Preoperative screening strategies for bacterial vaginosis prior to elective hysterectomy: a cost comparison study


      The purpose of this study is to compare costs of 3 strategies for women undergoing hysterectomy: (1) test all patients for bacterial vaginosis; treat if positive; (2) treat all patients for bacterial vaginosis; (3) neither test nor treat patients for bacterial vaginosis. For comparison purposes, a fourth strategy is examined: (4) no surgical site infection prophylaxis or bacterial vaginosis treatment.

      Study Design

      A cost minimization model was created using estimates obtained from the published literature, Medicare reimbursement data, and wholesale drug costs.


      In the base case, the optimal strategy was to treat all patients for bacterial vaginosis, with a cuff infection rate of 4.0% and mean cost of $593. The “test all patients for bacterial vaginosis; treat if positive” strategy was also inexpensive, with a mean cost of $623 and 4.2% cuff infection rate. “Neither test nor treat patients for bacterial vaginosis” and “no surgical site infection prophylaxis or bacterial vaginosis treatment” were more expensive and less effective than other strategies.


      This model suggests that consideration should be given to adding metronidazole to standard surgical site infection prophylaxis before hysterectomy.

      Key words

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        • American College of Obstetricians and Gynecologists
        ACOG practice bulletin no. 104: antibiotic prophylaxis for gynecologic procedures.
        Obstet Gynecol. 2009; 113: 1180-1189
        • Soper D.E.
        Bacterial vaginosis and postoperative infections.
        Am J Obstet Gynecol. 1993; 169: 467-469
        • Larsson P.G.
        • Platz-Christensen J.J.
        • Forsum U.
        • Pahlson C.
        Clue cells in predicting infections after abdominal hysterectomy.
        Obstet Gynecol. 1991; 77: 450-452
        • Persson E.
        • Bergstrom M.
        • Larsson P.G.
        • et al.
        Infections after hysterectomy: a prospective nation-wide Swedish study.
        Acta Obstet Gynecol Scand. 1996; 75: 757-761
        • Livengood C.H.
        Bacterial vaginosis: an overview for 2009.
        Rev Obstet Gynecol. 2009; 2: 28-37
        • Workowski K.A.
        • Berman S.M.
        Sexually transmitted diseases treatment guidelines, 2006.
        MMWR Recomm Rep. 2006; 55: 1-94
        • Lowe N.K.
        • Neal J.L.
        • Ryan-Wenger N.A.
        Accuracy of the clinical diagnosis of vaginitis compared with a DNA probe laboratory standard.
        Obstet Gynecol. 2009; 113: 89-95
        • Oduyebo O.O.
        • Anorlu R.I.
        • Ogunsola F.T.
        The effects of antimicrobial therapy on bacterial vaginosis in non-pregnant women.
        Cochrane Database Syst Rev. 2009; (CD006055)
        • Joesoef M.R.
        • Schmid G.P.
        • Hillier S.L.
        Bacterial vaginosis: review of treatment options and potential clinical indications for therapy.
        Clin Infect Dis. 1999; 28: S57-S65
        • Larsson P.G.
        Treatment of bacterial vaginosis.
        Int J STD AIDS. 1992; 3: 239-247
        • Larsson P.G.
        • Carlsson B.
        Does pre- and postoperative metronidazole treatment lower vaginal cuff infection rate after abdominal hysterectomy among women with bacterial vaginosis?.
        Infect Dis Obstet Gynecol. 2002; 10: 133-140
        • Lin L.
        • Song J.
        • Kimber N.
        • et al.
        The role of bacterial vaginosis in infection after major gynecologic surgery.
        Infect Dis Obstet Gynecol. 1999; 7: 169-174
        • Larsson P.G.
        • Platz-Christensen J.J.
        • Dalaker K.
        • et al.
        Treatment with 2% clindamycin vaginal cream prior to first trimester surgical abortion to reduce signs of postoperative infection: a prospective, double-blinded, placebo-controlled, multicenter study.
        Acta Obstet Gynecol Scand. 2000; 79: 390-396
