysis 3.2).

3.3 Urinary tract infection

3.3.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups in the rate of UTI (RR 0.50, 95% CI 0.05 to 4.67; one RCT, N = 20; Analysis 3.3).

3.3.2 Abdominal hysterectomy

It is unclear whether results showed a difference between groups in the rate of UTI (RR 0.60, 95% CI 0.21 to 1.76; two RCTs, N = 320; I2 = 0%; Analysis 3.3).

3.4 Pelvic infection

3.4.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups in the rate of pelvic infection (RR 0.14, 95% CI 0.01 to 2.45; one RCT, N = 20; Analysis 3.4).

3.4.2 Abdominal hysterectomy

The rate of pelvic infection was lower in women who received prophylactic antibiotics than in those given placebo (RR 1.33, 95% CI 0.31 to 5.82; one RCT, N = 220; Analysis 3.4).

3.5 Other serious infection

3.5.1 Abdominal hysterectomy

It is unclear whether data showed a difference between groups in the rate of other serious infection (RR 0.14, 95% CI 0.01 to 2.73; one RCT, N = 220; Analysis 3.5).

3.6 Postoperative fever

3.6.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups in the rate of postoperative fever (RR 0.14, 95% CI 0.01 to 2.45; one RCT, N = 20; Analysis 3.6; Figure 9).

Figure 9
Forest plot of comparison: 3 Penicillin versus placebo, outcome: 3.6 Postoperative fever.

Forest plot of comparison: 3 Penicillin versus placebo, outcome: 3.6 Postoperative fever.

3.6.2 Abdominal hysterectomy

It is unclear whether data showed a difference between groups in the rate of postoperative fever (RR 0.65, 95% CI 0.35 to 1.20; two RCTs, N = 320; I2 = 82%; Analysis 3.6). Heterogeneity for this comparison was substantial (I2 = 82%) with inconsistency in the direction of effects for the two studies. Evidence of no difference in reported cases of postoperative fever persisted whether sensitivity analysis was based on OR (OR 0.61, 95% CI 0.31 to 1.22) or on an RE model (RR 0.38, 95% CI 0.03 to 4.51).

3.7 Total adverse effects

Investigators provided no data for this outcome.

Secondary outcomes
3.8 Need for therapeutic antibiotics

Investigators provided no data for this outcome.

3.9 Length of hospital stay

Investigators provided no data for this outcome.

4. Antiprotozoal versus placebo

Primary outcomes
4.1 Total postoperative infections ‐ early and late

Investigators provided no data for this outcome.

4.2 Abdominal wound infection

4.2.1 Abdominal hysterectomy

It is unclear whether results showed a difference between groups in rates of abdominal wound infection (RR 0.71, 95% CI 0.32 to 1.57; two RCTs, N = 462; I2 = 0%; Analysis 4.1).

4.3 Urinary tract infection

4.3.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups in rates of UTI (RR 1.25, 95% CI 0.51 to 3.04; one RCT, N = 226; I2 = 75%; Analysis 4.2).

4.3.2 Abdominal hysterectomy

It is unclear whether results showed a difference between groups in rates of UTI (RR 1.00, 95% CI 0.34 to 2.96; one RCT, N = 146; Analysis 4.2).

4.4 Pelvic infection

4.4.1 Vaginal hysterectomy

The rate of pelvic infection was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.36, 95% CI 0.17 to 0.75; four RCTs, N = 375; I2 = 0%; Analysis 4.3).

4.4.2 Abdominal hysterectomy

The rate of pelvic infection was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.42, 95% CI 0.22 to 0.83; four RCTs, N = 662; I2 = 0%; Analysis 4.3).

4.5 Other serious infection

4.5.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups in rates of other serious infection (RR 0.25, 95% CI 0.03 to 2.21; two RCTs, N = 246; I2 = 0%; Analysis 4.4).

4.5.2 Abdominal hysterectomy

It is unclear whether results showed a difference between groups in rates of other serious infection (RR 1.00, 95% CI 0.14 to 6.91; one RCT, N = 146; Analysis 4.4).

4.6 Postoperative fever

4.6.1 Vaginal hysterectomy

The rate of postoperative fever was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.45, 95% CI 0.21 to 0.97; two RCTs, N = 130; I2 = 0%; Analysis 4.5; Figure 10).

Figure 10
Forest plot of comparison: 4 Antiprotozoal versus placebo, outcome: 4.5 Postoperative fever.

Forest plot of comparison: 4 Antiprotozoal versus placebo, outcome: 4.5 Postoperative fever.

4.6.2 Abdominal hysterectomy

The rate of postoperative fever was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.39, 95% CI 0.18 to 0.85; one RCT, N = 100; Analysis 4.5).

4.7 Total adverse effects

4.7.1 Abdominal hysterectomy

It is unclear whether results showed differences between groups in rates of adverse effects (RR 2.00, 95% CI 0.63 to 6.35; one RCT, N = 146; Analysis 4.6).

Secondary outcomes
4.8 Need for therapeutic antibiotics

4.8.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups in the need for therapeutic antibiotics (RR 0.58, 95% CI 0.29 to 1.15; two RCTs, N = 196; I2 = 67%; Analysis 4.7). Findings did not change whether sensitivity analysis was based on OR (OR 0.52, 95% CI 0.24 to 1.17) or on an RE model (RR 0.55, 95% CI 0.15 to 1.95).

4.8.2 Abdominal hysterectomy

It is unclear whether results showed a difference between groups in the need for therapeutic antibiotics (RR 0.62, 95% CI 0.36 to 1.06; two RCTs, N = 246; I2 = 78%; Analysis 4.7). Findings did not change whether sensitivity analysis was based on OR (OR 0.56, 95% CI 0.30 to 1.07) or on an RE model (RR 0.55, 95% CI 0.15 to 2.02).

4.9 Length of hospital stay

4.9.1 Vaginal hysterectomy

Mean length of hospital stay was shorter in women who received prophylactic antibiotics than in those given placebo (MD ‐0.86 days, 95% CI ‐1.22 to ‐0.49; three RCTs, N = 276; I2 = 63%; Analysis 4.8). Direction of effect estimates were consistent in the three studies. Evidence of a difference in outcome between the two groups persisted when subjected to sensitivity analysis based on an RE model (MD ‐0.97, 95% CI ‐1.72 to ‐0.23), with women in the placebo group staying longer in hospital than those in the antiprotozoal group.

4.9.2 Abdominal hysterectomy

Mean length of hospital stay was shorter in women who received prophylactic antibiotics than in those given placebo (MD ‐1.33 days, 95% CI ‐1.68 to ‐0.97; three RCTs; N = 358; I2 = 89%; Analysis 4.8). Direction of effect estimates of individual studies were not consistent. We investigated the presence of significant heterogeneity and found no evidence of a difference in outcome between the two groups when an RE model (MD ‐0.93, 95% CI ‐2.12 to 0.26) was used.

5. Sulphonamides versus placebo

Primary outcomes
5.1 Total postoperative infections ‐ early and late

Investigators provided no data for this outcome.

5.2 Abdominal wound infection

5.2.1 Abdominal hysterectomy

It is unclear whether results showed a difference between groups in rates of abdominal wound infection (RR 1.23, 95% CI 0.35 to 4.35; two RCTs, N = 119; I2 = 0%; Analysis 5.1).

5.3 Urinary tract infection

5.3.1 Vaginal hysterectomy

The rate of UTI was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.36, 95% CI 0.15 to 0.84; one RCT, N = 50; Analysis 5.2).

5.3.2 Abdominal hysterectomy

The rate of UTI was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.18, 95% CI 0.06 to 0.50; two RCTs, N = 157; I2 = 0%; Analysis 5.2).

5.4 Pelvic infection

5.4.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups in rates of pelvic infection (RR 0.14, 95% CI 0.01 to 2.63; one RCT, N = 50; Analysis 5.3).

5.4.2 Abdominal hysterectomy

The rate of pelvic infection was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.11, 95% CI 0.01 to 0.84; two RCTs, N = 119; I2 = 0%; Analysis 5.3).

5.5 Other serious infection

Investigators provided no data for this outcome.

5.6 Postoperative fever

5.6.1 Vaginal hysterectomy

The rate of postoperative fever was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.50, 95% CI 0.26 to 0.95; one RCT, N = 50; Analysis 5.4).

5.6.2 Abdominal hysterectomy

It is unclear whether data showed a difference between groups in the numbers of women with a diagnosis of postoperative fever (RR 0.63, 95% CI 0.38 to 1.04; two RCTs, N = 157; I2 = 69%; Analysis 5.4). Direction of effect estimates were consistent across studies. We examined the presence of significant heterogeneity using sensitivity analysis; whether sensitivity analysis was based on OR (OR 0.51, 95% CI 0.25 to 1.05) or an RE model (RR 0.63, 95% CI 0.24 to 1.62) did not substantially influence the findings.

5.7 Total adverse effects

Investigators provided no data for this outcome.

Secondary outcomes
5.8 Need for therapeutic antibiotics

5.8.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups in the need for therapeutic antibiotics as the study that reported on this outcome did not find any evidence of a difference Mathews 1977 (RR 0.33, 95% CI 0.10 to 1.09; one RCT, N = 50).

5.8.2 Abdominal hysterectomy

It is unclear whether data showed a difference between groups in the need for therapeutic antibiotics as the study that reported on this outcome did not find any evidence of a difference Mathews 1977 (RR 0.97, 95% CI 0.15 to 6.41; one RCT, N = 59).

5.9 Length of hospital stay

Investigators provided no data for this outcome.

6. Cephalosporin plus antiprotozoal versus placebo

Primary outcomes
6.1 Total postoperative infections ‐ early and late

Investigators provided no data for this outcome.

6.2 Abdominal wound infection

6.2.1 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 1.00, 95% CI 0.14 to 7.03; two RCTs, N = 406; I2 = 0%; Analysis 6.1).

6.3 Urinary tract infection

6.3.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.50, 95% CI 0.24 to 1.04; one RCT, N = 406; Analysis 6.2).

6.3.2 Abdominal hysterectomy

The rate of urinary tract infection was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.27, 95% CI 0.08 to 0.96; one RCT, N = 406; Analysis 6.2).

6.4 Pelvic infection

6.4.1 Vaginal hysterectomy

The rate of pelvic infection was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.05, 95% CI 0.01 to 0.37; one RCT, N = 406; Analysis 6.3).

6.5 Other serious infection

Investigators provided no data for this outcome.

6.6 Postoperative fever

6.6.1 Vaginal hysterectomy

The rate of postoperative fever was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.50, 95% CI 0.34 to 0.73; one RCT, N = 406; Analysis 6.4).

6.6.2 Abdominal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.79, 95% CI 0.58 to 1.09; one RCT, N = 406; Analysis 6.4).

6.7 Total adverse effects

Investigators provided no data for this outcome.

Secondary outcomes
6.8 Need for therapeutic antibiotics

6.8.1 Vaginal hysterectomy

The rate of need for therapeutic antibiotics was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.36, 95% CI 0.19 to 0.68; one RCT, N = 406; Analysis 6.5).

6.8.2 Abdominal hysterectomy

The rate of need for therapeutic antibiotics was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.38, 95% CI 0.15 to 0.94; one RCT, N = 406; Analysis 6.5).

6.9 Length of hospital stay

6.9.1 Abdominal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (MD ‐0.30 days, 95% CI ‐0.60 to ‐0.00; one RCT, N = 406; Analysis 6.6).

7. Penicillin plus antiprotozoal versus placebo

Primary outcomes
7.1 Total postoperative infections ‐ early and late

7.1.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.25, 95% CI 0.04 to 1.73; one RCT, n 18; Analysis 7.1).

7.1.2 Abdominal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.44, 95% CI 0.23 to 0.86; one RCT, N = 107; Analysis 7.1).

7.2 Abdominal wound infection

7.2.1 Abdominal hysterectomy

The rate of abdominal wound infection was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.14, 95% CI 0.03 to 0.60; one RCT, N = 107; Analysis 7.2).

7.3 Urinary tract infection

7.3.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.63, 95% CI 0.07 to 5.72; one RCT, n = 18; Analysis 7.3).

7.3.2 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.97, 95% CI 0.38 to 2.47; one RCT, N = 107; Analysis 7.3).

7.4 Pelvic infection

7.4.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.17, 95% CI 0.01 to 2.96; one RCT, N = 18; Analysis 7.4).

7.5 Other serious infection

Investigators provided no data for this outcome.

7.6 Postoperative fever

7.6.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.17, 95% CI 0.01 to 2.96; one RCT, N = 18; Analysis 7.5).

7.6.2 Abdominal hysterectomy

The rate of postoperative fever was lower in women who received prophylactic antibiotics than in those given placebo (RR 0.08, 95% CI 0.01 to 0.64; one RCT, N = 107; Analysis 7.5).

7.7 Total adverse effects

Researchers provided no data for this outcome.

