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Klifto KM, Rydz AC, Biswas S, Hultman CS, Erdmann D, Phillips BT. Evidence-Based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-Site Infections in Plastic and Reconstructive Surgery. Plast Reconstr Surg 2023; 152:1154e-1182e. [PMID: 37141459 DOI: 10.1097/prs.0000000000010608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND After nearly a decade of new data, the Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons was updated for prophylactic systemic antibiotics to prevent surgical-site infections (SSI). Pharmacotherapeutic concepts using antimicrobial stewardship were applied for clinical interpretation and management to optimize patient outcomes and minimize resistance. METHODS PRISMA, Cochrane, and GRADE certainty of evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched for randomized controlled trials (RCTs). The authors included patients who had plastic and reconstructive surgery and were treated with prophylactic systemic antibiotics administered perioperatively (preoperatively, intraoperatively, or postoperatively). Comparisons were made between active interventions and nonactive interventions (placebo) at different prespecified durations to determine the development of an SSI. Meta-analyses were performed. RESULTS The authors included 138 RCTs that met eligibility criteria. RCTs consisted of 18 breast, 10 cosmetic, 21 hand/peripheral nerve, 61 pediatric/craniofacial, and 41 reconstructive studies. The authors examined bacterial data extracted from studies for patients who did or did not take prophylactic systemic antibiotics for prevention of SSI. Clinical recommendations were provided using level I evidence. CONCLUSIONS Surgeons have long been overprescribing systemic antibiotic prophylaxis in plastic and reconstructive surgery. Evidence supports antibiotic prophylaxis to prevent SSI for specific indications and durations. Prolonged antibiotic use has not been linked to reductions in SSIs, and misuse may increase the bacterial diversity of infections. Greater efforts should focus on transitioning from practice-based to pharmacotherapeutic evidence-based medicine. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Affiliation(s)
- Kevin M Klifto
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery
| | | | - Sonali Biswas
- Division of Plastic and Reconstructive Surgery, University of Michigan School of Medicine
| | - C Scott Hultman
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Detlev Erdmann
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University School of Medicine
| | - Brett T Phillips
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University School of Medicine
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Desisto NG, Ortiz AS, Yang SF, Stephan SJ, Patel PN. State of the Evidence for Facial Skin Cancer Reconstruction. Facial Plast Surg 2023; 39:220-229. [PMID: 36603830 DOI: 10.1055/a-2008-2798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
This review provides a comprehensive presentation of the evidence available in facial reconstruction post-Mohs micrographic surgery. Given the large diversity in post-Mohs reconstruction, there are limited guidelines in the management of defects. The aim of the present work is to provide a review of the best evidence as it pertains to several considerations in facial reconstruction. Data suggests that Mohs micrographic surgery and many reconstructive procedures can be performed as outpatient procedures under local anesthesia, with narcotic pain medication only given in certain patient populations following a minority of reconstructive procedures. Perioperative and topical antibiotics are generally not indicated. Aspirin and warfarin can generally be continued for most reconstructive procedures, but clopidogrel and novel anticoagulants may predispose to increased bleeding complications. Delayed reconstruction appears to be safe, although data are discordant on this topic. No specific wound closure technique or suture choice appears to be consistently superior. Given the lack of robust comparative studies, consistent methodology, and variable defect sizes/locations, no robust evidence-based guidelines can be generated for reconstruction techniques of facial subsites.
