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Fronek L, Davis MJ, Greenway HT, Kelley B. Shared decision making for perioperative antibiotic use during Mohs micrographic surgery on the lower extremities. JAAD Int 2024; 16:155-162. [PMID: 39006918 PMCID: PMC11245999 DOI: 10.1016/j.jdin.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 07/16/2024] Open
Abstract
Background While there is a higher risk of surgical site infection (SSI) on the lower extremities following Mohs micrographic surgery (MMS), antibiotic prophylaxis (AP) is debated. Objective To determine the role of shared decision making (SDM) in guiding AP usage during MMS on the lower extremities. Materials and methods A prospective observational study was conducted whereby patients received a standardized SDM discussion or routine counseling. Patient satisfaction quantified by the shared decision-making questionnaire (SDMQ9) survey, rate of SSI, and rate of AP prescription were recorded. Results In total, 51 patients were included. While there were less antibiotics prescribed in the treatment group (20% versus 50%, P = .025), this did not affect incidence of SSI (8% in treatment group versus 7.7% in control group, P = .668). Patient satisfaction was statistically greater in SDM group (4.73 versus 2.18 in control (P < .001). Conclusion Patient satisfaction scores were higher among the patients who received SDM. While the usage of AP was lower in the SDM group, this did not affect incidence of SSI. This study allows the opportunity to apply SDM in the setting of MMS, which to our knowledge has not yet been attempted in the field of dermatologic surgery.
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Affiliation(s)
- Lisa Fronek
- Department of Dermatology, Scripps Clinic Torrey Pines Bighorn Mohs Surgery and Dermatology, San Diego, California
| | - Michael J Davis
- Department of Dermatology, Memorial Sloan Kettering, Mohs Micrographic Surgery, New York, New York
| | - Hubert T Greenway
- Department of Dermatology, Scripps Clinic Torrey Pines Bighorn Mohs Surgery and Dermatology, San Diego, California
| | - Benjamin Kelley
- Department of Dermatology, Scripps Clinic Torrey Pines Bighorn Mohs Surgery and Dermatology, San Diego, California
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Goh MF, Hollewand CE, McBride S, Mathy JA. Microbiology of surgical site infections (SSIs) following skin cancer surgery. ANZ J Surg 2022; 92:2269-2273. [PMID: 35912956 DOI: 10.1111/ans.17957] [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: 03/11/2022] [Revised: 07/08/2022] [Accepted: 07/18/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUNDS Surgical site infections (SSIs) represent one of the most common and potentially preventable sources of morbidity and healthcare cost escalation associated with skin cancer surgery. There is a lack of data reporting organisms cultured from SSIs in skin surgery, with guidelines for antibiotic prophylaxis based on common skin pathogens rather than actual cultured organisms. In this study, we sought to define the cultured microbiology of SSIs specific to skin cancer surgery and test these against empiric treatment guidelines. METHODS All consenting patients presenting to the Auckland regional skin cancer treatment centre over a 6-month period were included. Patients receiving any form of antibiotics within a week prior to surgery were excluded. All wounds were assessed postoperatively, with clinically significant infections identified as those with a standardized wound infection score of 4 (range 0-7) and/or prescribed post-operative antibiotics within 3 weeks of surgery. Wound cultures were recorded. RESULTS About 104 clinically significant SSIs were identified from 333 lesions treated, with cultures available in 27%. Cultured organisms included MSSA (79%), MRSA (14%), coagulase-negative Staphylococci (11%), and 'skin flora' (14%). Empiric guidelines inaccurately predicted effective treatment in 14% of cases, exclusively due to MRSA. CONCLUSION To our knowledge this is the first comprehensive report of SSI microbiology following skin cancer surgery. The overwhelmingly predominant organisms were Staphylococcus sp. (76%), with the rate of MRSA approaching prevalence warranting empiric first-line treatment. These data help inform effective rationalized empiric antibiotic treatment, when indicated, for optimal outcome following skin surgery.