Secondary outcomes
7.8 Need for therapeutic antibiotics

Researchers provided no data for this outcome.

7.9 Length of hospital stay

Researchers provided no data for this outcome.

8. Lincosamide versus placebo

Primary outcomes
8.1 Total postoperative infections ‐ early and late

Researchers provided no data for this outcome.

8.2 Abdominal wound infection

Researchers provided no data for this outcome.

8.3 Urinary tract infection

8.3.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups (RR 0.71, 95% CI 0.25 to 2.06; one RCT, N = 80; Analysis 8.1).

8.4 Pelvic infection

Researchers provided no data for this outcome.

8.5 Other serious infection

Researchers provided no data for this outcome.

8.6 Postoperative fever

8.6.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 1.00, 95% CI 0.06 to 15.44; one RCT, N = 80; Analysis 8.2).

8.7 Total adverse effects

Researchers provided no data for this outcome.

Secondary outcomes
8.8 Need for therapeutic antibiotics

Researchers provided no data for this outcome.

8.9 Length of hospital stay

8.9.1 Vaginal hysterectomy

Evidence showed a difference in length of hospital stay between the two treatment groups, with women in the placebo group staying longer in hospital than those in the lincosamide group (MD ‐0.40, 95% CI ‐0.77 to ‐0.03; one RCT, N = 80; Analysis 8.3).

9. Cephalosporin versus penicillin

Primary outcomes
9.1 Total postoperative infections ‐ early and late

9.1.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 1.04, 95% CI 0.55 to 2.00; two RCTs, N = 470; I2 = 0%; Analysis 9.1; Figure 11).

Figure 11
Forest plot of comparison: 9 Cephalosporin versus penicillin, outcome: 9.1 Total postoperative infections ‐ early and late.

Forest plot of comparison: 9 Cephalosporin versus penicillin, outcome: 9.1 Total postoperative infections ‐ early and late.

9.2 Abdominal wound infection

9.2.1 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.33, 95% CI 0.01 to 8.09; one RCT, N = 220; Analysis 9.2).

9.3 Urinary tract infection

9.3.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.20, 95% CI 0.01 to 3.98; one RCT, N = 95; Analysis 9.3).

9.3.2 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 1.00, 95% CI 0.06 to 15.79; one RCT, N = 220; Analysis 9.3).

9.4 Pelvic infection

9.4.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.88, 95% CI 0.47 to 1.64; three RCTs, N = 565; I2 = 0%; Analysis 9.4).

9.4.2 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.50, 95% CI 0.09 to 2.67; one RCT, N = 220; Analysis 9.4).

9.5 Other serious infection

9.5.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 2.90, 95% CI 0.12 to 69.68; one RCT, N = 114; Analysis 9.5).

9.5.2 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 3.00, 95% CI 0.12 to 72.85; one RCT, N = 220; Analysis 9.5).

9.6 Postoperative fever

9.6.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.82, 95% CI 0.58 to 1.15; three RCTs, N = 565; I2 = 0%; Analysis 9.6).

9.6.2 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.86, 95% CI 0.42 to 1.77; one RCT, N = 220; Analysis 9.6; Figure 12).

Figure 12
Forest plot of comparison: 9 Cephalosporin versus penicillin, outcome: 9.6 Postoperative fever.

Forest plot of comparison: 9 Cephalosporin versus penicillin, outcome: 9.6 Postoperative fever.

9.7 Total adverse effects

9.7.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.95, 95% CI 0.79 to 1.14; two RCTs, N = 451; I2 = 85%; Analysis 9.7; Figure 13).

Figure 13
Forest plot of comparison: 9 Cephalosporin versus penicillin, outcome: 9.7 Total adverse effects.

Forest plot of comparison: 9 Cephalosporin versus penicillin, outcome: 9.7 Total adverse effects.

Secondary outcomes
9.8 Need for therapeutic antibiotics

9.8.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 1.32, 95% CI 0.88 to 1.97; two RCTs, N = 470; I2 = 0%; Analysis 9.8).

9.9 Length of hospital stay

9.9.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (MD ‐0.47, 95% CI ‐0.97 to 0.04; two RCTs, N = 209; I2 = 0%; Analysis 9.9).

10 Cephalosporin versus tetracycline

Primary outcomes
10.1 Total postoperative infections ‐ early and late

10.1.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.59, 95% CI 0.20 to 1.78; one RCT, N = 51; Analysis 10.1).

10.2 Abdominal wound infection

Researchers provided no data for this outcome.

10.3 Urinary tract infection

Researchers provided no data for this outcome.

10.4 Pelvic infection

10.4.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.83, 95% CI 0.25 to 2.75; one RCT, N = 51; Analysis 10.2).

10.5 Other serious infection

Researchers provided no data for this outcome.

10.6 Postoperative fever

10.6.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.69, 95% CI 0.13 to 3.81; one RCT, N = 51; Analysis 10.3).

10.7 Total adverse effects

Researchers provided no data for this outcome.

Secondary outcomes
10.8 Need for therapeutic antibiotics

Researchers provided no data for this outcome.

10.9 Length of hospital stay

10.9.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (MD ‐0.20 days, 95% CI ‐1.11 to 0.71; one RCT, N = 51; Analysis 10.4).

11. Cephalosporin versus antiprotozoal

Primary outcomes
11.1 Total postoperative infections ‐ early and late

11.1.1 Vaginal hysterectomy

The rate of postoperative infection was lower in the cephalosporin group (RR 0.04, 95% CI 0.00 to 0.67; one RCT, N = 78; Analysis 11.1).

11.2 Abdominal wound infection

Researchers provided no data for this outcome.

11.3 Urinary tract infection

11.3.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.05, 95% CI 0.00 to 0.81; one RCT, N = 78; Analysis 11.2).

11.4 Pelvic infection

11.4.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.17, 95% CI 0.01 to 4.03; one RCT, N = 78; Analysis 11.3).

11.5 Other serious infection

Investigators provided no data for this outcome.

11.6 Postoperative fever

11.6.1 Vaginal hysterectomy

The rate of postoperative fever was lower in women who received cephalosporin than in those given antiprotozoal (RR 0.06, 95% CI 0.01 to 0.42; one RCT, N = 78; Analysis 11.4).

11.7 Total adverse effects

Investigators provided no data for this outcome.

Secondary outcomes
11.8 Need for therapeutic antibiotics

11.8.1 Vaginal hysterectomy

The rate of need for therapeutic antibiotics was lower in women who received cephalosporin than in those given antiprotozoal (RR 0.03, 95% CI 0.00 to 0.44; one RCT, N = 78; Analysis 11.5).

11.9 Length of hospital stay

11.9.1 Vaginal hysterectomy

Mean length of hospital stay was shorter in women who received cephalosporin than in those given antiprotozoal (MD ‐1.90 days, 95% CI ‐3.32 to ‐0.48; one RCT, N = 78; Analysis 11.6).

12. Antiprotozoal versus lincosamide

Primary outcomes
12.1 Total postoperative infections ‐ early and late

Researchers provided no data for this outcome.

12.2 Abdominal wound infection

Researchers provided no data for this outcome.

12.3 Urinary tract infection

12.3.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 4.00, 95% CI 0.47 to 34.24; one RCT, N = 80; Analysis 12.1).

12.4 Pelvic infection

Researchers provided no data for this outcome.

12.5 Other serious infection

Researchers provided no data for this outcome.

12.6 Postoperative fever

12.6.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.33, 95% CI 0.01 to 7.95; one RCT, N = 80; Analysis 12.2).

12.7 Total adverse effects

Researchers provided no data for this outcome.

Secondary outcomes
12.8 Need for therapeutic antibiotics

Researchers provided no data for this outcome.

12.9 Length of hospital stay

12.9.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (MD ‐0.20 days, 95% CI ‐0.60 to 0.20; one RCT, N = 80; Analysis 12.3).

13. Cephalosporin plus antiprotozoal versus cephalosporin

Primary outcomes
13.1 Total postoperative infections ‐ early and late

Researchers provided no data for this outcome.

13.2 Abdominal wound infection

Researchers provided no data for this outcome.

13.3 Urinary tract infection

Researchers provided no data for this outcome.

13.4 Pelvic infection

Researchers provided no data for this outcome.

13.5 Other serious infections

Researchers provided no data for this outcome.

13.6 Postoperative fever

13.6.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.50, 95% CI 0.03 to 7.68; one RCT, N = 78; Analysis 13.1).

13.7 Total adverse effects

Researchers provided no data for this outcome.

Secondary outcomes
13.8 Need for therapeutic antibiotics

Researchers provided no data for this outcome.

13.9 Length of hospital stay

13.9.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (MD 0.30 days, 95% CI ‐0.43 to 1.03; one RCT, N = 78; Analysis 13.2).

14. Cephalosporin plus antiprotozoal versus antiprotozoal only

Primary outcomes
14.1 Total postoperative infections ‐ early and late

14.1.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups (RR 0.04, 95% CI 0.00 to 0.67; one RCT, N = 78; Analysis 14.1).

14.2 Abdominal wound infection

Researchers provided no data for this outcome.

14.3 Urinary tract infection

14.3.1 Vaginal hysterectomy

The rate of UTI was lower in women who received cephalosporin plus antiprotozoal than in those given antiprotozoal only (RR 0.05, 95% CI 0.00 to 0.81; one RCT, N = 78; Analysis 14.2).

14.4 Pelvic infection

14.4.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.17, 95% CI 0.01 to 4.03; one RCT, N = 78; Analysis 14.3).

14.5 Other serious infection

Researchers provided no data for this outcome.

14.6 Postoperative fever

14.6.1 Vaginal hysterectomy

The rate of postoperative fever was lower in women who received cephalosporin plus antiprotozoal than in those given antiprotozoal only (RR 0.06, 95% CI 0.01 to 0.42; one RCT, N = 78; Analysis 14.4).

14.7 Total adverse effects

Investigators provided no data for this outcome.

Secondary outcomes
14.8 Need for therapeutic antibiotics

14.8.1 Vaginal hysterectomy

The rate of need for therapeutic antibiotics was lower in women who received cephalosporin plus antiprotozoal than in those given antiprotozoal only (RR 0.03, 95% CI 0.00 to 0.44; one RCT, N = 78; Analysis 14.5).

14.9 Length of hospital stay

14.9.1 Vaginal hysterectomy

Length of hospital stay was shorter in women who received cephalosporin plus antiprotozoal than in those given antiprotozoal only (MD ‐1.60 days, 95% CI ‐3.11 to ‐0.09; one RCT, N = 78; Analysis 14.6).

15. Penicillin plus antiprotozoal versus penicillin only

Primary outcomes
15.1 Total postoperative infections ‐ early and late

15.1.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 1.25, 95% CI 0.09 to 17.02; one RCT, N = 18; Analysis 15.1).

15.1.2 Abdominal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 1.47, 95% CI 0.57 to 3.75; one RCT, N = 109; Analysis 15.1).

15.2 Abdominal wound infection

15.2.1 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.94, 95% CI 0.25 to 3.59; two RCT, N = 155; I2 = 0%; Analysis 15.2).

15.3 Urinary tract infection

15.3.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 1.25, 95% CI 0.09 to 17.02; one RCT, N = 18; Analysis 15.3).

15.3.2 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 2.00, 95% CI 0.80 to 4.97; two RCTs, N = 155; I2 = 0%; Analysis 15.3).

15.4 Pelvic infection

Investigators provided no data for this outcome.

15.5 Other serious infection

Investigators provided no data for this outcome.

15.6 Postoperative fever

15.6.1 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.96, 95% CI 0.20 to 4.50; two RCTs, N = 155; I2 = 0%; Analysis 15.4).

15.7 Total adverse effects

Investigators provided no data for this outcome.

Secondary outcomes
15.8 Need for therapeutic antibiotics

Investigators provided no data for this outcome.

15.9 Length of hospital stay

Investigators provided no data for this outcome.

16. Cephalosporin early administration versus usual timing (both single dose)

Primary outcomes
16.1 Total postoperative infections ‐ early and late

Researchers provided no data for this outcome.

16.2 Abdominal wound infection

16.2.1 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.50, 95% CI 0.03 to 7.90; one RCT, n = 252; Analysis 16.1).

16.3 Urinary tract infection

Investigators provided no data for this outcome.

16.4 Pelvic infection

16.4.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 1.50, 95% CI 0.16 to 14.20; one RCT, N = 252; Analysis 16.2).

16.4.2 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 1.50, 95% CI 0.16 to 14.20; one RCT, N = 252; Analysis 16.2).

16.5 Other serious infection

Researchers provided no data for this outcome.

16.6 Postoperative fever

Researchers provided no data for this outcome.

16.7 Total adverse effects

Researchers provided no data for this outcome.

Secondary outcomes
16.8 Need for therapeutic antibiotics

Researchers provided no data for this outcome.

16.9 Length of hospital stay

Researchers provided no data for this outcome.

