Prevention of postoperative wound infection in dermatologic surgery and appropriate use of antibiotics to prevent endocarditis and joint-replacement infections are controversial issues. Dermatologists often may misunderstand the use of antibiotics to prevent endocarditis, surgical site infections, and prosthesis infections. In order to prevent endocarditis associated with surgical procedures, the American Heart Association (AHA) has developed clinical practice guidelines that apply to surgical patients with prosthetic cardiac valves, previous bacterial endocarditis, mitral valve prolapse with valvular regurgitation, or thickened leaflets. For these patients, the AHA recommends that antistaphylococcal antibiotics (eg, cephalosporins) be given before surgery only when the procedure involves significant risk of bacteremia (eg, incision into infected tissues). Routine dermatologic surgery of intact skin with sterile technique usually does not require prophylaxis. Antibiotic prophylaxis may also be justified in surgical patients who are at moderate to high risk for wound site infection. Patients should be given prophylactic antibiotics shortly before surgery or as soon as the risk is recognized. In patients allergic to penicillin, cross reactions are unlikely for most second- and third-generation agents (cefdinir, cefuroxime, cefixime, ceftibuten), because these agents lack a side chain similar to penicillin. By identifying the risk of infection, being aware of the risks of antibiotic therapy, and weighing the risks and benefits of each option, dermatologists can devise individualized treatments, thus optimizing outcomes of their patients.
In surgery, antibiotic prophylaxis refers to the use of antimicrobial agents in surgical patients without an established infection. (1)
Whether or not antibiotic prophylaxis is appropriate in dermatologic procedures depends partly on the type of wound, which may fall into 1 of 4 categories: clean (class I), clean-contaminated (class II), contaminated (class III), and infected (class IV). (2) Clean wounds (eg, from excision of skin cancers or noninflamed cysts) are noncontaminated and excisions are performed using sterile techniques. Since the infection rate of clean wounds is less than 5%, antibiotic prophylaxis is generally not necessary, the exception being extended surgical procedures (eg, extensive Mohs' surgical procedures). The second type, clean-contaminated wounds, comprises dermatologic surgical procedures in contaminated areas (mouth, respiratory tract, axillae). These have a 10% infection rate. Antibiotic prophylaxis should be considered, depending on the surgical site, length, and nature of the procedure, overall health of the patient, and level of contamination. (3) The third type, contaminated wounds, has visibly inflamed tissue (eg, infected cysts) or are associated with trauma or major breaches of sterile surgical technique. Their infection rate ranges from 20% to 30%. The fourth type, infected wounds (eg, traumatic wounds), is heavily laden with necrotic tissue, foreign bodies, or pus. These wounds have a 30% to 40% rate of infection. Antibiotic prophylaxis is recommended for both contaminated and infected wounds. (2)
In dermatologic surgery, whether to prescribe antibiotics to prevent postoperative infection at the wound site and at distant sites (eg, endocarditis) is a controversial issue.
Studies show that dermatologists misunderstand and overuse antibiotics to prevent endocarditis, surgical site infections, and prosthesis infections. (4-7)
The purpose of this paper is to summarize the current issues associated with antibiotic prophylaxis in cutaneous surgery.
Bacterial endocarditis has considerable morbidity and mortality. Patients at high risk for endocarditis are those with prosthetic heart valves, previous endocarditis, complex cyanotic congenital heart disease, or surgically constructed systemic pulmonary shunts. (4) Patients with a history of serious heart conditions or cardiac surgery are at the highest risk for endocarditis, but the level of seriousness should also be taken into account. Patients at moderate risk are those with uncorrected patent ductus arteriosus, ventricular septal defect, primum atrial septal defect, coarctation of the aorta, or bicuspid aortic valve; acquired valvular dysfunction (rheumatic); or hypertrophic cardiomyopathy.
To prevent endocarditis in surgical procedures, the American Heart Association (AHA) has developed clinical practice guidelines (9) that apply especially to surgical patients with prosthetic cardiac valves, previous bacterial endocarditis, mitral valve prolapse with valvular regurgitation, or thickened leaflets. For these patients, the AHA recommends that antistaphylococcal antibiotics (eg, cephalosporins) be given before surgery only when the procedure involves joints, bone, nonoral soft tissue, or clinically infected wounds. The AHA does not, however, recommend prophylaxis when incisions or biopsy specimens are taken from noninfected, surgically scrubbed skin. (9)
In surgical patients whose mitral valves have normal motion and minimal Doppler-shown leaks, the risk for infection is minimal and requires no antibiotic prophylaxis. The same is true in patients with mitral valve prolapse in which leaking, murmurs, or Doppler-shown regurgitation is absent. Risk increases (1) when normal valves undergo prolapse with leaking, clicks, and murmurs, and Doppler-shown insufficiency; (2) in the presence of myxomatous degeneration of the mitral valves, with or without prolapse or insufficiency; and (3) in men over age 45 years with prolapse, even in the absence of resting regurgitation. Antibiotic prophylaxis is justified in these high-risk patients.