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Affiliation(s)
- Maple F Goh
- Auckland Regional Plastic & Reconstructive Surgery Unit, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | - Clare E Hollewand
- Auckland Regional Plastic & Reconstructive Surgery Unit, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | - Stephen McBride
- Department of Infectious Diseases, Counties Manukau Health, Auckland, New Zealand
| | - Jon A Mathy
- Auckland Regional Plastic & Reconstructive Surgery Unit, Te Whatu Ora Counties Manukau, Auckland, New Zealand.,Faculty of Medical and Health Sciences, Surgery, Waipapa Taumata Rau - The University of Auckland, Auckland, New Zealand
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3
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Characteristics of Lower Extremity Infection Rates Following Mohs Micrographic Surgery. Dermatol Surg 2021; 47:1547-1550. [PMID: 34818271 DOI: 10.1097/dss.0000000000003260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical site infection (SSI) is the most common complication for Mohs micrographic surgery (MMS). Lower extremity surgical sites are at an increased risk for developing SSI. OBJECTIVE This study aimed to evaluate lower extremity SSI rates post-MMS based on closure type and antibiotic usage. MATERIALS AND METHODS A retrospective review was performed of all lower extremity MMS cases from 2011 to 2016 at Vanderbilt University Medical Center. Patient history, surgical details, and follow-up appointments were reviewed. RESULTS Six hundred twenty MMS lower extremity surgeries were eligible. Review identified an overall lower extremity SSI rate of 7.4%. Infection rates were significantly increased in wound closed by flaps/grafts (p < .001). Although wound size and preoperative antibiotic prophylaxis were initially associated with increased infection rate (p = .03, p = .015), the associations were fully attenuated when adjusting for closure type. CONCLUSION More complicated repair techniques (flap/graft) for larger wound sizes contribute to increased SSI risk among lower extremity MMS cases. Providers can use this information to guide antibiotic prophylaxis.
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Erickson SP, Foshee JP, Baumann BC, Council ML, MacArthur KM. Mohs Surgical Site Infection Rates and Pathogens for the Mask-Covered Face During the COVID-19 Pandemic Versus the Pre-COVID Era. Dermatol Surg 2021; 47:1507-1510. [PMID: 34699442 PMCID: PMC8547580 DOI: 10.1097/dss.0000000000003240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Stephen P. Erickson
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - James P. Foshee
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Brian C. Baumann
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Martha L. Council
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Kelly M. MacArthur
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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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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Ruffolo AM, Sampath AJ, Colbert S, Golda N. Preoperative Considerations for the Prevention of Surgical Site Infection in Superficial Cutaneous Surgeries: A Systematic Review. Facial Plast Surg Aesthet Med 2020; 23:205-223. [PMID: 32721241 DOI: 10.1089/fpsam.2020.0100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Background: Surgical site infections (SSIs) pose challenges to the outcome of superficial cutaneous procedures. Objective: The objective of this study was to summarize published data regarding appropriate perioperative considerations to decrease SSI, including antiseptic use, topical decolonization, antibiotic prophylaxis, and clean versus sterile technique in superficial cutaneous procedures. A literature search was performed via PubMed and Cochrane Library by using relevant keywords. A total of 37 articles met the inclusion criteria. Strength of data was assessed according to the Oxford Centre criteria and a modified Grading of Recommendations, Assessment, Development, and Evaluation approach. Results: Chlorhexidine is the antiseptic of choice in clean or outpatient superficial cutaneous procedures. Decolonization of carriers of Staphylococcus aureus with mupirocin is warranted for all superficial cutaneous procedures. Minor procedure rooms may be considered for superficial cutaneous procedures that possess an inherently low risk of SSI. Surgeons may consider nonsterile gloves instead of sterile gloves for clean or outpatient superficial cutaneous procedures. Postoperative use of topical antibiotics may be discontinued, as there are risks of adverse effects and increasing bacterial resistance without a significant reduction in SSI. Conclusion and Relevance: This systematic review provides new and updated evidence for the prevention of SSI in superficial cutaneous procedures through antiseptic use, antibiotic use, topical agents, and the surgical environment. The overall quality of evidence is good, with most articles being original research or systematic reviews. However, there is a need for dermatologic- and plastic surgery-specific studies regarding the prevention of SSI.