17. Cephalosporin one dose versus two doses

Primary outcomes
17.1 Total postoperative infections ‐ early and late

17.1.1 Abdominal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.67, 95% CI 0.14 to 3.18; one RCT, N = 150; Analysis 17.1).

17.2 Abdominal wound infection

Researchers provided no data for this outcome.

17.3 Urinary tract infection

Researchers provided no data for this outcome.

17.4 Pelvic infection

Researchers provided no data for this outcome.

17.5 Other serious infection

Researchers provided no data for this outcome.

17.6 Postoperative fever

17.6.1 Abdominal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 2.00, 95% CI 0.97 to 4.13; one RCT, N = 150; Analysis 17.2).

17.7 Total adverse effects

Researchers provided no data for this outcome.

Secondary outcomes
17.8 Need for therapeutic antibiotics

17.8.1 Abdominal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 9.90, 95% CI 0.48 to 202.43; one RCT, N = 150; Analysis 17.3).

17.9 Length of hospital stay

Researchers provided no data for this outcome.

18. Cephalosporin one dose versus three doses

Primary outcomes
18.1 Total postoperative infections ‐ early and late

18.1.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 0.50, 95% CI 0.05 to 5.36; one RCT, N = 116; Analysis 18.1).

18.2 Abdominal wound infection

Investigators provided no data for this outcome.

18.3 Urinary tract infection

Investigators provided no data for this outcome.

18.4 Pelvic infection

18.4.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.50, 95% CI 0.05 to 5.36; one RCT, N = 116; Analysis 18.2).

18.5 Other serious infection

Investigators provided no data for this outcome.

18.6 Postoperative fever

18.6.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 0.91, 95% CI 0.42 to 1.97; one RCT, N = 116; Analysis 18.3).

18.7 Total adverse effects

Investigators provided no data for this outcome.

Secondary outcomes
18.8 Need for therapeutic antibiotics

Investigators provided no data for this outcome.

18.9 Length of hospital stay

It is unclear whether data showed a difference between groups for this outcome (MD ‐0.30 days, 95% CI ‐0.72 to 0.12; one RCT, N = 116; Analysis 18.4).

19. Cephalosporin one dose versus multiple doses

Primary outcomes
19.1 Total postoperative infections ‐ early and late

19.1.1 Vaginal hysterectomy

We found no clear evidence of a difference between groups (RR 5.00, 95% CI 0.25 to 98.52; one RCT, N = 44; Analysis 19.1).

19.2 Abdominal wound infection

Researchers provided no data for this outcome.

19.3 Urinary tract infection

19.3.1 Vaginal hysterectomy

We found no clear evidence of a difference between groups (RR 3.00, 95% CI 0.13 to 69.87; one RCT, N = 44; Analysis 19.2).

19.4 Pelvic infection

19.4.1 Vaginal hysterectomy

We found no clear evidence of a difference between groups (RR 3.00, 95% CI 0.13 to 69.87; one RCT, N = 44; Analysis 19.3).

19.5 Other serious infection

Researchers provided no data for this outcome.

19.6 Postoperative fever

19.6.1 Vaginal hysterectomy

We found no clear evidence of a difference between groups for this outcome (RR 5.00, 95% CI 0.25 to 98.52; one RCT, N = 44; Analysis 19.4).

19.7 Total adverse effects

Researchers provided no data for this outcome.

Secondary outcomes
19.8 Need for therapeutic antibiotics

Researchers provided no data for this outcome.

19.9 Length of hospital stay

Researchers provided no data for this outcome.

20 Cephalosporin one gram versus two grams

Primary outcomes
20.1 Total postoperative infections ‐ early and late

20.1.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 1.49, 95% CI 0.25 to 8.74; one RCT, N = 237; Analysis 20.1).

20.2 Abdominal wound infection

Investigators reported no data for this outcome.

20.3 Urinary tract infection

Investigators reported no data for this outcome.

20.4 Pelvic infection

20.4.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 1.49, 95% CI 0.25 to 8.74; one RCT, N = 237; Analysis 20.2).

20.5 Other serious infection

Investigators provided no data for this outcome.

20.6 Postoperative fever

20.6.1 Vaginal hysterectomy

It is unclear whether results showed a difference between groups for this outcome (RR 1.49, 95% CI 0.43 to 5.14; one RCT, N = 237; Analysis 20.3).

20.7 Total adverse effects

Investigators provided no data for this outcome.

Secondary outcomes
20.8 Need for therapeutic antibiotics

20.8.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (RR 1.49, 95% CI 0.25 to 8.74; one RCT, N = 237; Analysis 20.4).

20.9 Length of hospital stay

20.9.1 Vaginal hysterectomy

It is unclear whether data showed a difference between groups for this outcome (MD ‐0.10 days, 95% CI ‐0.60 to 0.40; one RCT, N = 237; Analysis 20.5).

Funnel plots

We examined the presence of publication or reporting bias by analysing funnel plots in five subgroups: 1.2.1 (Figure 14); 1.3.2 (Figure 15); 1.4.1 and 1.4.2 (Figure 16); and 1.6.2 (Figure 17). We found evidence suggesting a tendency towards publication bias; smaller studies were likely to report beneficial effects with the use of antibiotic prophylaxis.

Figure 14
Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.2 Abdominal wound infection.

Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.2 Abdominal wound infection.

Figure 15
Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.3 Urinary tract infection.

Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.3 Urinary tract infection.

Figure 16
Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.4 Pelvic infection.

Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.4 Pelvic infection.

Figure 17
Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.6 Postoperative fever.

Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.6 Postoperative fever.

Discussion

Summary of main results

This is the first Cochrane review to assess the effectiveness and safety of antibiotic prophylaxis for elective hysterectomy for benign disease, and to determine which, if any, prophylactic regimen is most suitable. Thirty‐seven studies met the eligibility criteria for inclusion; they compared various antibiotics with placebo and with one another in 20 comparisons involving a total of 6079 participants. Primary outcomes reported were infection (total postoperative infections ‐ early and late, abdominal wound infection, urinary tract infection, pelvic infection, other serious infection, and postoperative fever) and total adverse effects. Secondary outcomes reported were need for therapeutic antibiotics and length of hospital stay.

We subsumed the various comparisons under four broad groups as follows.

1. Any antibiotics versus placebo

Antibiotics in this case included cephalosporin, penicillin, antiprotozoal, sulphonamide, and lincosamide. Researchers compared these individually or in combination with placebo in two subgroups.

Vaginal hysterectomy

We found evidence of a difference in the incidence of postoperative infection between women who received prophylactic antibiotics and those given placebo. Researchers reported fewer cases of total postoperative infection, urinary tract infection (UTI), pelvic infection, and postoperative fever in women who were given prophylactic antibiotics of any class compared with those who received placebo. However, we found no evidence of a difference between groups in the proportions of women who developed other serious infection.

On safety, we found no available data that would allow us to properly evaluate the adverse effects associated with each group.

With regard to need for therapeutic antibiotics, fewer women in the antibiotic groups required therapeutic antibiotics postoperatively compared with those in the placebo group. Similarly, women who received prophylactic antibiotics spent fewer days in hospital than those given placebo.

Abdominal hysterectomy

As in the vaginal hysterectomy subgroup, we found evidence of a difference between groups in the proportions of women given a diagnosis of postoperative infection. Lower proportions of women who received prophylactic antibiotics received a diagnosis of total postoperative infection, abdominal wound infection, UTI, pelvic infection, and postoperative fever compared with those given placebo. However, we found no evidence of a difference between groups in reported cases of other serious infection.

With regard to safety, we found evidence of a difference between groups in the incidence of total adverse effects, with fewer cases of adverse effects reported in women who received antibiotics compared with those given placebo.

On the need for therapeutic antibiotics, fewer women in the antibiotic group required therapeutic antibiotics compared with those in the placebo group. Similarly, women who received prophylactic antibiotics spent shorter days in hospital than those given placebo.

2. Head‐to‐head comparisons between antibiotics

We identified four different head‐to‐head comparisons: cephalosporin versus penicillin, cephalosporin versus tetracycline, cephalosporin versus antiprotozoal, and antiprotozoal versus lincosamide. Investigators compared participants in two subgroups as follows.

Vaginal hysterectomy

Investigators performed all four comparisons in this subgroup. We found no evidence of a difference between groups in reported cases of total postoperative infection, abdominal wound infection, UTI, pelvic infection, other serious infection, and postoperative fever with cephalosporin versus penicillin, cephalosporin versus tetracycline, and antiprotozoal versus lincosamide, when data were available. However, researchers reported fewer cases of total postoperative infection and postoperative fever in women who received cephalosporin compared with those given antiprotozoal.

Only one comparison (cephalosporin vs penicillin) yielded data on adverse effects, and no evidence showed differences in total adverse effects between the two groups.

With regard to the need for therapeutic antibiotics and length of hospital stay, we found no evidence of a difference between groups in the proportions of women requiring therapeutic antibiotics or in the numbers of days spent in hospital with cephalosporin versus penicillin, cephalosporin versus tetracycline, and antiprotozoal versus lincosamide. However, we found evidence of a difference in the two outcomes between cephalosporin and antiprotozoal groups: Fewer women in the cephalosporin group required therapeutic antibiotics, and women in this group spent fewer days in hospital, compared with those in the antiprotozoal group.

Abdominal hysterectomy

Researchers performed only one of the comparisons (cephalosporin vs penicillin) in this subgroup. We found no evidence of a difference in reported cases of infection (total postoperative infection, abdominal wound infection, UTI, pelvic infection, other serious infection, and postoperative fever) between the two groups. Investigators provided no data on adverse effects, need for therapeutic antibiotics, and length of hospital stay.

3. Combined antibiotics versus single antibiotic

We identified three different comparisons: cephalosporin plus antiprotozoal versus cephalosporin, cephalosporin plus antiprotozoal versus antiprotozoal, and penicillin plus antiprotozoal versus penicillin. Researchers performed these comparisons in two subgroups as follows.

Vaginal hysterectomy

Investigators performed all three comparisons in this subgroup but did not provide data for most outcomes, including adverse effects. When data were available, we found no evidence of a difference in outcomes between the two groups for two of the comparisons (cephalosporin plus antiprotozoal vs cephalosporin only and penicillin plus antiprotozoal vs penicillin only). However, fewer women who received cephalosporin combined with antiprotozoal received a diagnosis of total postoperative infection, UTI, or postoperative fever compared with those who received antiprotozoal only.

Abdominal hysterectomy

Researchers performed only one comparison (penicillin plus antiprotozoal vs penicillin only) in this subgroup. They provided no data on some outcomes, including adverse effects. When data were available, we found no evidence of a difference in outcomes between the two groups.

4. Cephalosporins in different dose regimens

Investigators addressed comparisons subsumed under this broad heading most often in single small trials and did not provide data on most of the outcome measures, including total adverse effects. When outcome data were reported, we found no evidence of a difference between groups in the incidence of postoperative infection, the need for therapeutic antibiotics, and length of hospital stay for each of these comparisons.

Overall completeness and applicability of evidence

Overall, the data demonstrate that prophylactic antibiotics are more effective than placebo in preventing postoperative infection, reducing the requirement for therapeutic antibiotics, and shortening length of hospital stay in women undergoing elective vaginal or abdominal hysterectomy. However, few studies reported data on adverse effects associated with the use of antibiotic prophylaxis; therefore, we were unable to determine whether prophylactic antibiotics are associated with significant adverse effects. However, as prophylaxis is usually given as a single shot, the adverse effect rate might truly be low.

Similarly, few studies compared antibiotics head‐to‐head; thus we were unable to determine which specific antibiotic is most effective, or whether individual antibiotics are similar with respect to effectiveness and safety.

We identified few studies evaluating antibiotics in different combinations, dose regimens, and routes of administration. Thus we could not determine whether it is possible to sustain the effectiveness of antibiotics while reducing adverse effects by combining lower doses of two different antibiotics, or by using certain dose regimens or routes of administration.

None of the included studies investigated laparoscopic hysterectomy (total or subtotal laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy). Thus the findings of this review are not applicable to this type of hysterectomy, which has been performed increasingly over the past decade.

One should interpret the results on "length of hospital stay" and "urinary tract infections" with caution, as some studies reporting these outcomes were conducted decades ago. Meanwhile, hospital stay has decreased tremendously over the past few decades owing to improved knowledge of postoperative care and doctors' adaptation of the principles of "early recovery after surgery" (ERAS®). These include striving postoperatively for early mobilisation, normalisation of oral intake, and early removal of urinary catheters, thus decreasing length of hospital stay, risk of nosocomial infection, and risk of UTI. For example, it is very rare nowadays for healthy patients who undergo uncomplicated vaginal hysterectomy to be admitted to a hospital for longer than three days, whereas the studies in Analysis 1.9 show mean hospitalisation duration of 8.3 to 11.9 days.