Procedures that produce a temporary bacteremia carry an increased risk of infection. Such procedures involve mucosal surfaces and include dental, respiratory tract, gastrointestinal tract, and genitourinary procedures. Whether the surgically manipulated skin is infected is a primary consideration in antibiotic prophylaxis. If skin is clinically infected, the incidence of bacteremia with endocarditis-causing pathogens exceeds 35%. (10-12) Antibiotic prophylaxis is therefore required. In clinically uninfected skin, the incidence of infection may be minimal. (3) negating the need for antibiotic prophylaxis unless the patient is classified as high risk by the AHA. In one study, (12) bacteremia was induced in only 7% of patients undergoing skin surgery in the sebaceous-rich areas of the head and neck.
Orthopedic Prosthetic Devices
The American Academy of Orthopedic Surgeons offers comparable guidelines for antibiotic pretreatment for dental patients with total joint replacements. (9,13) Dermatologic surgeons should use guidelines similar to those for prevention of endocarditis when determining which surgical candidates need appropriate prophylactic antibiotics.
For dermatologic surgical patients with orthopedic prosthetic devices, there are no published guidelines for antibiotic prophylaxis. High risk is associated with previous prosthetic joint infections, passing of less than 2 years since joint replacement when cutaneous surgery is contemplated, malnourishment, diabetes, hemophilia, inflammatory arthropathies, and immunosuppression. Antibiotic prophylaxis is not required when skin is clean and intact and more than 2 years have lapsed since prosthesis was implanted.
Infection of prosthetic devices as a result of transient bacteremia stemming from surgical procedures is rare, (14) however. Most cases of prosthesis infection are due to infection during implantation or from suppurative infection at different anatomical locations. (14) Staphylococcus aureus and Staphylococcus epidermidis are the most frequent causative agents of prosthesis infection.
Currently, if there is mucosal involvement or an otherwise clean-contaminated class II wound due to surgery, the risk of infection is slightly elevated and prophylaxis should be considered. Any surgical wound that is clearly contaminated (class III or IV) or infected, or the patient underwent the joint surgery less than 6 months prior to cutaneous surgery, prophylaxis is necessary. These people are at the highest risk for infection.
Prophylaxis for Wound Infection
Antibiotics for prophylaxis against pathogens at various sites are shown in Table 1. Although anatomic location is a critical factor in antibiotic selection to prevent endocarditis, prosthesis, and surgical site infection, (14) the choice of antibiotic should be based on the pathogen most likely to cause infection. S. aureus and S. pyogenes are the primary pathogens in nonoral skin sites. Cephalosporins and dicloxacillin eradicate both organisms safely and cost effectively. For Streptococcus viridans and peptostreptococci, AHA guidelines suggest the use of amoxicillin, (3,14). Extended-spectrum cephalosporins such as cefdinir offer excellent coverage for Gram-positive infections as above but have additional coverage for common Gram-negative skin pathogens.
In patients allergic to penicillin, cross-reactions may occur with early-generation cephalosporins. Cross-reactions are unlikely, however, for most second- and third-generation agents (cefdinir, cefuroxime, cefixime, ceftibuten) because they lack a side chain similar to penicillin. Alternatives include lincosamides (clindamycin, 300 mg BID) followed by macrolides (clarithromycin and azithromycin 250 mg BID). For the groin or perineum, metronidazole (500 mg BID) may be added to levofloxacin.
Figure 1 shows a patient with postoperative infection of glabrous skin.
Risk Factors for Infection
Risk factors for the development of infections at the surgical site are similar to the risk factors for bacterial endocarditis and orthopedic prosthesis infection. Diabetes mellitus is associated with impaired leucocyte mobilization and microangiopathy, and poor glucose control is associated with suboptimal wound healing. Malnutrition and chronic renal insufficiency are associated with impaired immune response, poor wound healing, and increased risk of postoperative infection. Smoking and obesity increase the risk for both superficial and deep-wound infections. (14) Other risk factors for infection include chronic use of steroids, advancing age, chronic illness, shaving less than 24 hours before surgery, length of the procedure, and concomitant infections. The infection rate doubles for each hour of the surgical procedure. Thus patients undergoing lengthy dermatologic surgical procedures such as multiple-stage Mohs surgical procedures may be candidates for surgical prophylaxis with broad-spectrum antibiotics.
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Antibiotic prophylaxis is justified in surgical patients who are at moderate to high risk for endocarditis, prosthesis infection, or wound site infection or in patients undergoing lengthy procedures. Since most dermatologic surgical procedures are performed on skin not surgically scrubbed. AHA guidelines have limited application in dermatologic surgery. By identifying the risk of infection, being aware of the choices of antibiotic therapy, and weighing the risks and benefits of each option, dermatologists can devise individualized treatments, thus optimizing outcomes of their patients.
Dr. Nestor is a member of the Speakers Bureau of Abbott Laboratories.
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Address for Correspondence
Mark S. Nestor MD PhD
Center for Cosmetic Enhancement
2925 Aventura Blvd, Ste. 205
Aventura, FL 33180-3108
Mark S. Nestor MD PhD
Center for Cosmetic Enhancement, Aventura, FL
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