Antimicrobial prophylaxis in dermatology

Carbon Dioxide Laser Rejuvenation of the Facial Skin

This article reviews the evaluation and techniques for facial skin rejuvenation using the fractionated carbon dioxide laser. It includes a detailed overview of laser skin rejuvenation and discusses the potential complications associated with this procedure. A review of clinical outcomes in the literature is also included.

Effect of a single prophylactic preoperative oral antibiotic dose on surgical site infection following complex dermatological procedures on the nose and ear: a prospective, randomised, controlled, double-blinded trial

OBJECTIVES

There is limited published research studying the effect of antibiotic prophylaxis on surgical site infection (SSI) in dermatological surgery, and there is no consensus for its use in higher-risk cases. The objective of this study was to determine the effectiveness of a single oral preoperative 2 g dose of cephalexin in preventing SSI following flap and graft dermatological closures on the nose and ear.

DESIGN

Prospective double-blinded, randomised, placebo-controlled trial testing for difference in infection rates.

SETTING

Primary care skin cancer clinics in North Queensland, Australia, were randomised to 2 g oral cephalexin or placebo 40-60 min prior to skin incision.

PARTICIPANTS

154 consecutive eligible patients booked for flap or graft closure following skin cancer excision on the ear and nose.

INTERVENTION

2 g dose of cephalexin administered 40-60 min prior to surgery.

RESULTS

Overall 8/69 (11.6%) controls and 1/73 (1.4%) in the intervention group developed SSI (p=0.015; absolute SSI reduction 10.2%; number needed to treat (NNT) for benefit 9.8, 95% CI 5.5 to 45.5). In males, 7/44 controls and 0/33 in the intervention group developed SSI (p=0.018; absolute SSI reduction 15.9%; NNT for benefit 6.3, 95% CI 3.8 to 19.2). SSI was much lower in female controls (1/25) and antibiotic prophylaxis did not further reduce this (p=1.0). There was no difference between the study groups in adverse symptoms attributable to high-dose antibiotic administration (p=0.871).

CONCLUSION

A single oral 2 g dose of cephalexin given before complex skin closure on the nose and ear reduced SSI.

TRIAL REGISTRATION NUMBER

ANZCTR 365115; Post-results.

Surgical site infections in skin surgery: a single center experience

The main interests covered in this article are the determination of risk factors and incidence of surgical site infections in dermatosurgery and suggestions for rational use of antibiotic prophylaxis. A total of 3284 consecutive dermatosurgical interventions in 1088 patients were performed in our dermatosurgery department. Data regarding patient characteristics and perioperative course were prospectively collected and retrospective analysis of this data was performed. Association of perioperative parameters and postoperative surgical site infections was assessed by χ(2) -test. Rate of postoperative infections in our study was low (1.9%). Purulent surgical sites showed the highest incidence of severe postoperative infections (4.7%; P < 0.001). The lowest incidence of mild infections was seen in preoperatively clean surgical sites (0.8%; P < 0.001). All patients with severe infections and 68% patients with mild infections were older than 70 years. The head and neck and acral regions were the groups mostly affected by mild postoperative conditions (2.4% and 1.7%, respectively; P = 0.006). The frequency of mild and severe infections in procedures performed by experienced surgeons was lower than in procedures performed by less experienced surgeons (0.6% vs 3.1% in mild infections, 0.1 vs 0.8 in severe infections; P < 0.001). The main risk factors for postoperative infections were wounds in the head and neck region, lips and oral mucosa or acral regions, older age of patients, worse preoperative state of surgical sites and less experienced surgeons. In the majority of cases where risk factors were missing there was no need of antibiotic prophylaxis.

Algorithm for the management of antibiotic prophylaxis in onychocryptosis surgery

BACKGROUND

Antibiotic prophylaxis in nail surgery is not clearly established, and there is scant scientific evidence regarding the need for its use in preventing surgical site infection, hematogenous total joint infection, and infective endocarditis.

OBJECTIVES

To propose an algorithm based on the evidence for the management of antibiotic prophylaxis in onychocryptosis surgery.

METHODS

A literature review was performed in Medline, Pubmed, Cochrane database and Scopus and recent prospective studies were examined. The most-current authoritative guidelines together with new classification system of the pathology have been taken into account.

RESULTS

In non-risk patients with onychocryptosis stage II or III phenol technique can be used without the need for antibiotics. In stages IV and V, specific antibiotic treatment should be administered before surgery together with partial ablation of nail until the infection is resolved and the process remits to stage II or III. In the case of long-developing onychocryptosis, osteomyelitis should be ruled out, and specific antibiotic treatment besides the preoperative dose should be administered. In high-risk cardiac patients with infective onychocryptosis, the need for prophylaxis for bacterial endocarditis should be considered.