Quality of the evidence

Most studies considered for this review were of poor quality in relation to risk of bias. We excluded many studies owing to unclear design, lack of double‐blinding, or non‐blinding. Among the included studies, very few clearly described their methods of sequence generation and allocation concealment. For most comparisons, effect estimates were associated with imprecision due to small sample sizes and wide confidence intervals.

We assessed the quality of evidence for the review's main comparison (any antibiotics vs placebo for vaginal and abdominal hysterectomy). The quality of evidence for our primary outcome ranged from very low to moderate. The main limitations in the body of evidence were risk of bias (due to poor reporting of sequence generation and allocation concealment), serious imprecision (associated with small sample size and low event rates, leading to wide confidence intervals), and inadequate reporting of adverse effects.

We rated the quality of evidence for head‐to head comparisons of antibiotics and for dose comparisons as very low owing to imprecision related to wide confidence intervals and low event rates, and to risk of bias associated with poor reporting of study methods.

We examined the presence of publication or reporting bias in a funnel plot for five subgroups in one of the comparisons (any antibiotics vs placebo) and found evidence suggesting a tendency towards publication or reporting bias, with smaller studies likely to report beneficial effects with antibiotic prophylaxis. However, we did not consider that evidence of publication bias was strong enough to necessitate downgrading the quality of evidence.

Potential biases in the review process

Although we undertook a comprehensive search to ensure that we identified potentially eligible studies, it is possible that some eligible studies might have been left out in the course of the search and selection process.

Agreements and disagreements with other studies or reviews

Clinical guidelines (ACOG 2009; Deffieux 2015; SIGN 2008) and narrative reviews (Clifford 2012; Hodges 2014; Steiner 2017) recommend antibiotic prophylaxis for women undergoing hysterectomy, and pragmatically opt to advise cephalosporins as a first choice. However, the evidence base for first‐line cephalosporins is limited by the lack of recent trials. Moreover, no randomised controlled trials (RCTs) at all examined the topic of antibiotic prophylaxis for laparoscopic hysterectomy.

Much of the evidence is very old: For example, Clifford 2012 is a narrative review that refers to old studies such as Duff 1982 and Tanos 1994 to recommend prophylactic antibiotics for hysterectomy, and Larsson 2002 to recommend preoperative treatment of bacterial vaginosis. We excluded both Larsson 2002 and Tanos 1994 from the current review because investigators utilised extended seven‐day prophylaxis as well as an historical comparison group (respectively).

A more recent review (Morrill 2013) investigated antibiotic prophylaxis in selected gynaecological surgeries, including hysteroscopic and cervical surgery, while excluding hysterectomy (Morrill 2013). Review authors concluded that evidence provides a strong case for prophylactic antibiotics for abdominal gynaecological surgery but acknowledged lack of evidence for their use in vaginal surgery. For laparoscopic surgery, we found no advantage of prophylactic antibiotics, but high‐quality evidence was lacking and results were hampered by heterogeneity of the population; women underwent widely varying surgeries, from diagnostic laparoscopy to ovarian cystectomy or extended endometriosis surgery.

A large retrospective cohort of 21,358 hysterectomies performed in the United States (Upall 2016) investigated associations between a composite outcome of "any surgical site infection" and classes of antibiotics administered preoperatively. Investigators found that women receiving beta‐lactam antibiotic regimens (i.e. first‐ or second‐generation cephalosporins, ampicillin plus sulbactam, or ertapenem) had lower risk of surgical site infection than women given a beta‐lactam alternative (i.e. clindamycin combination, gentamycin combination, metronidazole combination) or a non‐standard regimen (i.e. clindamycin, gentamycin, or aztreonam, or another antibiotic alone). We found comparable benefit for cephalosporins but only for vaginal hysterectomy when compared with antiprotozoal alone.

Several published systematic reviews and meta‐analyses of the use of antibiotics in hysterectomy have reported mainly on the same set of included RCTs.

Wttewaall‐Evelaar 1990 meta‐analysed 17 randomised blinded placebo‐controlled trials of prophylaxis for elective abdominal hysterectomy, all published between 1986 and 1988. In most cases, the antibiotics used were cephalosporins. Review authors concluded that prophylaxis significantly reduced levels of infection (p < 0.001; no odds ratio reported), and that additional placebo‐controlled trials were not warranted. Mittendorf 1993 meta‐analysed 31 English‐language RCTs published from 1972 to 1986, and concluded that antibiotic prophylaxis reduced the rate of serious infection after abdominal hysterectomy from 21.1% to 9% (P = 0.00001; no odds ratio reported in text). Trials that used different routes of administration and differing prophylaxis regimens, varying from a single dose to five days' duration, were pooled. Tanos 1994 meta‐analysed 17 "controlled or comparative" trials conducted between 1978 and 1990 to investigate single or one‐day prophylactic regimens of intravenous or intramuscular cephalosporins for abdominal hysterectomy. It is unclear whether all of the included trials were randomised, and some trials included oncology patients among their participants. Again, results clearly favoured the use of prophylaxis (odds ratio (OR) 0.35, 95% confidence interval (CI) 0.3 to 0.4).

Two of these meta‐analyses combined results from studies that included very different participants or interventions. The other (Wttewaall‐Evelaar 1990) was more rigorous but did not include any of the numerous studies carried out since 1986.

More recently, a systematic review by Costa and Krauss‐Silva meta‐analysed double‐blinded, placebo‐controlled trials on the use of antibiotic prophylaxis for elective, non‐radical abdominal hysterectomy (Costa 2004). Review authors meta‐analysed a total of 16 studies published between 1977 and 2003, but it is important to note that the most recent study was published in 1998, and the 15 remaining RCTs were published in 1988 or earlier. Review authors concluded that use of antibiotic prophylaxis is effective for prevention of postoperative infection (risk ratio (RR) 0.49, 95% CI 0.41 to 0.59). They concluded that no evidence showed benefit for multiple‐ versus single‐dose prophylaxis.

We identified no RCTs on the use of antibiotics in laparoscopic hysterectomy for inclusion in this review. A recent review by Lachiewicz on laparoscopic hysterectomy recommends use of antibiotics, with dose adjusted to body weight (increased dosage when patients weigh more than 120 kilograms), and use of antiprotozoals. The latter recommendation consists of using antiprotozoals routinely or after screening for bacterial vaginosis before surgery in which the vaginal‐abdominal barrier was breached (Lachiewicz 2015). However, arguments for these recommendations in laparoscopy derive from authority‐based guidelines or non‐randomised trials (Bratzler 2013; Soper 1993).

Findings from the studies above are consistent with the findings of this review, which found evidence that antibiotic prophylaxis is effective in preventing postoperative infection in women undergoing elective vaginal or abdominal hysterectomy.

PRISMA flow chart.
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Figure 1

PRISMA flow chart.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Forest plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.1 Total postoperative infections ‐ early and late.
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Figure 4

Forest plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.1 Total postoperative infections ‐ early and late.

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Forest plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.6 Postoperative fever.
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Figure 5

Forest plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.6 Postoperative fever.

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Forest plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.7 Total adverse effects.
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Figure 6

Forest plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.7 Total adverse effects.

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Forest plot of comparison: 2 Cephalosporin versus placebo, outcome: 2.1 Total postoperative infections ‐ early and late.
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Figure 7

Forest plot of comparison: 2 Cephalosporin versus placebo, outcome: 2.1 Total postoperative infections ‐ early and late.

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Forest plot of comparison: 2 Cephalosporin versus placebo, outcome: 2.6 Postoperative fever.
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Figure 8

Forest plot of comparison: 2 Cephalosporin versus placebo, outcome: 2.6 Postoperative fever.

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Forest plot of comparison: 3 Penicillin versus placebo, outcome: 3.6 Postoperative fever.
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Figure 9

Forest plot of comparison: 3 Penicillin versus placebo, outcome: 3.6 Postoperative fever.

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Forest plot of comparison: 4 Antiprotozoal versus placebo, outcome: 4.5 Postoperative fever.
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Figure 10

Forest plot of comparison: 4 Antiprotozoal versus placebo, outcome: 4.5 Postoperative fever.

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Forest plot of comparison: 9 Cephalosporin versus penicillin, outcome: 9.1 Total postoperative infections ‐ early and late.
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Figure 11

Forest plot of comparison: 9 Cephalosporin versus penicillin, outcome: 9.1 Total postoperative infections ‐ early and late.

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Forest plot of comparison: 9 Cephalosporin versus penicillin, outcome: 9.6 Postoperative fever.
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Figure 12

Forest plot of comparison: 9 Cephalosporin versus penicillin, outcome: 9.6 Postoperative fever.

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Forest plot of comparison: 9 Cephalosporin versus penicillin, outcome: 9.7 Total adverse effects.
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Figure 13

Forest plot of comparison: 9 Cephalosporin versus penicillin, outcome: 9.7 Total adverse effects.

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Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.2 Abdominal wound infection.
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Figure 14

Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.2 Abdominal wound infection.

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Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.3 Urinary tract infection.
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Figure 15

Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.3 Urinary tract infection.

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Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.4 Pelvic infection.
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Figure 16

Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.4 Pelvic infection.

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Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.6 Postoperative fever.
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Figure 17

Funnel plot of comparison: 1 Any antibiotic versus placebo, outcome: 1.6 Postoperative fever.

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Comparison 1 Any antibiotic versus placebo, Outcome 1 Total postoperative infections ‐ early and late.
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Analysis 1.1

Comparison 1 Any antibiotic versus placebo, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 1 Any antibiotic versus placebo, Outcome 2 Abdominal wound infection.
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Analysis 1.2

Comparison 1 Any antibiotic versus placebo, Outcome 2 Abdominal wound infection.

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Comparison 1 Any antibiotic versus placebo, Outcome 3 Urinary tract infection.
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Analysis 1.3

Comparison 1 Any antibiotic versus placebo, Outcome 3 Urinary tract infection.

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Comparison 1 Any antibiotic versus placebo, Outcome 4 Pelvic infection.
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Analysis 1.4

Comparison 1 Any antibiotic versus placebo, Outcome 4 Pelvic infection.

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Comparison 1 Any antibiotic versus placebo, Outcome 5 Other serious infections.
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Analysis 1.5

Comparison 1 Any antibiotic versus placebo, Outcome 5 Other serious infections.

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Comparison 1 Any antibiotic versus placebo, Outcome 6 Postoperative fever.
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Analysis 1.6

Comparison 1 Any antibiotic versus placebo, Outcome 6 Postoperative fever.

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Comparison 1 Any antibiotic versus placebo, Outcome 7 Total adverse effects.
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Analysis 1.7

Comparison 1 Any antibiotic versus placebo, Outcome 7 Total adverse effects.

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Comparison 1 Any antibiotic versus placebo, Outcome 8 Need for therapeutic antibiotics.
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Analysis 1.8

Comparison 1 Any antibiotic versus placebo, Outcome 8 Need for therapeutic antibiotics.

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Comparison 1 Any antibiotic versus placebo, Outcome 9 Length of hospital stay.
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Analysis 1.9

Comparison 1 Any antibiotic versus placebo, Outcome 9 Length of hospital stay.

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Comparison 2 Cephalosporin versus placebo, Outcome 1 Total postoperative infections ‐ early and late.
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Analysis 2.1

Comparison 2 Cephalosporin versus placebo, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 2 Cephalosporin versus placebo, Outcome 2 Abdominal wound infection.
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Analysis 2.2

Comparison 2 Cephalosporin versus placebo, Outcome 2 Abdominal wound infection.

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Comparison 2 Cephalosporin versus placebo, Outcome 3 Urinary tract infection.
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Analysis 2.3

Comparison 2 Cephalosporin versus placebo, Outcome 3 Urinary tract infection.

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Comparison 2 Cephalosporin versus placebo, Outcome 4 Pelvic infection.
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Analysis 2.4

Comparison 2 Cephalosporin versus placebo, Outcome 4 Pelvic infection.

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Comparison 2 Cephalosporin versus placebo, Outcome 5 Other serious infections.
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Analysis 2.5

Comparison 2 Cephalosporin versus placebo, Outcome 5 Other serious infections.

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Comparison 2 Cephalosporin versus placebo, Outcome 6 Postoperative fever.
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Analysis 2.6

Comparison 2 Cephalosporin versus placebo, Outcome 6 Postoperative fever.

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Comparison 2 Cephalosporin versus placebo, Outcome 7 Total adverse effects.
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Analysis 2.7

Comparison 2 Cephalosporin versus placebo, Outcome 7 Total adverse effects.

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Comparison 2 Cephalosporin versus placebo, Outcome 8 Need for therapeutic antibiotics.
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Analysis 2.8

Comparison 2 Cephalosporin versus placebo, Outcome 8 Need for therapeutic antibiotics.

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Comparison 2 Cephalosporin versus placebo, Outcome 9 Length of hospital stay.
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Analysis 2.9

Comparison 2 Cephalosporin versus placebo, Outcome 9 Length of hospital stay.

