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Dempsey MP, Riopelle AM, West M, Kumar A, Schanbacher CF. The Effect of Preoperative Chlorhexidine Gluconate Cleanse on Lower Extremity Surgical Site Infections: A Retrospective Cohort Study. Dermatol Surg 2024; 50:627-629. [PMID: 38518189 DOI: 10.1097/dss.0000000000004169] [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: 03/24/2024]
Abstract
BACKGROUND Lower extremity surgical sites are at an increased risk of wound infection following Mohs micrographic surgery. OBJECTIVE To evaluate the rate of lower extremity surgical site infections following a 14-day regimen of preoperative 4% chlorhexidine gluconate (CHG) rinses and postoperative wound occlusion for 14 days. MATERIALS AND METHODS Retrospective data were collected from procedures performed by the senior author from January 2022 through June 2023. To meet inclusion, patients must have completed waist-down CHG soak and rinse for 14 days before surgery, including the day before surgery. In addition, the patient must have kept the dressing clean, dry, and intact until the postoperative appointment at 14 days. RESULTS A total of 100 Mohs cases met inclusion criteria. Zero patients developed a surgical site infection. CONCLUSION Chlorhexidine gluconate preoperative rinsing and postoperative occlusion for 14 days may minimize the risk of wound infection. Although further research is indicated, an opportunity exists for the adoption of CHG into routine clinical practice in the outpatient dermatology setting.
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Affiliation(s)
- Michael P Dempsey
- Kuchnir Dermatology, Milford, Massachusetts
- Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | | | - Margaret West
- Kuchnir Dermatology, Milford, Massachusetts
- Eastern Virginia Medical School, Norfolk, Virginia
| | | | - Carl F Schanbacher
- Kuchnir Dermatology, Milford, Massachusetts
- Department of Surgery, Martha's Vineyard Hospital, Oak Bluffs, Massachusetts
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2
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Veerabagu SA, Aizman L, Cheng B, Lee MP, Barbieri JS, Golda N, Carrington AE, Mitevski AW, Bittar P, Carr DR, Eisen DB, Somani AK, Miller CJ, Sobanko JF, Shin TM, Higgins Ii HW, Giordano CN, Etzkorn JR. Antibiotic adherence in dermatologic surgery: a Multicenter prospective cohort study. Arch Dermatol Res 2024; 316:174. [PMID: 38758250 DOI: 10.1007/s00403-024-02912-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/23/2024] [Accepted: 04/26/2024] [Indexed: 05/18/2024]
Abstract
Understanding patient non-adherence to prescribed antibiotics can inform clinical practices, patient counseling, and antibiotic efficacy study design in dermatology. The primary objective was to determine the rate of and reasons for antibiotic non-adherence in the dermatologic surgery setting. The secondary objective was to test the applicability of previously studied survey questions for antibiotic non-adherence screening in the dermatologic surgery setting. Five academic outpatient dermatologic surgery centers across the United States conducted one multicenter prospective cohort study. Dermatologic surgery patients ≥ 18 years of age who were prescribed an antibiotic were included as part of this study. 15.2% (42/276) of patients did not adhere to their antibiotic regimen after dermatologic surgery. Most common reasons for incomplete antibiotic courses included forgotten antibiotics (42.9%,18/42) and side effects (28.6%, 12/42). Previously evaluated questions to identify and predict non-adherence had modest performance in the dermatologic surgery setting (Area under the curve of 0.669 [95% CI (0.583-0.754)]). Antibiotic non-adherence after skin surgery is prevalent and commonly due to reasons that physicians can address with patients.
