Postoperative Infection Risk in Sacrocolpopexy: Single vs Dual Antibiotic Prophylaxis

The optimal antibiotic prophylaxis for mesh-based prolapse surgery remains uncertain. Although cefazolin is widely used, its limited anaerobic coverage may increase the risk of postoperative infections, particularly in women undergoing concomitant hysterectomy. Evidence from hysterectomy cohorts suggests that adding metronidazole reduces surgical-site infections, prompting evaluation of this approach in laparoscopic mesh-augmented apical prolapse repair. The objective was to compare postoperative infection rates in women receiving single-agent versus dual-agent prophylactic antibiotics.

This retrospective cohort study included women with pelvic organ prolapse who underwent laparoscopic mesh-augmented apical prolapse repair between 2021 and 2025. Patients received either cefazolin alone or cefazolin plus metronidazole according to the routine practice of the operating urogynecologist. Demographic, operative, and postoperative data were extracted from electronic medical records. The primary outcome was composite postoperative infection within 30 days, including postoperative fever, surgical site or trocar site infection, mesh infection, pelvic abscess, or urinary tract infection. Associations between prophylactic regimen and postoperative infection were evaluated using univariable analyses. The antibiotic prophylaxis regimen was surgeon dependent, with one surgeon routinely administering cefazolin alone and the other cefazolin plus metronidazole. Multivariable logistic regression was performed to adjust for baseline differences between the groups.

A total of 523 women met the inclusion criteria; 204 (39.0%) received dual prophylaxis and 319 (61.0%) received cefazolin alone. Overall composite postoperative infection outcome occurred in 18 out of 523 patients (3.4%). Infection rates of the single-agent and dual-prophylaxis groups were similar (3.7% vs 2.9%, p = 0.64). Rates of postoperative fever, surgical-site infection, and urinary tract infection did not differ significantly between groups. No mesh-related infections or pelvic abscesses were observed. After adjustment for baseline differences, the antibiotic regimen was not significantly associated with the composite postoperative infection outcome (aOR 1.30, 95% CI 0.36-4.64; p = 0.689).

Composite postoperative infection outcome rates after laparoscopic sacrocolpopexy were low, with no significant difference observed between cefazolin alone and combined cefazolin-metronidazole prophylaxis.