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Comparison 3 Penicillin versus placebo, Outcome 1 Total postoperative infections ‐ early and late.
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Analysis 3.1

Comparison 3 Penicillin versus placebo, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 3 Penicillin versus placebo, Outcome 2 Abdominal wound infection.
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Analysis 3.2

Comparison 3 Penicillin versus placebo, Outcome 2 Abdominal wound infection.

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Comparison 3 Penicillin versus placebo, Outcome 3 Urinary tract infection.
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Analysis 3.3

Comparison 3 Penicillin versus placebo, Outcome 3 Urinary tract infection.

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Comparison 3 Penicillin versus placebo, Outcome 4 Pelvic infection.
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Analysis 3.4

Comparison 3 Penicillin versus placebo, Outcome 4 Pelvic infection.

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Comparison 3 Penicillin versus placebo, Outcome 5 Other serious infections.
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Analysis 3.5

Comparison 3 Penicillin versus placebo, Outcome 5 Other serious infections.

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Comparison 3 Penicillin versus placebo, Outcome 6 Postoperative fever.
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Analysis 3.6

Comparison 3 Penicillin versus placebo, Outcome 6 Postoperative fever.

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Comparison 4 Antiprotozoal versus placebo, Outcome 1 Abdominal wound infection.
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Analysis 4.1

Comparison 4 Antiprotozoal versus placebo, Outcome 1 Abdominal wound infection.

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Comparison 4 Antiprotozoal versus placebo, Outcome 2 Urinary tract infection.
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Analysis 4.2

Comparison 4 Antiprotozoal versus placebo, Outcome 2 Urinary tract infection.

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Comparison 4 Antiprotozoal versus placebo, Outcome 3 Pelvic infection.
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Analysis 4.3

Comparison 4 Antiprotozoal versus placebo, Outcome 3 Pelvic infection.

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Comparison 4 Antiprotozoal versus placebo, Outcome 4 Other serious infections.
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Analysis 4.4

Comparison 4 Antiprotozoal versus placebo, Outcome 4 Other serious infections.

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Comparison 4 Antiprotozoal versus placebo, Outcome 5 Postoperative fever.
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Analysis 4.5

Comparison 4 Antiprotozoal versus placebo, Outcome 5 Postoperative fever.

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Comparison 4 Antiprotozoal versus placebo, Outcome 6 Total adverse effects.
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Analysis 4.6

Comparison 4 Antiprotozoal versus placebo, Outcome 6 Total adverse effects.

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Comparison 4 Antiprotozoal versus placebo, Outcome 7 Need for therapeutic antibiotics.
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Analysis 4.7

Comparison 4 Antiprotozoal versus placebo, Outcome 7 Need for therapeutic antibiotics.

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Comparison 4 Antiprotozoal versus placebo, Outcome 8 Length of hospital stay.
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Analysis 4.8

Comparison 4 Antiprotozoal versus placebo, Outcome 8 Length of hospital stay.

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Comparison 5 Sulphonamides versus placebo, Outcome 1 Abdominal wound infection.
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Analysis 5.1

Comparison 5 Sulphonamides versus placebo, Outcome 1 Abdominal wound infection.

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Comparison 5 Sulphonamides versus placebo, Outcome 2 Urinary tract infection.
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Analysis 5.2

Comparison 5 Sulphonamides versus placebo, Outcome 2 Urinary tract infection.

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Comparison 5 Sulphonamides versus placebo, Outcome 3 Pelvic infection.
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Analysis 5.3

Comparison 5 Sulphonamides versus placebo, Outcome 3 Pelvic infection.

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Comparison 5 Sulphonamides versus placebo, Outcome 4 Postoperative fever.
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Analysis 5.4

Comparison 5 Sulphonamides versus placebo, Outcome 4 Postoperative fever.

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Comparison 5 Sulphonamides versus placebo, Outcome 5 Length of hospital stay.
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Analysis 5.5

Comparison 5 Sulphonamides versus placebo, Outcome 5 Length of hospital stay.

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Comparison 6 Cephalosporin + antiprotozoal versus placebo, Outcome 1 Abdominal wound infection.
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Analysis 6.1

Comparison 6 Cephalosporin + antiprotozoal versus placebo, Outcome 1 Abdominal wound infection.

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Comparison 6 Cephalosporin + antiprotozoal versus placebo, Outcome 2 Urinary tract infection.
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Analysis 6.2

Comparison 6 Cephalosporin + antiprotozoal versus placebo, Outcome 2 Urinary tract infection.

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Comparison 6 Cephalosporin + antiprotozoal versus placebo, Outcome 3 Pelvic infection.
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Analysis 6.3

Comparison 6 Cephalosporin + antiprotozoal versus placebo, Outcome 3 Pelvic infection.

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Comparison 6 Cephalosporin + antiprotozoal versus placebo, Outcome 4 Postoperative fever.
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Analysis 6.4

Comparison 6 Cephalosporin + antiprotozoal versus placebo, Outcome 4 Postoperative fever.

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Comparison 6 Cephalosporin + antiprotozoal versus placebo, Outcome 5 Need for therapeutic antibiotics.
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Analysis 6.5

Comparison 6 Cephalosporin + antiprotozoal versus placebo, Outcome 5 Need for therapeutic antibiotics.

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Comparison 6 Cephalosporin + antiprotozoal versus placebo, Outcome 6 Length of hospital stay.
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Analysis 6.6

Comparison 6 Cephalosporin + antiprotozoal versus placebo, Outcome 6 Length of hospital stay.

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Comparison 7 Penicillin + antiprotozoal versus placebo, Outcome 1 Total postoperative infections ‐ early and late.
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Analysis 7.1

Comparison 7 Penicillin + antiprotozoal versus placebo, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 7 Penicillin + antiprotozoal versus placebo, Outcome 2 Abdominal wound infection.
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Analysis 7.2

Comparison 7 Penicillin + antiprotozoal versus placebo, Outcome 2 Abdominal wound infection.

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Comparison 7 Penicillin + antiprotozoal versus placebo, Outcome 3 Urinary tract infection.
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Analysis 7.3

Comparison 7 Penicillin + antiprotozoal versus placebo, Outcome 3 Urinary tract infection.

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Comparison 7 Penicillin + antiprotozoal versus placebo, Outcome 4 Pelvic infection.
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Analysis 7.4

Comparison 7 Penicillin + antiprotozoal versus placebo, Outcome 4 Pelvic infection.

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Comparison 7 Penicillin + antiprotozoal versus placebo, Outcome 5 Postoperative fever.
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Analysis 7.5

Comparison 7 Penicillin + antiprotozoal versus placebo, Outcome 5 Postoperative fever.

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Comparison 8 Lincosamide versus placebo, Outcome 1 Urinary tract infection.
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Analysis 8.1

Comparison 8 Lincosamide versus placebo, Outcome 1 Urinary tract infection.

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Comparison 8 Lincosamide versus placebo, Outcome 2 Postoperative fever.
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Analysis 8.2

Comparison 8 Lincosamide versus placebo, Outcome 2 Postoperative fever.

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Comparison 8 Lincosamide versus placebo, Outcome 3 Length of hospital stay.
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Analysis 8.3

Comparison 8 Lincosamide versus placebo, Outcome 3 Length of hospital stay.

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Comparison 9 Cephalosporin versus penicillin, Outcome 1 Total postoperative infections ‐ early and late.
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Analysis 9.1

Comparison 9 Cephalosporin versus penicillin, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 9 Cephalosporin versus penicillin, Outcome 2 Abdominal wound infection.
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Analysis 9.2

Comparison 9 Cephalosporin versus penicillin, Outcome 2 Abdominal wound infection.

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Comparison 9 Cephalosporin versus penicillin, Outcome 3 Urinary tract infection.
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Analysis 9.3

Comparison 9 Cephalosporin versus penicillin, Outcome 3 Urinary tract infection.

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Comparison 9 Cephalosporin versus penicillin, Outcome 4 Pelvic infection.
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Analysis 9.4

Comparison 9 Cephalosporin versus penicillin, Outcome 4 Pelvic infection.

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Comparison 9 Cephalosporin versus penicillin, Outcome 5 Other serious infections.
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Analysis 9.5

Comparison 9 Cephalosporin versus penicillin, Outcome 5 Other serious infections.

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Comparison 9 Cephalosporin versus penicillin, Outcome 6 Postoperative fever.
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Analysis 9.6

Comparison 9 Cephalosporin versus penicillin, Outcome 6 Postoperative fever.

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Comparison 9 Cephalosporin versus penicillin, Outcome 7 Total adverse effects.
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Analysis 9.7

Comparison 9 Cephalosporin versus penicillin, Outcome 7 Total adverse effects.

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Comparison 9 Cephalosporin versus penicillin, Outcome 8 Need for therapeutic antibiotics.
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Analysis 9.8

Comparison 9 Cephalosporin versus penicillin, Outcome 8 Need for therapeutic antibiotics.

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Comparison 9 Cephalosporin versus penicillin, Outcome 9 Length of hospital stay.
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Analysis 9.9

Comparison 9 Cephalosporin versus penicillin, Outcome 9 Length of hospital stay.

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Comparison 10 Cephalosporin versus tetracycline, Outcome 1 Total postoperative infections ‐ early and late.
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Analysis 10.1

Comparison 10 Cephalosporin versus tetracycline, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 10 Cephalosporin versus tetracycline, Outcome 2 Pelvic infection.
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Analysis 10.2

Comparison 10 Cephalosporin versus tetracycline, Outcome 2 Pelvic infection.

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Comparison 10 Cephalosporin versus tetracycline, Outcome 3 Postoperative fever.
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Analysis 10.3

Comparison 10 Cephalosporin versus tetracycline, Outcome 3 Postoperative fever.

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Comparison 10 Cephalosporin versus tetracycline, Outcome 4 Length of hospital stay.
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Analysis 10.4

Comparison 10 Cephalosporin versus tetracycline, Outcome 4 Length of hospital stay.

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Comparison 11 Cephalosporin versus antiprotozoal, Outcome 1 Total postoperative infections ‐ early and late.
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Analysis 11.1

Comparison 11 Cephalosporin versus antiprotozoal, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 11 Cephalosporin versus antiprotozoal, Outcome 2 Urinary tract infection.
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Analysis 11.2

Comparison 11 Cephalosporin versus antiprotozoal, Outcome 2 Urinary tract infection.

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Comparison 11 Cephalosporin versus antiprotozoal, Outcome 3 Pelvic infection.
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Analysis 11.3

Comparison 11 Cephalosporin versus antiprotozoal, Outcome 3 Pelvic infection.

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Comparison 11 Cephalosporin versus antiprotozoal, Outcome 4 Postoperative fever.
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Analysis 11.4

Comparison 11 Cephalosporin versus antiprotozoal, Outcome 4 Postoperative fever.

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Comparison 11 Cephalosporin versus antiprotozoal, Outcome 5 Need for therapeutic antibiotics.
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Analysis 11.5

Comparison 11 Cephalosporin versus antiprotozoal, Outcome 5 Need for therapeutic antibiotics.

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Comparison 11 Cephalosporin versus antiprotozoal, Outcome 6 Length of hospital stay.
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Analysis 11.6

Comparison 11 Cephalosporin versus antiprotozoal, Outcome 6 Length of hospital stay.

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Comparison 12 Antiprotozoal versus lincosamide, Outcome 1 Urinary tract infection.
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Analysis 12.1

Comparison 12 Antiprotozoal versus lincosamide, Outcome 1 Urinary tract infection.

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Comparison 12 Antiprotozoal versus lincosamide, Outcome 2 Postoperative fever.
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Analysis 12.2

Comparison 12 Antiprotozoal versus lincosamide, Outcome 2 Postoperative fever.

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Comparison 12 Antiprotozoal versus lincosamide, Outcome 3 Length of hospital stay.
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Analysis 12.3

Comparison 12 Antiprotozoal versus lincosamide, Outcome 3 Length of hospital stay.

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Comparison 13 Cephalosporin + antiprotozoal versus cephalosporin only, Outcome 1 Postoperative fever.
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Analysis 13.1

Comparison 13 Cephalosporin + antiprotozoal versus cephalosporin only, Outcome 1 Postoperative fever.

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Comparison 13 Cephalosporin + antiprotozoal versus cephalosporin only, Outcome 2 Length of hospital stay.
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Analysis 13.2

Comparison 13 Cephalosporin + antiprotozoal versus cephalosporin only, Outcome 2 Length of hospital stay.

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Comparison 14 Cephalosporin + antiprotozoal versus antiprotozoal only, Outcome 1 Total postoperative infections ‐ early and late.
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Analysis 14.1

Comparison 14 Cephalosporin + antiprotozoal versus antiprotozoal only, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 14 Cephalosporin + antiprotozoal versus antiprotozoal only, Outcome 2 Urinary tract infection.
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Analysis 14.2

Comparison 14 Cephalosporin + antiprotozoal versus antiprotozoal only, Outcome 2 Urinary tract infection.