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Affiliation(s)
- Alexis M Ruffolo
- Division of Plastic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Ashwath J Sampath
- Department of Dermatology, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Stephen Colbert
- Head of Hand and Microsurgery, Division of Plastic Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Nicholas Golda
- Director of Dermatologic Surgery, Department of Dermatology, University of Missouri School of Medicine, Columbia, Missouri, USA
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8
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Variation in Prescribing and Factors Associated With the Use of Prophylactic Antibiotics for Mohs Surgery: A Single-Institution Retrospective Study. Dermatol Surg 2020; 46:868-875. [DOI: 10.1097/dss.0000000000002203] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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9
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Kirby JS, Lim JS. Dermatologists and Antibiotics-Reflecting on Our Habits, the Evidence, and Next Steps. JAMA Dermatol 2020; 155:286-287. [PMID: 30649130 DOI: 10.1001/jamadermatol.2018.4877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Joslyn S Kirby
- Department of Dermatology, Penn State Hershey, Hershey, Pennsylvania
| | - Jordan S Lim
- Department of Dermatology, Penn State Hershey, Hershey, Pennsylvania
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Positive Bacterial Culture Results at a Dermatologic Surgery Center: A Single-Site Retrospective Review. Dermatol Surg 2019; 46:773-779. [PMID: 31592927 DOI: 10.1097/dss.0000000000002166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Typical prophylactic coverage of suspected cutaneous surgical-site infections (SSIs) predominantly covers gram-positive bacteria. Data regarding the frequency of infection with unusual bacteria, not covered by prophylaxis, are not available. OBJECTIVE A retrospective 10-year review of culture-positive infections at a single academic site was performed. MATERIALS AND METHODS All positive bacterial culture results at the Washington University Center for Dermatologic and Cosmetic Surgery between October 31, 2007, and October 31, 2017, were collected and analyzed. RESULTS Coagulase-negative staphylococcus accounted for 20.8% of positive culture results. Staphylococcus aureus caused 45.4% of infections. The remaining 33.8% were due to non-S. aureus bacteria, most frequently with Pseudomonas aeruginosa (10.8%). Numerous other gram-negative organisms and unusual gram-positive organisms were cultured. The lower extremity and ear were the only sites more likely to be infected with non-S. aureus bacteria. Smokers and immunosuppressed individuals were not more likely to have an SSI with non-S. aureus bacteria. CONCLUSION A significant proportion of all SSIs with positive culture results was due to bacteria that are not sensitive to beta-lactam prophylaxis. Broader coverage for suspected SSI should be considered, particularly on the lower extremity and ear.
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Ghias MH, Shamloul N, Khachemoune A. Dispelling myths in dermatologic surgery. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2019. [DOI: 10.15570/actaapa.2019.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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12
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Balakirski G, Felcht M, Bayer H, Schmitt L. Analyse des Status quo der perioperativen Antibiotikaprophylaxe in der Dermatochirurgie in Deutschland: Ergebnisse der DESSI-Studie. J Dtsch Dermatol Ges 2019; 17:703-715. [PMID: 31364303 DOI: 10.1111/ddg.13864_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 02/23/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Galina Balakirski
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum der Rheinischen Friedrich-Wilhelms-Universität Bonn
| | - Moritz Felcht
- Dermatologie, Venerologie und Allergologie, Universitätsmedizin Mannheim der Universität Heidelberg, Exzellenzzentrum Dermatologie des Landes Baden-Württemberg, und European Center for Angioscience (ECAS), Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim
| | - Hans Bayer
- Klinik für Dermatologie und Venerologie, Universitätsklinik Freiburg
| | - Laurenz Schmitt
- Klinik für Dermatologie und Allergologie, Universitätsklinikum der RWTH Aachen
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13
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Balakirski G, Felcht M, Bayer H, Schmitt L. Analysis of the status quo of perioperative antibiotic prophylaxis in dermatosurgery in Germany: results of the DESSI-study. J Dtsch Dermatol Ges 2019; 17:703-713. [PMID: 31124600 DOI: 10.1111/ddg.13864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 02/23/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Perioperative antibiotic prophylaxis (PAP) is recommended for the prevention of postoperative infections by the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute. However, how PAP is currently used in the field of dermatosurgery in Germany is unclear. METHODS All members of the German Society for Dermatosurgery (DGDC) were asked to participate in a web-based survey in order to investigate the use of PAP by German dermatological surgeons. RESULTS 78 DGDC members completed the questionnaire. Of these, 89.7 % (70/78) were medical specialists with a median work experience of 15 years in the field of dermatosurgery, and 53.8 % (42/78) of the respondents regularly use PAP in dermatosurgery. Of these, 35.7 % (15/42) reported that they perform PAP for immunocompromised patients. Only a small proportion of skin surgeons stated that they administer PAP parenterally (5.9 %, 4/67). The most commonly used drug was cephalosporin cefuroxime. The duration of the PAP varied between single-dose and prolonged administration for more than five days. CONCLUSION Currently, the use of PAP in dermatosurgical procedures in Germany is not standardized. Prospective randomized dermatosurgical studies are needed in order to investigate whether the PAP recommendations of KRINKO are applicable to the field of dermatological surgery.