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Affiliation(s)
- Surya A Veerabagu
- Department of Dermatology, University of New Mexico, Albuquerque, NM, USA.
| | - Leora Aizman
- Department of Dermatology, Johns Hopkins University, Baltimore, MD, USA
| | - Brian Cheng
- Department of Medicine, Indiana University, Vincennes, IN, USA
| | - Michael P Lee
- Department of Dermatology, Loma Linda University, Loma Linda, CA, USA
| | - John S Barbieri
- Department of Dermatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Nicholas Golda
- Department of Dermatology, University of Missouri, Columbia, MO, USA
| | - Alexis E Carrington
- Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Peter Bittar
- Department of Dermatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David R Carr
- Division of Dermatology, The Ohio State University, Columbus, OH, USA
| | - Daniel B Eisen
- Department of Dermatology, University of California - Davis, Davis, CA, USA
| | - Ally-Khan Somani
- Department of Dermatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph F Sobanko
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Thuzar M Shin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - H William Higgins Ii
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Cerrene N Giordano
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy R Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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3
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McKesey J, Mazhar M, Alam M, Srivastava D, Nijhawan RI. Incidence of Bacteremia, Infective Endocarditis, or Prosthetic Joint Infection in Dermatologic Surgery: A Systematic Review. Dermatol Surg 2024; 50:428-433. [PMID: 38318842 DOI: 10.1097/dss.0000000000004101] [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: 02/07/2024]
Abstract
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.
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Affiliation(s)
| | - Momina Mazhar
- University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Murad Alam
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Divya Srivastava
- University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Rajiv I Nijhawan
- University of Texas Southwestern Medical Center, Dallas, Texas; and
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Marous M, Lambert Smith F, Brown M. Antibiotic Prophylaxis for Nasal Skin Flaps in Mohs Micrographic Surgery: A Retrospective Case Series. Dermatol Surg 2024; 50:199-201. [PMID: 37962111 DOI: 10.1097/dss.0000000000004010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Affiliation(s)
- Molly Marous
- All authors are affiliated with the Department of Dermatologic Surgery, University of Rochester Medical Center, Rochester, New York
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Kasse GE, Humphries J, Cosh SM, Islam MS. Factors contributing to the variation in antibiotic prescribing among primary health care physicians: a systematic review. BMC PRIMARY CARE 2024; 25:8. [PMID: 38166736 PMCID: PMC10759428 DOI: 10.1186/s12875-023-02223-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/24/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Antibiotic resistance is growing globally. The practice of health professionals when prescribing antibiotics in primary health care settings significantly impacts antibiotic resistance. Antibiotic prescription is a complex process influenced by various internal and external factors. This systematic review aims to summarize the available evidence regarding factors contributing to the variation in antibiotic prescribing among physicians in primary healthcare settings. METHODS This systematic review was conducted based on PRISMA guidelines. We included qualitative, quantitative and mixed methods studies that examined factors influencing prescription practice and variability among primary healthcare physicians. We excluded editorials, opinions, systematic reviews and studies published in languages other than English. We searched studies from electronic databases: PubMed, ProQuest Health and Medicine, Web Science, and Scopus. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool (Version 2018). Narrative synthesis was employed to synthesize the result and incorporate quantitative studies. RESULTS Of the 1816 identified studies, 49 studies spanning 2000-2023 were eligible for review. The factors influencing antibiotic prescription practice and variability were grouped into physician-related, patient-related, and healthcare system-related factors. Clinical guidelines, previous patient experience, physician experience, colleagues' prescribing practice, pharmaceutical pressure, time pressure, and financial considerations were found to be influencing factors of antibiotic prescribing practice. In addition, individual practice patterns, practice volume, and relationship with patients were also other factors for the variability of antibiotic prescription, especially for intra-physician prescription variability. CONCLUSION Antibiotic prescription practice in primary health care is a complex practice, influenced by a combination of different factors and this may account for the variation. To address the factors that influence the variability of antibiotic prescription (intra- and inter-physician), interventions should aim to reduce diagnostic uncertainty and provide continuous medical education and training to promote patient-centred care.
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Affiliation(s)
- Gashaw Enbiyale Kasse
- School of Health, Faculty of Medicine and Health, University of New England, Armidale, 2351, Australia.