        • Larsson P.G.
        • Platz-Christensen J.J.
        • Thejls H.
        • Forsum U.
        • Pahlson C.
        Incidence of pelvic inflammatory disease after first-trimester legal abortion in women with bacterial vaginosis after treatment with metronidazole: a double-blind, randomized study.
        Am J Obstet Gynecol. 1992; 166: 100-103
        • Grossman 3rd, J.H.
        • Greco T.P.
        • Minkin M.J.
        • Adams R.L.
        • Hierholzer Jr, W.J.
        • Andriole V.T.
        Prophylactic antibiotics in gynecologic surgery.
        Obstet Gynecol. 1979; 53: 537-544
        • Polk B.F.
        • Tager I.B.
        • Shapiro M.
        • Goren-White B.
        • Goldstein P.
        • Schoenbaum S.C.
        Randomised clinical trial of perioperative cefazolin in preventing infection after hysterectomy.
        Lancet. 1980; 1: 437-440
        • Soper D.E.
        • Bump R.C.
        • Hurt W.G.
        Bacterial vaginosis and trichomoniasis vaginitis are risk factors for cuff cellulitis after abdominal hysterectomy.
        Am J Obstet Gynecol. 1990; 163 (discussion 21-3): 1016-1021
        • Soper D.E.
        • Bump R.C.
        • Hurt W.G.
        Wound infection after abdominal hysterectomy: effect of the depth of subcutaneous tissue.
        Am J Obstet Gynecol. 1995; 173 (discussion 9-71): 465-469
        • Stovall T.G.
        • Summitt Jr, R.L.
        • Lipscomb G.H.
        • Ling F.W.
        Vaginal cuff closure at abdominal hysterectomy: comparing sutures with absorbable staples.
        Obstet Gynecol. 1991; 78: 415-418
        • Allsworth J.E.
        • Peipert J.F.
        Prevalence of bacterial vaginosis: 2001-2004 National Health and Nutrition Examination Survey data.
        Obstet Gynecol. 2007; 109: 114-120
        • Yen S.
        • Shafer M.A.
        • Moncada J.
        • Campbell C.J.
        • Flinn S.D.
        • Boyer C.B.
        Bacterial vaginosis in sexually experienced and non-sexually experienced young women entering the military.
        Obstet Gynecol. 2003; 102: 927-933
        • Cauci S.
        • Driussi S.
        • De Santo D.
        • et al.
        Prevalence of bacterial vaginosis and vaginal flora changes in peri- and postmenopausal women.
        J Clin Microbiol. 2002; 40: 2147-2152
        • Amsel R.
        • Totten P.A.
        • Spiegel C.A.
        • Chen K.C.
        • Eschenbach D.
        • Holmes K.K.
        Nonspecific vaginitis: diagnostic criteria and microbial and epidemiologic associations.
        Am J Med. 1983; 74: 14-22
        • Hemsell D.L.
        • Cunningham F.G.
        • Kappus S.
        • Nobles B.
        Cefoxitin for prophylaxis in premenopausal women undergoing vaginal hysterectomy.
        Obstet Gynecol. 1980; 56: 629-634
      1. 2008 Clinical Diagnostic Laboratory Fee Schedule (CLAB) Public Use File (PUF). American Medical Association, 2008
        • Bartlett J.G.
        Johns Hopkins ABX Guide.
        in: Baltimore M.D. The Johns Hopkins University Division of Infectious Diseases 2010. 2000–2010
      2. Product Information: Flagyl (R) metronidazole tablets.
        G.D. Searle, New York, NY2010
      3. Clinical Phamacology.
        in: Gold Standard Incorporated; 2010. March 2010
        • Flabbee J.
        • Petit N.
        • Jay N.
        • et al.
        The economic costs of severe anaphylaxis in France: an inquiry carried out by the Allergy Vigilance Network.
        Allergy. 2008; 63: 360-365
        • HCUPnet
        Healthcare cost and utilization project.
        Agency for Healthcare Research and Quality, Rockville, MD2008
      4. Nationwide Inpatient Sample.
        Healthcare cost and utilization project agency for healthcare research and quality. 2008
        • Groot Koerkamp B.
        • Weinstein M.C.
        • Stijnen T.
        • Heijenbrok-Kal M.H.
        • Hunink M.G.
        Uncertainty and patient heterogeneity in medical decision models.
        Med Decis Making. 2010; 30: 194-205