CONCLUSION

Current evidence does not support the use of preoperative antibiotic prophylaxis in onychocrytosis surgery except in special patients with infective onychocryptosis.

Antibacterial prophylaxis in dermatologic surgery: an evidence-based review

Clean, non-contaminated skin surgery is associated with low rates of surgical site infection (SSI), bacterial endocarditis, and joint prosthesis infection. Hence, antibacterial prophylaxis, which may be associated with adverse effects, the emergence of multidrug-resistant pathogens, and anaphylaxis, is generally not recommended in dermatologic surgery. Some body sites and surgical reconstructive procedures are associated with higher infection rates, and guidelines for SSI antibacterial prophylaxis have been proposed for these cases. Large prospective, controlled trials are needed to ascertain the role of oral SSI prophylaxis for these surgical sites and procedures especially in patients with diabetes mellitus who are intrinsically at greater risk of SSI. Topical antibacterial ointment and sterile paraffin appear to make no difference to healing or the incidence of SSIs in clean wounds. Although further research is needed, preliminary studies have shown that intraincisional antibacterials, which may be associated with fewer adverse effects and a lower risk of multidrug-resistant bacteria, could potentially be helpful for SSI prophylaxis. Trials using honey- and silver-impregnated dressings have found no advantage in the healing of chronic wounds. However, several case studies, which need corroboration in larger studies, suggest that these dressings may be helpful in preventing and treating SSIs. Bacterial endocarditis and joint prosthesis infection prophylaxis are not routinely recommended in cutaneous surgery. The updated 2007 American Heart Association guidelines now advocate bacterial endocarditis prophylaxis for high-risk cardiac patients having surgery involving the oral mucosa or infected skin. The latest American Dental Association/American Academy of Orthopaedic Surgery guidelines recommend considering antibacterial prophylaxis for oral procedures where bleeding is anticipated and for surgery involving acute orofacial skin infections if the patient has had a total joint replacement within 2 years or is in a high-risk group and has had a joint replacement at any time.

Prospective evaluation of surgical site infection rate among patients with Mohs micrographic surgery without the use of prophylactic antibiotics

BACKGROUND

Antibiotics may be indiscriminately given to patients undergoing Mohs micrographic surgery (MMS) for the prevention of surgical site infections, despite a low risk of infection in these patients.

OBJECTIVE

We sought to evaluate the rate of wound infections among patients undergoing MMS without the use of prophylactic antibiotics.

METHODS

We prospectively evaluated 1000 consecutive patients undergoing MMS for nonmelanoma skin cancer or modified MMS/"slow Mohs" for lentigo maligna melanoma in situ.

RESULTS

The overall wound infection rate among 1000 patients with 1115 tumors was 0.7% (8/1115 tumors). Five (62.5%) of 8 infections occurred on the nose with an overall 1.7% (5/302) nose infection rate. Seven (87.5%) of 8 infections occurred after flap reconstruction with an overall 2.4% (7/296) flap closure infection rate. Four (50%) of 8 infections occurred in patients requiring more than one Mohs stage for tumor clearance with a 0.8% (4/487) overall infection rate in cases requiring multiple Mohs stages. Two (25%) of 8 infections had cultures positive for oxacillin-resistant Staphylococcus aureus. No wound infections occurred in cases involving the lips or ears, skin-graft closures, or below-knee or modified MMS procedures.

LIMITATIONS

This was a prospective single institution uncontrolled study.

CONCLUSION

Rates of infections among patients undergoing MMS or modified MMS are exceedingly low. Indiscriminate use of antibiotics increases patient risk to adverse drug reactions and antibiotic resistance. Administration of antibiotics to patients undergoing MMS should be on a case-by-case basis according to the known risk factors combined with clinical judgment.

Prospective study of wound infections in dermatologic surgery in the absence of prophylactic antibiotics

OBJECTIVE

The study aimed to identify wound sites/procedures where infection incidence was over 5%, such that these circumstances may warrant wound infection antibiotic prophylaxis.

METHOD

We undertook a 3-year prospective study of 5,091 lesions (predominantly nonmelanoma skin cancer) treated on 2,424 patients from July 2002 to June 2005. No patient was given prophylactic antibiotics, and no patient ceased warfarin or aspirin.