- Department of Clinical Medicine, College of Veterinary Medicine and Animal Science, University of Gondar, Gondar, 196, Ethiopia.
| | - Judy Humphries
- School of Health, Faculty of Medicine and Health, University of New England, Armidale, 2351, Australia
| | - Suzanne M Cosh
- School of Psychology, Faculty of Medicine and Health, University of New England, Armidale, 2351, Australia
| | - Md Shahidul Islam
- School of Health, Faculty of Medicine and Health, University of New England, Armidale, 2351, Australia
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Schlager JG, Patzer K, Wallmichrath J, French LE, Kunrad E, Schlingmann S, Stiefel D, Kendziora B, Hartmann D. Surgical site infection in skin surgery-An observational study. Int Wound J 2023; 20:3514-3522. [PMID: 37156639 PMCID: PMC10588314 DOI: 10.1111/iwj.14224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/21/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Surgical site infection (SSI) has a significant impact on patients' morbidity and aesthetic results. OBJECTIVE To identify risk factors for SSI in dermatologic surgery. PATIENTS AND METHODS This prospective, single-centre, observational study was performed between August 2020 and May 2021. Patients that presented for dermatologic surgery were included and monitored for the occurrence of SSI. For statistical analysis, we used a mixed effects logistic regression model. RESULTS Overall, 767 patients with 1272 surgical wounds were included in the analysis. The incidence of SSI was 6.1%. Significant risk factors for wound infection were defect size over 10cm2 (OR 3.64, 95% confidence interval [CI] 1.80-7.35), surgery of cutaneous malignancy (OR 2.96, CI 1.41-6.24), postoperative bleeding (OR 4.63, CI 1.58-13.53), delayed defect closure by local skin flap (OR 2.67, CI 1.13-6.34) and localisation of surgery to the ear (OR 7.75, CI 2.07-28.99). Wound localisation in the lower extremities showed a trend towards significance (OR 3.16, CI 0.90-11.09). Patient-related factors, such as gender, age, diabetes, or immunosuppression, did not show a statistically significant association with postoperative infection. CONCLUSION Large defects, surgery of cutaneous malignancy, postoperative bleeding, and delayed flap closure increase the risk for SSI. High-risk locations are the ears and lower extremities.
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Affiliation(s)
- Justin Gabriel Schlager
- Department of Dermatology and AllergyUniversity Hospital, Ludwig Maximilian University (LMU) MunichMunichGermany
| | - Kathrin Patzer
- Department of Dermatology and AllergyUniversity Hospital, Ludwig Maximilian University (LMU) MunichMunichGermany
| | - Jens Wallmichrath
- Department of Dermatology and AllergyUniversity Hospital, Ludwig Maximilian University (LMU) MunichMunichGermany
| | - Lars E. French
- Department of Dermatology and AllergyUniversity Hospital, Ludwig Maximilian University (LMU) MunichMunichGermany
- Dr. Philip Frost, Department of Dermatology and Cutaneous SurgeryUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Elena Kunrad
- Department of Dermatology and AllergyUniversity Hospital, Ludwig Maximilian University (LMU) MunichMunichGermany
| | - Sophia Schlingmann
- Department of Dermatology and AllergyUniversity Hospital, Ludwig Maximilian University (LMU) MunichMunichGermany
| | - Daniel Stiefel
- Department of Dermatology and AllergyUniversity Hospital, Ludwig Maximilian University (LMU) MunichMunichGermany
| | - Benjamin Kendziora
- Department of Dermatology and AllergyUniversity Hospital, Ludwig Maximilian University (LMU) MunichMunichGermany
| | - Daniela Hartmann
- Department of Dermatology and AllergyUniversity Hospital, Ludwig Maximilian University (LMU) MunichMunichGermany
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7
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Antibiotic Use and Surgical Site Infections in Immunocompromised Patients After Mohs Micrographic Surgery: A Single-Center Retrospective Study. Dermatol Surg 2022; 48:1283-1288. [DOI: 10.1097/dss.0000000000003620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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8
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Marous M, Bax M, Smith FL, Brown M. Antibiotic prophylaxis for full thickness and split thickness skin grafts in Mohs micrographic surgery: A retrospective case series and review of the literature. J Am Acad Dermatol 2022; 87:1117-1119. [PMID: 35101529 DOI: 10.1016/j.jaad.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/31/2021] [Accepted: 01/20/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Molly Marous
- Department of Dermatologic Surgery, University of Rochester Medical Center, Rochester, New Yorka.