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Comparison 14 Cephalosporin + antiprotozoal versus antiprotozoal only, Outcome 3 Pelvic infection.
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Analysis 14.3

Comparison 14 Cephalosporin + antiprotozoal versus antiprotozoal only, Outcome 3 Pelvic infection.

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Comparison 14 Cephalosporin + antiprotozoal versus antiprotozoal only, Outcome 4 Postoperative fever.
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Analysis 14.4

Comparison 14 Cephalosporin + antiprotozoal versus antiprotozoal only, Outcome 4 Postoperative fever.

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Comparison 14 Cephalosporin + antiprotozoal versus antiprotozoal only, Outcome 5 Need for therapeutic antibiotics.
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Analysis 14.5

Comparison 14 Cephalosporin + antiprotozoal versus antiprotozoal only, Outcome 5 Need for therapeutic antibiotics.

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Comparison 14 Cephalosporin + antiprotozoal versus antiprotozoal only, Outcome 6 Length of hospital stay.
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Analysis 14.6

Comparison 14 Cephalosporin + antiprotozoal versus antiprotozoal only, Outcome 6 Length of hospital stay.

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Comparison 15 Penicillin + antiprotozoal versus penicillin only, Outcome 1 Total postoperative infections ‐ early and late.
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Analysis 15.1

Comparison 15 Penicillin + antiprotozoal versus penicillin only, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 15 Penicillin + antiprotozoal versus penicillin only, Outcome 2 Abdominal wound infection.
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Analysis 15.2

Comparison 15 Penicillin + antiprotozoal versus penicillin only, Outcome 2 Abdominal wound infection.

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Comparison 15 Penicillin + antiprotozoal versus penicillin only, Outcome 3 Urinary tract infection.
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Analysis 15.3

Comparison 15 Penicillin + antiprotozoal versus penicillin only, Outcome 3 Urinary tract infection.

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Comparison 15 Penicillin + antiprotozoal versus penicillin only, Outcome 4 Postoperative fever.
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Analysis 15.4

Comparison 15 Penicillin + antiprotozoal versus penicillin only, Outcome 4 Postoperative fever.

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Comparison 15 Penicillin + antiprotozoal versus penicillin only, Outcome 5 Length of hospital stay.
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Analysis 15.5

Comparison 15 Penicillin + antiprotozoal versus penicillin only, Outcome 5 Length of hospital stay.

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Comparison 16 Cephalosporin: early administration versus usual timing (both single dose), Outcome 1 Abdominal wound infection.
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Analysis 16.1

Comparison 16 Cephalosporin: early administration versus usual timing (both single dose), Outcome 1 Abdominal wound infection.

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Comparison 16 Cephalosporin: early administration versus usual timing (both single dose), Outcome 2 Pelvic infection.
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Analysis 16.2

Comparison 16 Cephalosporin: early administration versus usual timing (both single dose), Outcome 2 Pelvic infection.

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Comparison 17 Cephalosporin: one dose versus two doses, Outcome 1 Total postoperative infections ‐ early and late.
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Analysis 17.1

Comparison 17 Cephalosporin: one dose versus two doses, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 17 Cephalosporin: one dose versus two doses, Outcome 2 Postoperative fever.
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Analysis 17.2

Comparison 17 Cephalosporin: one dose versus two doses, Outcome 2 Postoperative fever.

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Comparison 17 Cephalosporin: one dose versus two doses, Outcome 3 Need for therapeutic antibiotics.
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Analysis 17.3

Comparison 17 Cephalosporin: one dose versus two doses, Outcome 3 Need for therapeutic antibiotics.

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Comparison 18 Cephalosporin: one dose versus three doses, Outcome 1 Total postoperative infections ‐ early and late.
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Analysis 18.1

Comparison 18 Cephalosporin: one dose versus three doses, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 18 Cephalosporin: one dose versus three doses, Outcome 2 Pelvic infection.
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Analysis 18.2

Comparison 18 Cephalosporin: one dose versus three doses, Outcome 2 Pelvic infection.

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Comparison 18 Cephalosporin: one dose versus three doses, Outcome 3 Postoperative fever.
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Analysis 18.3

Comparison 18 Cephalosporin: one dose versus three doses, Outcome 3 Postoperative fever.

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Comparison 18 Cephalosporin: one dose versus three doses, Outcome 4 Length of hospital stay.
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Analysis 18.4

Comparison 18 Cephalosporin: one dose versus three doses, Outcome 4 Length of hospital stay.

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Comparison 19 Cephalosporin: one dose versus multiple doses, Outcome 1 Total postoperative infections ‐ early and late.
Figures and Tables -
Analysis 19.1

Comparison 19 Cephalosporin: one dose versus multiple doses, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 19 Cephalosporin: one dose versus multiple doses, Outcome 2 Urinary tract infection.
Figures and Tables -
Analysis 19.2

Comparison 19 Cephalosporin: one dose versus multiple doses, Outcome 2 Urinary tract infection.

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Comparison 19 Cephalosporin: one dose versus multiple doses, Outcome 3 Pelvic infection.
Figures and Tables -
Analysis 19.3

Comparison 19 Cephalosporin: one dose versus multiple doses, Outcome 3 Pelvic infection.

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Comparison 19 Cephalosporin: one dose versus multiple doses, Outcome 4 Postoperative fever.
Figures and Tables -
Analysis 19.4

Comparison 19 Cephalosporin: one dose versus multiple doses, Outcome 4 Postoperative fever.

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Comparison 20 Cephalosporin one gram versus two grams, Outcome 1 Total postoperative infections ‐ early and late.
Figures and Tables -
Analysis 20.1

Comparison 20 Cephalosporin one gram versus two grams, Outcome 1 Total postoperative infections ‐ early and late.

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Comparison 20 Cephalosporin one gram versus two grams, Outcome 2 Pelvic infection.
Figures and Tables -
Analysis 20.2

Comparison 20 Cephalosporin one gram versus two grams, Outcome 2 Pelvic infection.

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Comparison 20 Cephalosporin one gram versus two grams, Outcome 3 Postoperative fever.
Figures and Tables -
Analysis 20.3

Comparison 20 Cephalosporin one gram versus two grams, Outcome 3 Postoperative fever.

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Comparison 20 Cephalosporin one gram versus two grams, Outcome 4 Need for therapeutic antibiotics.
Figures and Tables -
Analysis 20.4

Comparison 20 Cephalosporin one gram versus two grams, Outcome 4 Need for therapeutic antibiotics.

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Comparison 20 Cephalosporin one gram versus two grams, Outcome 5 Length of hospital stay.
Figures and Tables -
Analysis 20.5

Comparison 20 Cephalosporin one gram versus two grams, Outcome 5 Length of hospital stay.

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Summary of findings for the main comparison. Antibiotics compared with placebo for prophylaxis in elective vaginal hysterectomy

Antibiotics compared with placebo for prophylaxis in elective vaginal hysterectomy

Population: women having elective vaginal hysterectomy
Settings: hospital
Intervention: antibiotics
Comparison: placebo

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Placebo

Antibiotics

Total postoperative infections ‐ early and late

Moderatea

RR 0.28
(0.19 to 0.4)

293
(4 studies)

⊕⊕⊕⊝
lowb,c,f

618 per 1000

173 per 1000
(117 to 247)

Urinary tract infection

Moderatea

RR 0.58
(0.43 to 0.77)

1473
(8 studies)

⊕⊕⊕⊝
moderateb

127 per 1000

74 per 1000
(55 to 98)

Pelvic infection

Moderatea

RR 0.28
(0.20 to 0.39)

1693
(11 studies)

⊕⊕⊕⊝
moderateb,d

134 per 1000

38 per 1000
(27 to 52)

Other serious infections

Moderatea

RR 0.20
(0.01 to 4.10)

146
(1 study)

⊕⊝⊝⊝
very lowb,e

27 per 1000

5 per 1000
(0 to 111)

Postoperative fever

Moderatea

RR 0.43
(0.34 to 0.54)

1562
(9 studies)

⊕⊕⊕⊝
moderateb

219 per 1000

94 per 1000
(74 to 118)

Total adverse effects ‐ not reported

This outcome was not reported

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI)
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

aMedian baseline risk of control group
bDowngraded one level for serious risk of bias: sequence generation and allocation concealment assessed as "unclear" in some studies owing to poor reporting
cSubstantial heterogeneity for this comparison (I2 = 85%). The quality of the evidence was not downgraded for inconsistency, as the direction of effect was consistent and all inconsistency was attributable to a study that measured only early postoperative infection rates (to hospital discharge), whereas the other three studies measured both early and late infection
dSubstantial heterogeneity for this comparison (I2 = 57%), but the quality of the evidence was not downgraded for inconsistency, as the direction of effect was consistent
eDowngraded two levels for very serious imprecision: small sample size and effect estimate with wide confidence interval

fDowngraded two levels for serious imprecision: small sample size

Figures and Tables -
Summary of findings for the main comparison. Antibiotics compared with placebo for prophylaxis in elective vaginal hysterectomy
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Summary of findings 2. Antibiotics compared with placebo for prophylaxis in elective abdominal hysterectomy

Antibiotics compared with placebo for prophylaxis in elective abdominal hysterectomy

Population: women having elective abdominal hysterectomy
Settings: hospital
Intervention: antibiotics
Comparison: placebo

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Placebo

Antibiotics

Total postoperative infections ‐ early and late

Moderatea

RR 0.38
(0.21 to 0.67)

158
(1 study)

⊕⊕⊝⊝
lowb,c

388 per 1000

147 per 1000
(82 to 260)

Abdominal wound infection

Moderatea

RR 0.51
(0.36 to 0.73)

2247
(11 studies)

⊕⊕⊕⊝
moderateb

65 per 1000

33 per 1000
(23 to 47)

Urinary tract infection

Moderatea

RR 0.41
(0.31 to 0.53)

2705
(11 studies)

⊕⊕⊕⊝
moderateb

132 per 1000

54 per 1000
(41 to 70)

Pelvic infection

Moderatea

RR 0.50
(0.35 to 0.71)

1883
(11 studies)

⊕⊕⊕⊝
moderateb

83 per 1000

42 per 1000
(29 to 59)

Other serious infections

Moderatea

RR 0.44
(0.12 to 1.69)

476
(2 studies)

⊕⊝⊝⊝
very lowb,d,e

27 per 1000

12 per 1000
(3 to 46)

Postoperative fever

Moderatea

RR 0.59
(0.50 to 0.70)

2394
(11 studies)

⊕⊕⊕⊝
moderateb

242 per 1000

143 per 1000
(121 to 169)

Total adverse effects

Moderatea

RR 1.80
(0.62 to 5.18)

430
(2 studies)

⊕⊝⊝⊝
very lowb,e

23 per 1000

41 per 1000
(14 to 119)

*The basis for assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI)
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

aMedian baseline risk of control group
bDowngraded one level for serious risk of bias: sequence generation and/or allocation concealment assessed as "unclear" in some studies owing to poor reporting
cDowngraded one level for serious imprecision: small sample size
dSubstantial heterogeneity for this comparison (I2 = 51%), but the quality of the evidence was not downgraded for inconsistency, as the direction of effect was consistent
eDowngraded two levels for very serious imprecision: small sample size and effect estimate with wide confidence interval

Figures and Tables -
Summary of findings 2. Antibiotics compared with placebo for prophylaxis in elective abdominal hysterectomy
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Summary of findings 3. Head‐to‐head comparisons of antibiotics for prophylaxis in elective vaginal hysterectomy

Antibiotics compared with alternative antibiotics for prophylaxis in elective vaginal hysterectomy

Population: women having elective vaginal hysterectomy
Settings: hospital
Intervention: antibiotics
Comparison: alternative antibiotics

Outcomes

Illustrative comparative risks

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Antibiotics vs alternative antibiotics

  • Total postoperative infections ‐ early and late

  • Urinary tract infection

  • Pelvic infection

  • Other serious infections

  • Postoperative fever

When data were available, no evidence showed a difference between any groups compared for any of our primary outcomes, except:

  • fewer cases of total postoperative infection and postoperative fever in women who received cephalosporin than in those who received antiprotozoal

  • fewer cases of total postoperative infection, UTI, or postoperative fever in women receiving cephalosporin with antiprotozoal than in those receiving antiprotozoal only

  • cephalosporin vs penicillin (2 RCTs, 470 women)

  • cephalosporin vs tetracycline (1 RCT, 51 women)

  • cephalosporin vs antiprotozoal (1 RCT, 78 women)

  • antiprotozoal vs lincosamide (1 RCT, 80 women)

  • cephalosporin plus antiprotozoal vs cephalosporin only (1 RCT, 78 women)

  • cephalosporin plus antiprotozoal vs antiprotozoal only (1 RCT, 78 women)

  • penicillin plus antiprotozoal vs penicillin only (1 RCT, 18 women)

⊕⊝⊝⊝
very lowa,b

Total adverse effects

  • No evidence of a difference between cephalosporin and penicillin.