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Affiliation(s)
- Galina Balakirski
- Department of Dermatology and Allergology, University Hospital of Bonn, Bonn, Germany
| | - Moritz Felcht
- Department of Dermatology, Venereology and Allergology, University Medicine Mannheim, Ruprecht-Karls-University of Heidelberg, Mannheim, Germany
| | - Hans Bayer
- Department of Dermatology and Venereology, University Hospital of Freiburg, Freiburg, Germany
| | - Laurenz Schmitt
- Department of Dermatology and Allergology, University Hospital of RWTH Aachen, Aachen, Germany
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Affiliation(s)
- Tomas J Saun
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto (T.J.S., K.W), the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre (S.P.D.), and the Division of Plastic and Reconstructive Surgery, Department of Surgery, St. Joseph's Health Centre (K.W.), Toronto, and the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Western Ontario Schulich School of Medicine and Dentistry, London (J.T.) - all in Canada
| | - Jessica Truong
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto (T.J.S., K.W), the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre (S.P.D.), and the Division of Plastic and Reconstructive Surgery, Department of Surgery, St. Joseph's Health Centre (K.W.), Toronto, and the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Western Ontario Schulich School of Medicine and Dentistry, London (J.T.) - all in Canada
| | - Shelly P Dev
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto (T.J.S., K.W), the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre (S.P.D.), and the Division of Plastic and Reconstructive Surgery, Department of Surgery, St. Joseph's Health Centre (K.W.), Toronto, and the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Western Ontario Schulich School of Medicine and Dentistry, London (J.T.) - all in Canada
| | - Kyle Wanzel
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto (T.J.S., K.W), the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre (S.P.D.), and the Division of Plastic and Reconstructive Surgery, Department of Surgery, St. Joseph's Health Centre (K.W.), Toronto, and the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Western Ontario Schulich School of Medicine and Dentistry, London (J.T.) - all in Canada
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Rosengren H, Heal CF, Buettner PG. Effect of a Single Preoperative Dose of Oral Antibiotic to Reduce the Incidence of Surgical Site Infection Following Below-Knee Dermatological Flap and Graft Repair. Dermatol Pract Concept 2019; 9:28-35. [PMID: 30775145 PMCID: PMC6368070 DOI: 10.5826/dpc.0901a08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background Surgical site infection (SSI) rates for below-knee dermatological surgery are unacceptably high, particularly following complex flap and graft closures. The role of antibiotic prophylaxis for these surgical cases is uncertain. Objective To determine whether SSI following complex dermatological closures on the leg could be reduced by antibiotic prophylaxis administered as a single oral preoperative dose. Methods A total of 115 participants were randomized to 2 g of oral cephalexin or placebo 40–60 minutes prior to surgical incision in a prospective, randomized, double-blind, placebo-controlled trial at a primary care skin cancer clinic in North Queensland, Australia. Results Overall 17/55 (30.9%) controls and 14/55 (25.5%) intervention participants developed infection (P = 0.525). There was no difference between the study groups in adverse symptoms that could be attributed to high-dose antibiotic administration (P = 1). Conclusion A single oral 2-g dose of cephalexin given before complex below-knee dermatological closure did not reduce SSI.
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Affiliation(s)
- Helena Rosengren
- School of Medicine, James Cook University, Townsville, Queensland, Australia; Skin Cancer College of Australasia, Brisbane, Queensland, Australia; Skin Repair Skin Cancer Clinic, Townsville, Queensland, Australia
| | - Clare F Heal
- School of Medicine, James Cook University, Mackay, Queensland, Australia
| | - Petra G Buettner
- Centre for Chronic Disease Prevention, James Cook University, Cairns, Queensland, Australia
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Rosengren H, Heal CF, Buttner PG. 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. BMJ Open 2018; 8:e020213. [PMID: 29674370 PMCID: PMC5914724 DOI: 10.1136/bmjopen-2017-020213] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Helena Rosengren
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Skin Cancer College of Australasia, Brisbane, Queensland, Australia
- Skin Repair Skin Cancer Clinic, Townsville, Queensland, Australia
| | - Clare F Heal
- College of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia
| | - Petra G Buttner
- