Prophylactic antibiotics in gynaecological surgery — structured SAQ (15 marks)

(a) Wound class and flora — 3 marks

• Clean-contaminated because the vagina is entered under controlled conditions.
• Skin flora plus polymicrobial genital tract flora matter.
• Anaerobes are relevant, so choose procedure-specific coverage.

(b) Prescription — 4 marks

• Clarify allergy: nausea is intolerance, not immediate beta-lactam hypersensitivity.
• Cefazolin 2 g IV at induction, completed within 60 minutes before incision.
• Add metronidazole 500 mg IV when required by the current local hysterectomy protocol.
• Document agent, dose and administration time at sign-in/time-out.

(c) Re-dose and stop — 4 marks

• Assign anaesthesia/theatre ownership of the re-dose clock.
• Re-dose cefazolin after the locally specified prolonged-surgery interval.
• Re-dose after major blood loss or fluid shift where policy directs.
• Stop prophylaxis after the perioperative window unless infection or contamination creates a treatment indication.

(d) Day-five fever and pelvic pain — 4 marks

• Assess ABCDE, sepsis physiology, wound, vaginal cuff, abdomen and urinary symptoms.
• Differentiate superficial SSI, pelvic abscess, UTI, haematoma and bowel/urinary injury.
• Obtain cultures before treatment when safe and relevant blood tests.
• Image suspected deep collection and give therapeutic antibiotics plus source control; do not repeat prophylaxis.