  • No data available for other comparisons

  • cephalosporin vs penicillin (2 RCTs, 451 women)

⊕⊝⊝⊝
very lowa,b

CI: confidence interval; RCT: randomised controlled trial

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

aDowngraded two levels for very serious imprecision with very few events and wide confidence intervals
bDowngraded one level for serious risk of bias: methods were poorly reported in most studies

Figures and Tables -
Summary of findings 3. Head‐to‐head comparisons of antibiotics for prophylaxis in elective vaginal hysterectomy
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Summary of findings 4. Head‐to‐head comparisons of antibiotics for prophylaxis in elective abdominal hysterectomy

Head‐to‐head comparisons of antibiotics for prophylaxis in elective abdominal hysterectomy

Population: women having elective abdominal hysterectomy
Settings: hospital
Intervention: antibiotics
Comparison: alternative antibiotics

Outcomes

Illustrative comparative risks

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Antibiotics vs alternative antibiotics

  • Total postoperative infections ‐ early and late

  • Abdominal wound infection

  • Urinary tract infection

  • Pelvic infection

  • Other serious infections

  • Postoperative fever

  • No clear evidence of differences between groups

  • cephalosporin vs penicillin (1 RCT, 220 women)

  • penicillin plus antiprotozoal vs penicillin only (2 RCT, 155 women)

⊕⊝⊝⊝
very low1,2

  • Total adverse effects

  • No data reported on adverse effects

CI: confidence interval; RCT: randomised controlled trial

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

aDowngraded two levels for very serious imprecision with very few events and wide confidence intervals
bDowngraded one level for serious risk of bias: methods were poorly reported in most studies

Figures and Tables -
Summary of findings 4. Head‐to‐head comparisons of antibiotics for prophylaxis in elective abdominal hysterectomy
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Comparison 1. Any antibiotic versus placebo

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

4

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

4

293

Risk Ratio (M‐H, Fixed, 95% CI)

0.28 [0.19, 0.40]

1.2 Abdominal hysterectomy

1

158

Risk Ratio (M‐H, Fixed, 95% CI)

0.38 [0.21, 0.67]

2 Abdominal wound infection Show forest plot

11

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Abdominal hysterectomy

11

2247

Risk Ratio (M‐H, Fixed, 95% CI)

0.51 [0.36, 0.73]

3 Urinary tract infection Show forest plot

16

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

8

1473

Risk Ratio (M‐H, Fixed, 95% CI)

0.58 [0.43, 0.77]

3.2 Abdominal hysterectomy

12

2705

Risk Ratio (M‐H, Fixed, 95% CI)

0.41 [0.31, 0.53]

4 Pelvic infection Show forest plot

19

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

11

1693

Risk Ratio (M‐H, Fixed, 95% CI)

0.28 [0.20, 0.39]

4.2 Abdominal hysterectomy

11

1883

Risk Ratio (M‐H, Fixed, 95% CI)

0.50 [0.35, 0.71]

5 Other serious infections Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1 Vaginal hysterectomy

1

146

Risk Ratio (M‐H, Fixed, 95% CI)

0.2 [0.01, 4.10]

5.2 Abdominal hysterectomy

2

476

Risk Ratio (M‐H, Fixed, 95% CI)

0.44 [0.12, 1.69]

6 Postoperative fever Show forest plot

16

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

6.1 Vaginal hysterectomy

9

1562

Risk Ratio (M‐H, Fixed, 95% CI)

0.43 [0.34, 0.54]

6.2 Abdominal hysterectomy

11

2394

Risk Ratio (M‐H, Fixed, 95% CI)

0.59 [0.50, 0.70]

7 Total adverse effects Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

7.1 Abdominal hysterectomy

2

430

Risk Ratio (M‐H, Fixed, 95% CI)

1.8 [0.62, 5.18]

8 Need for therapeutic antibiotics Show forest plot

9

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

8.1 Vaginal hysterectomy

6

1309

Risk Ratio (M‐H, Fixed, 95% CI)

0.51 [0.37, 0.68]

8.2 Abdominal hysterectomy

6

1359

Risk Ratio (M‐H, Fixed, 95% CI)

0.74 [0.59, 0.93]

9 Length of hospital stay Show forest plot

9

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

9.1 Vaginal hysterectomy

4

853

Mean Difference (IV, Fixed, 95% CI)

‐1.35 [‐1.78, ‐0.92]

9.2 Abdominal hysterectomy

7

1510

Mean Difference (IV, Fixed, 95% CI)

‐0.59 [‐0.76, ‐0.43]
Figures and Tables -
Comparison 1. Any antibiotic versus placebo
Navigate to table in Review
Comparison 2. Cephalosporin versus placebo

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

3

265

Risk Ratio (M‐H, Fixed, 95% CI)

0.29 [0.20, 0.42]

2 Abdominal wound infection Show forest plot

7

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Abdominal hysterectomy

7

1528

Risk Ratio (M‐H, Fixed, 95% CI)

0.41 [0.25, 0.66]

3 Urinary tract infection Show forest plot

8

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

5

499

Risk Ratio (M‐H, Fixed, 95% CI)

0.71 [0.46, 1.08]

3.2 Abdominal hysterectomy

6

1668

Risk Ratio (M‐H, Fixed, 95% CI)

0.42 [0.31, 0.58]

4 Pelvic infection Show forest plot

10

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

6

1281

Risk Ratio (M‐H, Fixed, 95% CI)

0.15 [0.09, 0.28]

4.2 Abdominal hysterectomy

7

1528

Risk Ratio (M‐H, Fixed, 95% CI)

0.60 [0.39, 0.93]

5 Other serious infections Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1 Vaginal hysterectomy

1

206

Risk Ratio (M‐H, Fixed, 95% CI)

0.2 [0.01, 4.12]

5.2 Abdominal hysterectomy

1

220

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.04, 3.16]

6 Postoperative fever Show forest plot

9

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

6.1 Vaginal hysterectomy

5

1028

Risk Ratio (M‐H, Fixed, 95% CI)

0.37 [0.25, 0.54]

6.2 Abdominal hysterectomy

6

1463

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.49, 0.77]

7 Total adverse effects Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

7.1 Abdominal hysterectomy

1

284

Risk Ratio (M‐H, Fixed, 95% CI)

1.0 [0.06, 15.83]

8 Need for therapeutic antibiotics Show forest plot

5

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

8.1 Vaginal hysterectomy

3

863

Risk Ratio (M‐H, Fixed, 95% CI)

0.55 [0.37, 0.81]

8.2 Abdominal hysterectomy

4

1138

Risk Ratio (M‐H, Fixed, 95% CI)

0.79 [0.61, 1.01]

9 Length of hospital stay Show forest plot

5

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

9.1 Vaginal hysterectomy

2

657

Mean Difference (IV, Fixed, 95% CI)

‐1.30 [‐1.88, ‐0.72]

9.2 Abdominal hysterectomy

4

818

Mean Difference (IV, Fixed, 95% CI)

‐0.43 [‐0.67, ‐0.19]
Figures and Tables -
Comparison 2. Cephalosporin versus placebo
Navigate to table in Review
Comparison 3. Penicillin versus placebo

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

1

20

Risk Ratio (M‐H, Fixed, 95% CI)

0.2 [0.03, 1.42]

1.2 Abdominal hysterectomy

1

100

Risk Ratio (M‐H, Fixed, 95% CI)

0.30 [0.13, 0.70]

2 Abdominal wound infection Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Abdominal hysterectomy

2

320

Risk Ratio (M‐H, Fixed, 95% CI)

0.16 [0.05, 0.53]

3 Urinary tract infection Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

20

Risk Ratio (M‐H, Fixed, 95% CI)

0.5 [0.05, 4.67]

3.2 Abdominal hysterectomy

2

320

Risk Ratio (M‐H, Fixed, 95% CI)

0.60 [0.21, 1.76]

4 Pelvic infection Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

1

20

Risk Ratio (M‐H, Fixed, 95% CI)

0.14 [0.01, 2.45]

4.2 Abdominal hysterectomy

1

220

Risk Ratio (M‐H, Fixed, 95% CI)

1.33 [0.31, 5.82]

5 Other serious infections Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1 Abdominal hysterectomy

1

220

Risk Ratio (M‐H, Fixed, 95% CI)

0.14 [0.01, 2.73]

6 Postoperative fever Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

6.1 Vaginal hysterectomy

1

20

Risk Ratio (M‐H, Fixed, 95% CI)

0.14 [0.01, 2.45]

6.2 Abdominal hysterectomy

2

320

Risk Ratio (M‐H, Fixed, 95% CI)

0.65 [0.35, 1.20]
Figures and Tables -
Comparison 3. Penicillin versus placebo
Navigate to table in Review
Comparison 4. Antiprotozoal versus placebo

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Abdominal wound infection Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Abdominal hysterectomy

2

462

Risk Ratio (M‐H, Fixed, 95% CI)

0.71 [0.32, 1.57]

2 Urinary tract infection Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

2

226

Risk Ratio (M‐H, Fixed, 95% CI)

1.25 [0.51, 3.04]

2.2 Abdominal hysterectomy

1

146

Risk Ratio (M‐H, Fixed, 95% CI)

1.0 [0.34, 2.96]

3 Pelvic infection Show forest plot

6

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

4

375

Risk Ratio (M‐H, Fixed, 95% CI)

0.36 [0.17, 0.75]

3.2 Abdominal hysterectomy

4

662

Risk Ratio (M‐H, Fixed, 95% CI)

0.42 [0.22, 0.83]

4 Other serious infections Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

2

246

Risk Ratio (M‐H, Fixed, 95% CI)

0.25 [0.03, 2.21]

4.2 Abdominal hysterectomy

1

146

Risk Ratio (M‐H, Fixed, 95% CI)

1.0 [0.14, 6.91]

5 Postoperative fever Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1 Vaginal hysterectomy

2

130

Risk Ratio (M‐H, Fixed, 95% CI)

0.45 [0.21, 0.97]

5.2 Abdominal hysterectomy

1

100

Risk Ratio (M‐H, Fixed, 95% CI)

0.39 [0.18, 0.85]

6 Total adverse effects Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

6.1 Abdominal hysterectomy

1

146

Risk Ratio (M‐H, Fixed, 95% CI)

2.0 [0.63, 6.35]

7 Need for therapeutic antibiotics Show forest plot

3

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

7.1 Vaginal hysterectomy

2

196

Risk Ratio (M‐H, Random, 95% CI)

0.55 [0.15, 1.95]

7.2 Abdominal hysterectomy

2

246

Risk Ratio (M‐H, Random, 95% CI)

0.55 [0.15, 2.02]

8 Length of hospital stay Show forest plot

5

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

8.1 Vaginal hysterectomy

3

276

Mean Difference (IV, Fixed, 95% CI)

‐0.86 [‐1.22, ‐0.49]

8.2 Abdominal hysterectomy

3

358

Mean Difference (IV, Fixed, 95% CI)

‐1.33 [‐1.68, ‐0.97]
Figures and Tables -
Comparison 4. Antiprotozoal versus placebo
Navigate to table in Review
Comparison 5. Sulphonamides versus placebo

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Abdominal wound infection Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Abdominal hysterectomy

2

119

Risk Ratio (M‐H, Fixed, 95% CI)

1.23 [0.35, 4.35]

2 Urinary tract infection Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

1

50

Risk Ratio (M‐H, Fixed, 95% CI)

0.36 [0.15, 0.84]

2.2 Abdominal hysterectomy

2

157

Risk Ratio (M‐H, Fixed, 95% CI)

0.18 [0.06, 0.50]

3 Pelvic infection Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

50

Risk Ratio (M‐H, Fixed, 95% CI)

0.14 [0.01, 2.63]

3.2 Abdominal hysterectomy

2

119

Risk Ratio (M‐H, Fixed, 95% CI)

0.11 [0.01, 0.84]

4 Postoperative fever Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

1

50

Risk Ratio (M‐H, Fixed, 95% CI)

0.5 [0.26, 0.95]

4.2 Abdominal hysterectomy

2

157

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.38, 1.04]

5 Length of hospital stay Show forest plot

5

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

5.1 Vaginal hysterectomy

3

276

Mean Difference (IV, Fixed, 95% CI)

‐0.86 [‐1.22, ‐0.49]

5.2 Abdominal hysterectomy

3

358

Mean Difference (IV, Fixed, 95% CI)

‐1.33 [‐1.68, ‐0.97]
Figures and Tables -
Comparison 5. Sulphonamides versus placebo
Navigate to table in Review
Comparison 6. Cephalosporin + antiprotozoal versus placebo

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Abdominal wound infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Abdominal hysterectomy

1

406

Risk Ratio (M‐H, Fixed, 95% CI)

1.0 [0.14, 7.03]

2 Urinary tract infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

1

406

Risk Ratio (M‐H, Fixed, 95% CI)

0.5 [0.24, 1.04]

2.2 Abdominal hysterectomy

1

406

Risk Ratio (M‐H, Fixed, 95% CI)