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Affiliation(s)
- Nicole G Desisto
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexandra S Ortiz
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shiayin F Yang
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott J Stephan
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Priyesh N Patel
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
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Homsy P, Romo I, Kauhanen S. Antibiotic prophylaxis in clean and clean-contaminated plastic surgery: A critical review. J Plast Reconstr Aesthet Surg 2023; 83:233-245. [PMID: 37285776 DOI: 10.1016/j.bjps.2023.04.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 04/07/2023] [Accepted: 04/19/2023] [Indexed: 06/09/2023]
Abstract
Antibiotic prophylaxis is frequently used in plastic surgery procedures, despite the generally low rates of infection and few guidelines on the practice. The increasing prevalence of bacterial resistance to antibiotics calls for a reduction in unnecessary antibiotic use. The aim of this review was to create an updated summary of the available data on the effectiveness of antibiotic prophylaxis in reducing the postoperative infection in clean and clean-contaminated plastic surgery. A systematic literature search was performed on the databases Medline, Web of Science, and Scopus, limited to articles published January 2000 onward. Randomized controlled trials (RCTs) were included in the primary review, whereas older RCTs and other studies were sought if 2 or fewer relevant RCTs were identified. Overall, 28 relevant RCTs, 2 nonrandomized trials, and 15 cohort studies were identified. Although the number of studies for each type of surgery is limited, the data suggest that prophylactic systemic antibiotic may be unnecessary in noncontaminated facial plastic surgery, reduction mammaplasty, and breast augmentation. In addition, no benefit is apparent from extending the antibiotic prophylaxis over 24 h in rhinoplasty, aerodigestive tract reconstruction, and breast reconstruction. No studies assessing the necessity of antibiotic prophylaxis in abdominoplasty, lipotransfer, soft tissue tumor surgery, or gender affirmation surgery were identified. In conclusion, limited data are available on the effectiveness of antibiotic prophylaxis in clean and clean-contaminated plastic surgery. More studies on this topic are needed before strong recommendations can be made on the use of antibiotics in this setting.
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Affiliation(s)
- Pauliina Homsy
- Department of Plastic Surgery, Puistosairaala, University of Helsinki and Helsinki University Central Hospital, P.O. Box 281, 00029 HUS, Finland.
| | - Inka Romo
- Department of Infectious Diseases, Meilahden Kolmiosairaala, University of Helsinki and Helsinki University Central Hospital, P.O. Box 372, 00029 HUS, Finland
| | - Susanna Kauhanen
- Department of Plastic Surgery, Puistosairaala, University of Helsinki and Helsinki University Central Hospital, P.O. Box 281, 00029 HUS, Finland
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Lalla SC, Bonadurer GF, Murad MH, Brewer JD. Prophylactic antibiotics and Postoperative Surgical Site Infections in cutaneous surgery: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Davis M, Baird D, Hill D, Layher H, Akin R. Management of full-thickness skin grafts. Proc (Bayl Univ Med Cent) 2021; 34:683-686. [PMID: 34732986 DOI: 10.1080/08998280.2021.1953867] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Full-thickness skin grafts are a commonly used reconstructive method following Mohs micrographic surgery. The literature varies on the most appropriate methods of suturing and securing grafts as well as best practices to dress the graft postoperatively. Our objective was to review various approaches to management of full-thickness skin grafts, including suturing the graft, securing the graft, and topical emollient use on the graft postoperatively. It was found that absorbable sutures, plain gut, provide preferable outcomes with full-thickness skin grafts. The tie-over bolster is the most-used method for securing skin grafts after placement, although several other methods have demonstrated efficacy, including the polyurethane foam, sandwich, and quilting suture methods. While various topical emollients are used in the immediate postoperative period, plain white petrolatum is the least likely to form allergic contact dermatitis.
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Affiliation(s)
- Mitchell Davis
- Department of Internal Medicine, HCA Las Palmas Del Sol Healthcare, El Paso, Texas
| | - Daniel Baird
- Department of Dermatology, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Dane Hill
- Department of Dermatology, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Heather Layher
- Department of Dermatology, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Russell Akin
- Department of Dermatology, Texas Tech University Health Sciences Center, Lubbock, Texas
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Harvey JA, Ochoa SA. Delayed-onset Pseudomonas infection manifesting as pain. JAAD Case Rep 2021; 15:123-125. [PMID: 34471663 PMCID: PMC8387840 DOI: 10.1016/j.jdcr.2021.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
| | - Shari A. Ochoa
- Division of Dermatology Surgery, Department of Dermatology, Mayo Clinic, Scottsdale, Arizona
- Correspondence to: Shari A. Ochoa, MD, Division of Dermatology Surgery, Department of Dermatology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259.