RESULTS

Overall infection incidence was 1.47%. Individual procedures had the following infection incidence: curettage 0.73% (3/412); skin flap repairs 2.94% (47/1601); simple excision and closure 0.54% (16/2974); skin grafts 8.70% (6/69); and wedge excision 8.57% (3/35). Analysis of regions of the body demonstrated that surgery below the knee (n = 448) had an infection incidence of 6.92% (31/448) (p < .0001). Subanalysis demonstrated that all regions below the knee were at high infection risk. Elsewhere, groin excisional surgery had an infection incidence of 10% (1/10) (p = .027). No other body site demonstrated an infection incidence beyond 5% of statistical significance. Procedures on the face demonstrated an infection incidence of 0.81% (18/2,209). Diabetic patients, those on warfarin and/or aspirin, and smokers showed no difference in infection incidence.

CONCLUSION

Based on a prediction of infection incidence over 5%, the following cutaneous oncologic procedures warrant consideration of oral antibiotic wound infection prophylaxis: all procedures below the knee, wedge excisions of lip and ear, all skin grafts, and lesions in the groin. Other than under these circumstances, surgery to the nose, ear, fingers, lips, skin flap surgery, and surgery on diabetics, smokers, and those on anticoagulants have previously been considered for wound infection prophylaxis but do not warrant such intervention based on our data. The authors have indicated no significant interest with commercial supporters.

Update on the Use of Antibiotics in Cutaneous Surgery

BACKGROUND

Antibiotics are often prescribed in perioperative settings, including dermatologic surgery. Given the continued evolution in the breadth and complexity of cutaneous procedures performed and inevitable localized or distant infections that occasionally occur, it seems prudent to periodically evaluate findings and recommendations from the literature regarding the use of antibiotics in cutaneous surgery.

MATERIALS AND METHODS

Literature review from English-language sources from the past 30 years, especially focusing on sources from the past 5 to 10 years. Data were examined for a variety of cutaneous surgical procedures, routes of antibiotic administration, and consideration of both cutaneous and distant infections.

RESULTS

The literature suggests that, for most routine skin procedures, antibiotic use is probably not warranted for the prevention of surgical wound infection, endocarditis, and late prosthetic joint infections. During prolonged Mohs procedures, delayed repairs, grafts, takedowns of interpolation flaps, or any procedure that breaches a mucosal surface, the evidence is less clear, and decisions should be made on a case-by-case basis. Topical antibiotics are probably overused, although silver sulfadiazine may have an undeserved negative reputation among dermatologists. Systemic prophylactic antibiotics for laser resurfacing and liposuction appear not to be routinely necessary, although patients with known prior herpes infection likely should receive antiviral prophylaxis. The overall reported infection rates and infectious complications remain low in dermatologic surgery, and antibiotic therapy may be prescribed excessively or inappropriately as a result. CONCLUSION.: Antibiotics continue to be widely used, and through varying routes of administration, in the setting of dermatologic surgery. Prudent use of these agents is indicated in high-risk patients, certain anatomic locations, and the presence of overt infection. Additional studies may help clarify the most appropriate indications, and in which patient populations, in the future.

Antibiotic Prophylaxis in Dermatologic Surgery: Updated Guidelines

BACKGROUND

Antibiotic prophylaxis in dermatologic surgery is poorly understood, and data on its use are lacking. Prophylaxis is indicated for the prevention of endocarditis and prosthesis infection, as well as surgical site infection.

OBJECTIVE

We review essential considerations for the use of antibiotic prophylaxis in dermatologic surgery and provide clear guidelines for practical implementation.

METHODS

Guidelines were developed after review of the literature and consultation with infectious disease specialists and subspecialists in the areas of cardiac, orthopedic, and neurosurgical infectious disease at Mayo Clinic.

RESULTS

Three factors affect the decision to use prophylactic antibiotics in dermatologic surgery: (1) the underlying indication for prophylaxis (patient risk stratification), (2) the condition of the skin, and (3) the specific procedure planned. Thorough preoperative evaluation and surgical planning are critical in identifying and optimizing patient and environmental risk factors that may increase the risk of infection. Appropriate antibiotic selections with site-specific consideration and appropriate timing of antibiotic administration are key factors in providing effective prophylaxis.

CONCLUSIONS

Low rates of infection associated with dermatologic surgical procedures warrant selective use of antibiotic prophylaxis. The proposed guidelines reflect current standards of practice.

Postsurgical wound management

Successful outcomes in cutaneous surgery depend on a variety of factors, including preoperative assessment of the patient's health and expectations, intraoperative skill and attention to detail, and managing the postoperative period. Once the procedure is complete, careful selection of dressings, provision of adequate analgesia, judicious management of complications and monitoring the phases of early maturation while providing patient education improve the likelihood of long-term patient and physician satisfaction.