Perioperative Antibiotic Use in Cutaneous Surgery

Incidence of Bacteremia, Infective Endocarditis, or Prosthetic Joint Infection in Dermatologic Surgery: A Systematic Review

BACKGROUND

Prophylactic antibiotic therapy is widely used in dermatologic surgery to prevent surgical site infections and bacteremia, which can lead to prosthetic joint infections (PJI) and infective endocarditis (IE) in high-risk populations.

OBJECTIVE

To evaluate the incidence of bacteremia, PJI, and IE after dermatologic surgery and assess the current evidence for antibiotic prophylaxis.

MATERIALS AND METHODS

A search of the computerized bibliographic databases was performed using key terms from the date of inception to March 21, 2021. Data extraction was performed independently by 2 data extractors.

RESULTS

The review resulted in 9 publications that met inclusion criteria, including 5 prospective cohort studies and 4 case reports or case series. The prospective studies reported a wide range of bacteremia incidence (0%-7%) after dermatologic surgery. No cases of PJI resulting directly from cutaneous surgery were identified, and only 1 case series reported IE after various skin procedures.

CONCLUSION

These findings suggest a low rate of bacteremia and a lack of direct evidence linking dermatologic surgery to PJI or IE. The scarcity of published data on this topic is a limitation, highlighting the need for further research, particularly randomized controlled trials, to guide antibiotic prophylaxis recommendations.

Surgery for benign nail tumor

The vast majority of tumors in the nail apparatus have a different clinical presentation and course from their equivalents on the skin. Some, such as onychomatricoma and onychopapilloma, are unique to the nail and others, such as superficial acral fibromyxoma, have a tropism for the nail apparatus. As a rule, benign lesions respect the general architecture of the nail apparatus, whereas malignant tumors are destructive. Treatment is always surgical and good knowledge of the anatomy and the procedures is mandatory in order not to induce postoperative nail dystrophy.

Effect of Microdoses of Incisional Antibiotics on the Rate of Surgical Site Infections in Skin Cancer Surgery: A Randomized Clinical Trial

Importance

Surgical site infections (SSIs) represent a costly and preventable complication of cutaneous surgery. However, there is a paucity of randomized clinical trials investigating antibiotic prophylaxis for reducing SSIs in skin cancer surgery, and evidence-based guidelines are lacking. Incisional antibiotics have been shown to reduce the rate of SSIs before Mohs micrographic surgery, but this represents a small subset of skin cancer surgery.

Objective

To determine whether microdosed incisional antibiotics reduce the rate of SSIs before skin cancer surgery.

Design, Setting, and Participants

In this double-blind, controlled, parallel-design randomized clinical trial, adult patients presenting to a high-volume skin cancer treatment center in Auckland, New Zealand, for any form of skin cancer surgery over 6 months from February to July 2019 were included. Patient presentations were randomized to one of 3 treatment arms. Data were analyzed from October 2021 to February 2022.

Interventions

Patients received an incision site injection of buffered local anesthetic alone (control), buffered local anesthetic with microdosed flucloxacillin (500 µg/mL), or buffered local anesthetic with microdosed clindamycin (500 µg/mL).

Main Outcomes and Measures

The primary end point was the rate of postoperative SSI (calculated as number of lesions with SSI per total number of lesions in the group), defined as a standardized postoperative wound infection score of 5 or more.

Results

A total of 681 patients (721 total presentations; 1133 total lesions) returned for postoperative assessments and were analyzed. Of these, 413 (60.6%) were male, and the mean (SD) age was 70.4 (14.8) years. Based on treatment received, the proportion of lesions exhibiting a postoperative wound infection score of 5 or greater was 5.7% (22 of 388) in the control arm, 5.3% (17 of 323) in the flucloxacillin arm, and 2.1% (9 of 422) in the clindamycin arm (P = .01 for clindamycin vs control). Findings were similar after adjusting for baseline differences among arms. Compared with lesions in the control arm (31 of 388 [8.0%]), significantly fewer lesions in the clindamycin arm (9 of 422 [2.1%]; P < .001) and flucloxacillin (13 of 323 [4.0%]; P = .03) arms required postoperative systemic antibiotics.

Conclusions and Relevance

This study evaluated the use of incisional antibiotics for SSI prophylaxis in general skin cancer surgery and compared the efficacy of flucloxacillin vs clindamycin relative to control in cutaneous surgery. The significant reduction in SSI with locally applied microdosed incisional clindamycin provides robust evidence to inform treatment guidelines in this area, which are currently lacking.

Trial Registration

anzctr.org.au Identifier: ACTRN12616000364471.

Multifunctional antibacterial bioactive nanoglass hydrogel for normal and MRSA infected wound repair

Large-scale skin damage brings potential risk to patients, such as imbalance of skin homeostasis, inflammation, fluid loss and bacterial infection. Moreover, multidrug resistant bacteria (MDRB) infection is still a great challenge for skin damage repair. Herein, we developed an injectable self-healing bioactive nanoglass hydrogel (FABA) with robust antibacterial and anti-inflammatory ability for normal and Methicillin-resistant Staphylococcus aureus (MRSA) infected skin wound repair. FABA hydrogel was fabricated facilely by the self-crosslinking of F127-CHO (FA) and alendronate sodium (AL)-decorated Si-Ca-Cu nanoglass (BA). FABA hydrogel could significantly inhibit the growth of Staphylococcus aureus, Escherichia coli and MRSA in vitro, while showing good cytocompatibility and hemocompatibility. In addition, FABA hydrogel could inhibit the expression of proinflammatory factor TNF-α and enhance the expression of anti-inflammatory factor IL-4/ IL-10. Based on its versatility, FABA hydrogel could complete wound closure efficiently (75% at day 3 for normal wound, 70% at day 3 for MRSA wound), which was almost 3 times higher than control wound, which was related with the decrease of inflammatory factor in early wound. This work suggested that FABA hydrogel could be a promising dressing for acute and MRSA-infected wound repair.

Review of the Current Antibiotic Guidelines used in Dermatologic Surgery

Antibiotics have been used as a prophylaxis for dermatologic procedures. We will review the various procedures that specific antibiotics with dosages are used for, depending on the procedure, diagnosis, and circumstance of the patient. We will examine the current and updated guidelines used in dermatologic surgery and the overlapping guidelines across other fields. Physicians must consider the side effects of antibiotics and the resistance that may occur as a result before using the class or level of prophylaxis. Initial evaluation for alcohol, chlorhexidine or iodine should be measured as well. Updated guidelines aim to address the contraindications of antibiotics, yet further research is needed to avoid antibiotic resistance and to explore alternative methods of antibiotic application, such as intranasal and intravenous. This article is protected by copyright. All rights reserved.

Hydrocolloid dressing versus conventional wound care after dermatologic surgery

Background

Hydrocolloid dressings (HCD) are helpful in chronic wound care, but research is limited in acute postoperative wounds. HCD can potentially be incorporated into a simplified wound care regimen after excisional surgeries.

Objective

To examine whether a one-time HCD application after dermatologic surgery results in greater patient satisfaction and improved postoperative outcomes compared with conventional daily dressings (CDD).

Methods

We examined patients who underwent Mohs or standard surgical excision with linear closure followed by HCD. The patients additionally had a history of excisional surgery with CDD in the past 5 years. A modified version of the validated Bluebelle Wound Healing Questionnaire was administered.

Results

The survey response rate was 74.4% (64/86). Compared with CDD, HCD rated higher in comfort, convenience, scar appearance, and simplicity of wound care instructions (P < .0001). Nearly all patients (96.8%) preferred HCD over CDD.

Limitations

Variability in time from prior dermatologic surgery may introduce recall bias. Prior surgeries involving CDD were sometimes performed by a different surgeon, which could introduce other confounding factors.

Conclusions

A simplified wound care regimen involving HCD can potentially lead to increased comfort, convenience, simplicity, and a subjective improvement in scar appearance, though additional studies are needed.

Surgical Site Infection After Dermatologic Procedures: Critical Reassessment of Risk Factors and Reappraisal of Rates and Causes

While rates are low, surgical site infections are the most common complication of dermatologic surgery. Surgical site infections have important consequences including impairment of wound healing, suboptimal cosmetic outcome, hospitalization, increased healthcare costs, and rarely, systemic infection. It is imperative to understand the risk factors and existing preventative measures to minimize the development of infection. This article reviews the available literature regarding surgical site infections following dermatologic procedures, to evaluate the standard of diagnosis and role of wound culture, risk factors, mimicking conditions, and significance of antibiotic prophylaxis. We offer a critical reassessment of the current literature on risk factors and reappraisal of infection rates to promote evidence-based patient care. We conclude that the strongest evidence suggests that diabetes mellitus is likely associated with increased surgical site infections. Immunosuppression is often clinically considered a risk factor; however, the evidence is mixed. In general the addition of antibiotics does not confer benefit except in high-risk sites. Conclusively, Mohs micrographic surgery has been proven safe in office and inpatient settings. We agree that sterile glove use for simple procedures is likely not a significant factor in the development of surgical site infections; however, we hypothesize that the overall sterile technique and setting may play a role in longer and/or more complex procedures.

The impact of COVID-19 pandemics on dermatologic surgery: real-life data from the Italian Red-Zone

BACKGROUND

The COVID-19 pandemic is challenging healthcare systems worldwide. Dermatology had to re-prioritize visits, guarantee urgent care, and ensure continuity for chronic patients.

OBJECTIVES

To evaluate the COVID-19 impact on dermatologic surgery outpatient management.

MATERIAL AND METHODS

In this real-life retrospective observational study, we evaluated both major and minor outpatient surgeries (MaOS and MiOS) performance in 2020, before and during the first month of lockdown declaration, in a primary referral center in Northern Italy. During the lockdown, all lifesaving and cancer surgery, (approximately 80% of our usual activities), were continued. Data from 2020 were compared with the 2019 corresponding periods to assess the real-life impact of COVID-19 in dermatologic surgical activities.

RESULTS

From January 1st to April 3rd, 2020 we performed 769 interventions, compared to 908 over the corresponding 2019 period. After the lockdown, scheduled surgeries were reduced by 14.8%; overall performed ones displayed a reduction of 46.5% (51.6% MaOS, 44.2% MiOS). 52.9% and 12.5% procedures were canceled due to patients' renunciation and due to confirmed/suspected COVID-19, respectively.

CONCLUSIONS

While reduced in number, dermatologic surgeries, similarly to other surgical specialties, remained operative to provide oncological and/or life-saving procedures.