0.27 [0.08, 0.96]

3 Pelvic infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

406

Risk Ratio (M‐H, Fixed, 95% CI)

0.05 [0.01, 0.37]

4 Postoperative fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

1

406

Risk Ratio (M‐H, Fixed, 95% CI)

0.5 [0.34, 0.73]

4.2 Abdominal hysterectomy

1

406

Risk Ratio (M‐H, Fixed, 95% CI)

0.79 [0.58, 1.09]

5 Need for therapeutic antibiotics Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1 Vaginal hysterectomy

1

406

Risk Ratio (M‐H, Fixed, 95% CI)

0.36 [0.19, 0.68]

5.2 Abdominal hysterectomy

1

406

Risk Ratio (M‐H, Fixed, 95% CI)

0.38 [0.15, 0.94]

6 Length of hospital stay Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

6.1 Abdominal hysterectomy

1

406

Mean Difference (IV, Fixed, 95% CI)

‐0.30 [‐0.60, ‐0.00]
Figures and Tables -
Comparison 6. Cephalosporin + antiprotozoal versus placebo
Navigate to table in Review
Comparison 7. Penicillin + antiprotozoal versus placebo

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

1

18

Risk Ratio (M‐H, Fixed, 95% CI)

0.25 [0.04, 1.73]

1.2 Abdominal hysterectomy

1

107

Risk Ratio (M‐H, Fixed, 95% CI)

0.44 [0.23, 0.86]

2 Abdominal wound infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Abdominal hysterectomy

1

107

Risk Ratio (M‐H, Fixed, 95% CI)

0.14 [0.03, 0.60]

3 Urinary tract infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

18

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.07, 5.72]

3.2 Abdominal hysterectomy

1

107

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.38, 2.47]

4 Pelvic infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

1

18

Risk Ratio (M‐H, Fixed, 95% CI)

0.17 [0.01, 2.96]

5 Postoperative fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1 Vaginal hysterectomy

1

18

Risk Ratio (M‐H, Fixed, 95% CI)

0.17 [0.01, 2.96]

5.2 Abdominal hysterectomy

1

107

Risk Ratio (M‐H, Fixed, 95% CI)

0.08 [0.01, 0.64]
Figures and Tables -
Comparison 7. Penicillin + antiprotozoal versus placebo
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Comparison 8. Lincosamide versus placebo

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Urinary tract infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

1

80

Risk Ratio (M‐H, Fixed, 95% CI)

0.71 [0.25, 2.06]

2 Postoperative fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

1

80

Risk Ratio (M‐H, Fixed, 95% CI)

1.0 [0.06, 15.44]

3 Length of hospital stay Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

80

Mean Difference (IV, Fixed, 95% CI)

‐0.40 [‐0.77, ‐0.03]
Figures and Tables -
Comparison 8. Lincosamide versus placebo
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Comparison 9. Cephalosporin versus penicillin

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

2

470

Risk Ratio (M‐H, Fixed, 95% CI)

1.04 [0.55, 2.00]

2 Abdominal wound infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Abdominal hysterectomy

1

220

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.01, 8.09]

3 Urinary tract infection Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

95

Risk Ratio (M‐H, Fixed, 95% CI)

0.20 [0.01, 3.98]

3.2 Abdominal hysterectomy

1

220

Risk Ratio (M‐H, Fixed, 95% CI)

1.0 [0.06, 15.79]

4 Pelvic infection Show forest plot

4

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

3

565

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.47, 1.64]

4.2 Abdominal hysterectomy

1

220

Risk Ratio (M‐H, Fixed, 95% CI)

0.5 [0.09, 2.67]

5 Other serious infections Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1 Vaginal hysterectomy

1

114

Risk Ratio (M‐H, Fixed, 95% CI)

2.90 [0.12, 69.68]

5.2 Abdominal hysterectomy

1

220

Risk Ratio (M‐H, Fixed, 95% CI)

3.0 [0.12, 72.85]

6 Postoperative fever Show forest plot

4

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

6.1 Vaginal hysterectomy

3

565

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.58, 1.15]

6.2 Abdominal hysterectomy

1

220

Risk Ratio (M‐H, Fixed, 95% CI)

0.86 [0.42, 1.77]

7 Total adverse effects Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

7.1 Vaginal hysterectomy

2

451

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.79, 1.14]

8 Need for therapeutic antibiotics Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

8.1 Vaginal hysterectomy

2

470

Risk Ratio (M‐H, Fixed, 95% CI)

1.32 [0.88, 1.97]

9 Length of hospital stay Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

9.1 Vaginal hysterectomy

2

209

Mean Difference (IV, Fixed, 95% CI)

‐0.47 [‐0.97, 0.04]
Figures and Tables -
Comparison 9. Cephalosporin versus penicillin
Navigate to table in Review
Comparison 10. Cephalosporin versus tetracycline

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

1

51

Risk Ratio (M‐H, Fixed, 95% CI)

0.59 [0.20, 1.78]

2 Pelvic infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

1

51

Risk Ratio (M‐H, Fixed, 95% CI)

0.83 [0.25, 2.75]

3 Postoperative fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

51

Risk Ratio (M‐H, Fixed, 95% CI)

0.69 [0.13, 3.81]

4 Length of hospital stay Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

1

51

Mean Difference (IV, Fixed, 95% CI)

‐0.20 [‐1.11, 0.71]
Figures and Tables -
Comparison 10. Cephalosporin versus tetracycline
Navigate to table in Review
Comparison 11. Cephalosporin versus antiprotozoal

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

1

78

Risk Ratio (M‐H, Fixed, 95% CI)

0.04 [0.00, 0.67]

2 Urinary tract infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

1

78

Risk Ratio (M‐H, Fixed, 95% CI)

0.05 [0.00, 0.81]

3 Pelvic infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

78

Risk Ratio (M‐H, Fixed, 95% CI)

0.17 [0.01, 4.03]

4 Postoperative fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

1

78

Risk Ratio (M‐H, Fixed, 95% CI)

0.06 [0.01, 0.42]

5 Need for therapeutic antibiotics Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1 Vaginal hysterectomy

1

78

Risk Ratio (M‐H, Fixed, 95% CI)

0.03 [0.00, 0.44]

6 Length of hospital stay Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

6.1 Vaginal hysterectomy

1

78

Mean Difference (IV, Fixed, 95% CI)

‐1.90 [‐3.32, ‐0.48]
Figures and Tables -
Comparison 11. Cephalosporin versus antiprotozoal
Navigate to table in Review
Comparison 12. Antiprotozoal versus lincosamide

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Urinary tract infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

1

80

Risk Ratio (M‐H, Fixed, 95% CI)

4.0 [0.47, 34.24]

2 Postoperative fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

1

80

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.01, 7.95]

3 Length of hospital stay Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

80

Mean Difference (IV, Fixed, 95% CI)

‐0.20 [‐0.60, 0.20]
Figures and Tables -
Comparison 12. Antiprotozoal versus lincosamide
Navigate to table in Review
Comparison 13. Cephalosporin + antiprotozoal versus cephalosporin only

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Postoperative fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

1

78

Risk Ratio (M‐H, Fixed, 95% CI)

0.5 [0.03, 7.68]

2 Length of hospital stay Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

1

78

Mean Difference (IV, Fixed, 95% CI)

0.30 [‐0.43, 1.03]
Figures and Tables -
Comparison 13. Cephalosporin + antiprotozoal versus cephalosporin only
Navigate to table in Review
Comparison 14. Cephalosporin + antiprotozoal versus antiprotozoal only

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

1

78

Risk Ratio (M‐H, Fixed, 95% CI)

0.04 [0.00, 0.67]

2 Urinary tract infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

1

78

Risk Ratio (M‐H, Fixed, 95% CI)

0.05 [0.00, 0.81]

3 Pelvic infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

78

Risk Ratio (M‐H, Fixed, 95% CI)

0.17 [0.01, 4.03]

4 Postoperative fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

1

78

Risk Ratio (M‐H, Fixed, 95% CI)

0.06 [0.01, 0.42]

5 Need for therapeutic antibiotics Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

5.1 Vaginal hysterectomy

1

78

Risk Ratio (M‐H, Fixed, 95% CI)

0.03 [0.00, 0.44]

6 Length of hospital stay Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

6.1 Vaginal hysterectomy

1

78

Mean Difference (IV, Fixed, 95% CI)

‐1.60 [‐3.11, ‐0.09]
Figures and Tables -
Comparison 14. Cephalosporin + antiprotozoal versus antiprotozoal only
Navigate to table in Review
Comparison 15. Penicillin + antiprotozoal versus penicillin only

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

1

18

Risk Ratio (M‐H, Fixed, 95% CI)

1.25 [0.09, 17.02]

1.2 Abdominal hysterectomy

1

109

Risk Ratio (M‐H, Fixed, 95% CI)

1.47 [0.57, 3.75]

2 Abdominal wound infection Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Abdominal hysterectomy

2

155

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.25, 3.59]

3 Urinary tract infection Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

18

Risk Ratio (M‐H, Fixed, 95% CI)

1.25 [0.09, 17.02]

3.2 Abdominal hysterectomy

2

155

Risk Ratio (M‐H, Fixed, 95% CI)

2.00 [0.80, 4.97]

4 Postoperative fever Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Abdominal hysterectomy

2

155

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.20, 4.50]

5 Length of hospital stay Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

5.1 Vaginal hysterectomy

1

78

Mean Difference (IV, Fixed, 95% CI)

‐1.60 [‐3.11, ‐0.09]
Figures and Tables -
Comparison 15. Penicillin + antiprotozoal versus penicillin only
Navigate to table in Review
Comparison 16. Cephalosporin: early administration versus usual timing (both single dose)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Abdominal wound infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Abdominal hysterectomy

1

252

Risk Ratio (M‐H, Fixed, 95% CI)

0.5 [0.03, 7.90]

2 Pelvic infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

1

252

Risk Ratio (M‐H, Fixed, 95% CI)

1.5 [0.16, 14.20]

2.2 Abdominal hysterectomy

1

252

Risk Ratio (M‐H, Fixed, 95% CI)

1.5 [0.16, 14.20]
Figures and Tables -
Comparison 16. Cephalosporin: early administration versus usual timing (both single dose)
Navigate to table in Review
Comparison 17. Cephalosporin: one dose versus two doses

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Abdominal hysterectomy

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.14, 3.18]

2 Postoperative fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Abdominal hysterectomy

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

2.0 [0.97, 4.13]

3 Need for therapeutic antibiotics Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Abdominal hysterectomy

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

9.90 [0.48, 202.43]
Figures and Tables -
Comparison 17. Cephalosporin: one dose versus two doses
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Comparison 18. Cephalosporin: one dose versus three doses

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

1

116

Risk Ratio (M‐H, Fixed, 95% CI)

0.5 [0.05, 5.36]

2 Pelvic infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

1

116

Risk Ratio (M‐H, Fixed, 95% CI)

0.5 [0.05, 5.36]

3 Postoperative fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

116

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.42, 1.97]

4 Length of hospital stay Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

1

116

Mean Difference (IV, Fixed, 95% CI)

‐0.30 [‐0.72, 0.12]
Figures and Tables -
Comparison 18. Cephalosporin: one dose versus three doses
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Comparison 19. Cephalosporin: one dose versus multiple doses

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

1

44

Risk Ratio (M‐H, Fixed, 95% CI)

5.0 [0.25, 98.52]

2 Urinary tract infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

1

44

Risk Ratio (M‐H, Fixed, 95% CI)

3.0 [0.13, 69.87]

3 Pelvic infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

44

Risk Ratio (M‐H, Fixed, 95% CI)

3.0 [0.13, 69.87]

4 Postoperative fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

1

44

Risk Ratio (M‐H, Fixed, 95% CI)

5.0 [0.25, 98.52]
Figures and Tables -
Comparison 19. Cephalosporin: one dose versus multiple doses
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Comparison 20. Cephalosporin one gram versus two grams

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total postoperative infections ‐ early and late Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Vaginal hysterectomy

1

237

Risk Ratio (M‐H, Fixed, 95% CI)

1.49 [0.25, 8.74]

2 Pelvic infection Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Vaginal hysterectomy

1

237

Risk Ratio (M‐H, Fixed, 95% CI)

1.49 [0.25, 8.74]

3 Postoperative fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 Vaginal hysterectomy

1

237

Risk Ratio (M‐H, Fixed, 95% CI)

1.49 [0.43, 5.14]

4 Need for therapeutic antibiotics Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

4.1 Vaginal hysterectomy

1

237

Risk Ratio (M‐H, Fixed, 95% CI)

1.49 [0.25, 8.74]

5 Length of hospital stay Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

5.1 Vaginal hysterectomy

1

237

Mean Difference (IV, Fixed, 95% CI)

‐0.10 [‐0.60, 0.40]
Figures and Tables -
Comparison 20. Cephalosporin one gram versus two grams
Navigate to table in Review