| | - Michael Bax
- Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Franki Lambert Smith
- Department of Dermatologic Surgery, University of Rochester Medical Center, Rochester, New Yorka
| | - Marc Brown
- Department of Dermatologic Surgery, University of Rochester Medical Center, Rochester, New Yorka
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9
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Practice Patterns for Mohs Surgeons of Varying Clinical Experience: A Cross-Sectional Analysis of a Medicare Claims Database. Dermatol Surg 2022; 48:1029-1032. [PMID: 36095278 DOI: 10.1097/dss.0000000000003562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/04/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Use of Mohs micrographic surgery (MMS) is highly prevalent, but little data are available on how surgeon experience affects surgical practice patterns. OBJECTIVE To determine differences in use of MMS among surgeons of varying experience. MATERIALS AND METHODS This cross-sectional study sampled from clinicians billing ≥200 mean annual Mohs surgery claims from the 2012 to 2018 Medicare Public Use File. The primary outcome was mean annual Mohs surgery claims for clinicians of varying experience. Secondary outcomes included use of flaps/grafts and prescribing of oral antibiotics, benzodiazepines, and opioids. RESULTS Among 1,759 unique surgeons, those with 16 to 20 years of experience performed the most mean annual (95% confidence interval) Mohs surgical cases (578.7 [556.7-600.6]). Surgeons with 21 to 25 years of experience prescribed the most antibiotics (240.2 [216.5-263.8] mean annual claims), whereas those with >35 years of experience prescribed the longest courses (15.3 [14.2-16.4] days). CONCLUSION Midcareer surgeons performed the most mean annual Mohs surgery cases, whereas later career surgeons prescribed more frequent and longer courses of antibiotics suggesting changing practice patterns with additional years of experience.
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10
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Schlager JG, Ruiz San Jose V, Patzer K, French LE, Kendziora B, Hartmann D. Are Specific Body Sites Prone for Wound Infection After Skin Surgery? A Systematic Review and Meta-Analysis. Dermatol Surg 2022; 48:406-410. [PMID: 35066551 DOI: 10.1097/dss.0000000000003387] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Identifying risk factors for wound infection may guide clinical practice for optimal use of perioperative antibiotic prophylaxis in dermatologic surgery. OBJECTIVE To summarize the current evidence whether specific body sites have higher risks for surgical site infections (SSI). METHODS The systematic literature search included MEDLINE, Embase, CENTRAL, and trial registers. Only observational studies qualified for inclusion and meta-analysis. We assessed the risk of bias according to the Newcastle-Ottawa Scale. RESULTS Eighteen studies with 33,086 surgical wounds were eligible. Eight studies were of good, 4 of fair, and 6 of poor quality. The mean infection rate was 4.08%. Meta-analysis showed that the lips had significantly higher infection rates. The lower extremity and ears had or tended toward a higher risk for infection, but studies were clinically heterogeneous. A large prospective trial found that surgical wounds on the hands were at higher risk for infection. The trunk showed the lowest infection rate. The risk for SSI in other body locations was not different or remained uncertain because of substantial heterogeneity among studies. CONCLUSION Lips, lower extremities, and probably ears and hands may have a higher risk for wound infection after skin surgery. The trunk showed the lowest infection rate.
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Affiliation(s)
- Justin Gabriel Schlager
- Department of Dermatology and Allergy, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Virginia Ruiz San Jose
- Department of Ear, Nose and Throat (Otolaryngology)-Head and Neck Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Kathrin Patzer
- Department of Dermatology and Allergy, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Lars E French
- Department of Dermatology and Allergy, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Benjamin Kendziora
- Department of Dermatology and Allergy, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Daniela Hartmann
- Department of Dermatology and Allergy, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
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11
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Hansen T, Gangal A, Hijab E, Barrett D, Yeung H, Cao Y, Switchenko J, Blalock TW. Postoperative Surgical Site Infection Rate in Patients with Diabetes following Mohs Micrographic Surgery: A Retrospective Analysis. J Eur Acad Dermatol Venereol 2022; 36:927-931. [PMID: 35122334 DOI: 10.1111/jdv.17986] [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: 09/23/2021] [Accepted: 01/19/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Incidence of surgical site infection (SSI) following Mohs micrographic surgery (MMS) among patients with diabetes is largely unknown. OBJECTIVE Evaluate diabetes as a potential SSI risk factor in MMS by comparing SSI incidence in a cohort of patients with and without diabetes. METHODS 5-year retrospective review to determine SSI rate in patients with diabetes compared to patients without diabetes. SSI incidence in patients with diabetes was further compared by A1c, and the impact of antibiotics on SSI rate was also examined. RESULTS Overall rate of SSI was 1.47% (53/3,597 cases). SSI rate among patients with diabetes was 1.95% (14/719 cases) compared to 1.35% (39/2,878 cases) in patients without diabetes, with a non-significant odds ratio for SSI of 1.45 (95% CI = 0.78-2.68, p = 0.241). Multivariable logistic regression analysis revealed no difference in SSI. Stratification of diabetic patients by A1c into ≥7.0 and <7.0 compared to patients without diabetes yielded no statistically significant difference in SSI among all groups (p = 0.815). Whether an antibiotic was prescribed did not significantly impact SSI rate between groups. CONCLUSION No significant difference in postoperative SSI was found in patients with diabetes compared to patients without diabetes following MMS regardless of degree of glycemic control.
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Affiliation(s)
- Trevor Hansen
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Ameya Gangal
- Emory University School of Medicine, Atlanta, GA, USA
| | - Eman Hijab
- Emory University School of Medicine, Atlanta, GA, USA
| | - Devon Barrett
- Emory University School of Medicine, Atlanta, GA, USA
| | - Howa Yeung
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Yichun Cao
- Department of Biostatistics & Bioinformatics, Emory University, Atlanta, GA, USA
| | - Jeffrey Switchenko
- Department of Biostatistics & Bioinformatics, Emory University, Atlanta, GA, USA
| | - Travis W Blalock
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
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12
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Aizman L, Barbieri JS, Feit EM, Lukowiak TM, Perz AM, Shin TM, Miller CJ, Golda N, Leitenberger JJ, Carr DR, Nijhawan RI, Hasan A, Eisen DB, Etzkorn JR. Preferences for Prophylactic Oral Antibiotic Use in Dermatologic Surgery: A Multicenter Discrete Choice Experiment. Dermatol Surg 2021; 47:1214-1219. [PMID: 34081047 DOI: 10.1097/dss.0000000000003113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antibiotics are often prescribed after dermatologic surgery for infection prophylaxis, but patient preferences about prophylactic antibiotics are not well understood. OBJECTIVE To understand patient preferences about taking antibiotics to prevent surgical site infection (SSI) relative to antibiotic efficacy and antibiotic-associated adverse drug reactions. MATERIALS AND METHODS Multi-center, prospective discrete choice experiment (DCE). RESULTS Three hundred thirty-eight respondents completed the survey and DCE. 54.8% of respondents preferred to take an antibiotic if it reduced the SSI rate from 5% to 2.5% and if the risk of adverse drug reactions was low (1% risk gastrointestinal upset, 0.5% risk itchy skin rash, 0.01% risk emergency department visit). Even if an antibiotic could eliminate SSI risk (0% risk SSI) and had a low adverse drug reaction profile, 26.7% of respondents prefer not to take prophylactic oral antibiotics. CONCLUSION Risk-benefit thresholds for taking antibiotics to prevent SSI vary widely. Clinical trials are needed to better characterize the effectiveness and risks of oral antibiotic SSI prophylaxis to guide decision-making. Future studies should also evaluate whether shared decision-making can improve the patient experience.
