BACKGROUND The cephalosporins, which have been widely used in gynecologic surgery, are considered by many to be the drug of choice for chemoprophylaxis. However, their benefit in total abdominal hysterectomy has remained controversial. This study was done to evaluate the effectiveness of the commonly used cephalosporins in preventing inflammatory complications which may occur after elective abdominal hysterectomy. METHODS A MEDLINE and manual review of the literature from the past 15 years (1977 to 1991), using the terms "prophylactic antibiotics," "abdominal hysterectomy," and "cephalosporins," was performed. Seventeen prospective trials using cephalosporin prophylaxis alone for 24 hours perioperatively were evaluated. A meta-analysis of the 2,752 study and control patients abstracted was performed to compare postoperative infection and febrile morbidity rates. RESULTS The cephalosporin group as well as the various generations and individual drugs were found to be useful in preventing postoperative infection (p < 0.001). Febrile morbidity, however, was effectively prevented (p < 0.001) by first but not by some second and third generation drugs. Multivariate analysis revealed no advantage for the newer, more expensive second and third generation cephalosporins studied. When adjusted for confounding factors, the number of doses, the amount of the dose, and the route of administration had significant impact on the outcome events. CONCLUSIONS Chemoprophylaxis with cephalosporins was found to be effective in preventing posthysterectomy infectious complications. A single dose, preoperative injection of first (cefazolin) or second (cefoxitin) generation cephalosporin, when administrated intravenously, has been shown to yield the best, cost-effective clinical results.