For a reproductive‑age woman presenting with acute lower abdominal pain due to ovarian torsion, what pre‑operative antibiotic prophylaxis is recommended, what are the alternatives for β‑lactam allergy, and when should postoperative antimicrobial coverage be extended?

Antibiotic Prophylaxis for Ovarian Torsion Surgery

For ovarian torsion requiring surgical intervention, administer standard preoperative antibiotic prophylaxis within 60 minutes before skin incision (or within 120 minutes for fluoroquinolones/vancomycin), discontinue within 24 hours postoperatively, and extend antimicrobial coverage only if intraoperative findings reveal contamination, necrosis with infection, or the patient develops systemic inflammatory response criteria. 1

Preoperative Antibiotic Prophylaxis

Standard Prophylaxis Protocol

• Administer prophylactic antibiotics within 60 minutes before skin incision to maintain tissue levels exceeding the minimum inhibitory concentration from incision through wound closure 1
• For fluoroquinolones and vancomycin specifically, begin administration within 120 minutes before incision due to longer infusion requirements 1
• Ovarian torsion surgery is classified as a clean (Class I) surgical wound, which qualifies for prophylaxis rather than therapeutic antibiotics 1

Antibiotic Selection

• First- or second-generation cephalosporins (e.g., cefazolin) are the standard choice for clean gynecologic procedures 1
• These agents provide appropriate coverage against Staphylococcus aureus, streptococci, and common skin flora that cause surgical site infections 1

β-Lactam Allergy Alternatives

• Vancomycin is the primary alternative for patients with β-lactam allergies 1
• Fluoroquinolones (e.g., ciprofloxacin) represent another option, offering broad-spectrum coverage with good bioavailability 1
• Remember to initiate these alternatives within 120 minutes (not 60 minutes) before incision due to prolonged infusion requirements 1

Duration of Prophylaxis

Standard Duration

• Discontinue prophylactic antibiotics within 24 hours postoperatively 1
• There is no evidence supporting postoperative antibiotic prophylaxis continuation beyond this timeframe 1
• Single-dose prophylaxis has demonstrated significant reduction in surgical site infections (relative risk 0.4) 1

Common Pitfall to Avoid

The WHO and CDC guidelines explicitly state that antibiotics should not be used after surgery for prophylaxis, as is often incorrectly done in practice 1. Extending prophylaxis beyond 24 hours increases risks of antibiotic-associated complications and antimicrobial resistance without clinical benefit 1.

When to Extend Postoperative Antimicrobial Coverage

Indications for Therapeutic Antibiotics

Transition from prophylaxis to therapeutic antibiotics when intraoperative findings or postoperative course reveal:

• Contaminated or dirty-infected wounds (Class III or IV) discovered during surgery 1
• Ovarian necrosis with signs of infection identified intraoperatively 1
• Systemic inflammatory response syndrome (SIRS) criteria postoperatively: fever, tachycardia, tachypnea, or abnormal white blood cell count 1
• Signs of organ dysfunction: hypotension, oliguria, decreased mental alertness 1
• Immunocompromised status with any signs of infection 1

Duration of Therapeutic Coverage

• Base continuation of antibiotics on pathology and contamination found during surgery 1
• For contaminated wounds without established infection, typically 3-5 days of therapeutic antibiotics 1
• Follow local and national guidelines for specific antibiotic choice, dosing, and duration 1

Additional Surgical Site Infection Prevention

Beyond antibiotics, implement these evidence-based measures:

• Preoperative skin antisepsis with chlorhexidine-alcohol solutions (or chlorhexidine alone if alcohol allergy) 1
• Fascial wound protector use during abdominal procedures 1
• Change gloves and instruments before wound closure, which reduces surgical site infection by 13% 1
• Maintain normothermia and glycemic control intraoperatively 1

Clinical Context for Ovarian Torsion

While the question focuses on antibiotics, recognize that ovarian torsion is a surgical emergency requiring immediate laparoscopic detorsion regardless of ovarian appearance 2, 3, 4. The primary goal is ovarian preservation and fertility protection, not infection prevention 2, 3. Antibiotic prophylaxis serves as an adjunct to reduce surgical site infection risk in what is typically a clean surgical procedure 1.