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Affiliation(s)
- Leora Aizman
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - John S Barbieri
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elea M Feit
- LeBow College of Business, Drexel University, Philadelphia, Pennsylvania
| | - Tess M Lukowiak
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Allison M Perz
- Cooper Medical School of Rowan University, Camden, New Jersey
| | - Thuzar M Shin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas Golda
- Department of Dermatology, University of Missouri School of Medicine, Columbia, Missouri
| | - Justin J Leitenberger
- Department of Dermatology, Oregon Health and Science University School of Medicine, Portland, Oregon
| | - David R Carr
- Division of Dermatology, the Ohio State University Medical Center, Columbus, Ohio
| | - Rajiv I Nijhawan
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Aliza Hasan
- Department of Dermatology, University of California-Davis, Sacramento, California
| | - Daniel B Eisen
- Department of Dermatology, University of California-Davis, Sacramento, California
| | - Jeremy R Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Attitudes on Prophylactic Antibiotic Use in Dermatologic Surgery: A Survey Study of American College of Mohs Surgery Members. Dermatol Surg 2021; 47:339-342. [PMID: 32897951 DOI: 10.1097/dss.0000000000002676] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antibiotic prescriptions associated with dermatologic surgical visits are increasing and prescribing practices vary among surgeons. OBJECTIVE To describe dermatologic surgeons' attitudes and practices regarding prophylactic antibiotic use for surgical site infection (SSI), to compare current prescribing practices to those of a 2012 survey, and to determine surgeons' interest in clinical trial data on the utility of prophylactic antibiotics. MATERIALS AND METHODS This was a cross-sectional online survey of the American College of Mohs Surgery (ACMS) members. Survey items were adapted from a 2012 survey of ACMS members. RESULTS The survey was initiated by 101 ACMS members. 75.25% (76/101) of surgeons reported routinely prescribing prophylactic antibiotics to reduce SSI risk. The use of prophylactic antibiotics varied with clinical scenario. Most providers (84.21%, 64/76) prescribe postoperative antibiotics, with an average course of 6.56 days. 40.21% (39/97) of respondents were uncertain if prophylaxis prevents SSI, and up to 90.63% (87/96) indicated interest in clinical trial data evaluating the efficacy of oral antibiotics for SSI prevention. CONCLUSION Dermatologic surgeons continue to report varied attitudes and practices for SSI prophylaxis. Evidence from clinical trials is desired by surgeons to guide clinical practice.
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Surgical Site Infection After Dermatologic Procedures: Critical Reassessment of Risk Factors and Reappraisal of Rates and Causes. Am J Clin Dermatol 2021; 22:503-510. [PMID: 33797060 DOI: 10.1007/s40257-021-00599-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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15
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The effect of antibiotic prophylaxis on infection rates in mohs micrographic surgery: a single-institution retrospective study. Arch Dermatol Res 2020; 313:663-667. [PMID: 33098449 DOI: 10.1007/s00403-020-02153-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/14/2020] [Accepted: 10/09/2020] [Indexed: 10/23/2022]
Abstract
As data and recommendations regarding antibiotic prophylaxis in dermatologic surgery vary, we tried to describe the effect of antibiotic prophylaxis (AP) in Mohs micrographic surgery (MMS) on infective endocarditis, prosthetic joint infection, and surgical site infection using a single-institution retrospective cohort study of antibiotic use (pre-/intra-operative, post-operative or none) among 2,364 patient encouters treated with MMS. Bivariate logistic regression was evaluated for associations between patient and operative characteristics, antibiotic use, and infectious complications. 85.8% of patients received no AP, 10.0% received post-operative AP, and 4.1% received pre-/intra-operative AP. The overall surgical site infection (SSI) rate was 1.3%. SSI did not differ between patients who received pre-/intra-operative prophylaxis, post-operative prophylaxis or no antibiotics. One patient receiving pre-/intra-operative prophylaxis developed SSI. Repairs involving porcine xenografts and interpolation/pedicle flaps were associated with increased SSI. In addition, there were no patients who post-operatively experienced an infected joint or infective endocarditis. Limitations include selection bias, use of observational retrospective data, low infection rates, single institution analysis, and possible omission of explanatory variables or confounders. There was no difference in rates of SSI when comparing MMS patients who received pre-/intra-operative, post-operative or no AP. There were no cases of infective endocarditis or infected prosthetic joint.
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