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ElHawary H, Hintermayer MA, Alam P, Brunetti VC, Janis JE. Decreasing Surgical Site Infections in Plastic Surgery: A Systematic Review and Meta-analysis of Level 1 Evidence. Aesthet Surg J 2021; 41:NP948-NP958. [PMID: 33693462 DOI: 10.1093/asj/sjab119] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although many interventions are implemented to prevent surgical site infections (SSIs) in plastic surgery, their supporting evidence is inconsistent. OBJECTIVES The goal of this study was to assess the efficacy of methods for decreasing SSIs in plastic surgery. METHODS A systematic review and meta-analysis were performed to compare the effects of SSI prevention methods. All the studies were assessed for quality of evidence according to the GRADE assessment. RESULTS Fifty Level 1 randomized controlled trials were included. The most common interventions for preventing SSIs were antibiotic prophylaxis, showering, prepping, draping, and the use of dressings. Current evidence suggests that antibiotic prophylaxis is largely unnecessary and overused in many plastic surgical procedures, with the exception of head and neck oncologic, oral craniofacial, and traumatic hand surgeries. CONCLUSIONS Efficacy of antibiotic prophylaxis in plastic surgery is dependent on surgery type. There is a lack evidence that showering and prepping with chlorohexidine and povidone reduces SSIs. LEVEL OF EVIDENCE: 1
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Affiliation(s)
- Hassan ElHawary
- Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Canada
| | | | - Peter Alam
- Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Canada
| | | | - Jeffrey E Janis
- Department of Plastic and Reconstructive Surgery, Ohio State University Wexner Medical Center, Columbus, OH, USA
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Strickler AG, Shah P, Bajaj S, Mizuguchi R, Nijhawan RI, Odueyungbo M, Rossi A, Ratner D. Preventing and managing complications in dermatologic surgery: Procedural and postsurgical concerns. J Am Acad Dermatol 2021; 84:895-903. [PMID: 33493570 DOI: 10.1016/j.jaad.2021.01.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 01/14/2021] [Accepted: 01/14/2021] [Indexed: 12/17/2022]
Abstract
The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety.
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Affiliation(s)
- Allen G Strickler
- Department of Dermatology, Geisinger Medical Center of Geisinger Commonwealth School of Medicine, Danville, Pennsylvania; Department of Laboratory Medicine, Geisinger Medical Center of Geisinger Commonwealth School of Medicine, Danville, Pennsylvania.
| | - Payal Shah
- School of Medicine, New York University Langone Health, New York, New York
| | - Shirin Bajaj
- Department of Dermatology, New York University Langone Health, New York, New York
| | - Richard Mizuguchi
- Department of Dermatology, Mount Sinai Medical School, New York, New York
| | - Rajiv I Nijhawan
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Anthony Rossi
- Weill Cornell Medical College, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Désirée Ratner
- Department of Dermatology, New York University Langone Health, New York, New York
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Oral and Intraincisional Antibiotic Prophylaxis in Mohs Surgery: A Systematic Review and Meta-analysis. Dermatol Surg 2019; 46:558-560. [PMID: 30883482 DOI: 10.1097/dss.0000000000001838] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Rosengren H, Heal C, Smith S. An Update on Antibiotic Prophylaxis in Dermatologic Surgery. CURRENT DERMATOLOGY REPORTS 2012. [DOI: 10.1007/s13671-012-0012-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Profilaxis antibiótica en cirugía otorrinolaringológica. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2010; 61:54-68. [DOI: 10.1016/j.otorri.2008.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Accepted: 12/22/2009] [Indexed: 11/18/2022]
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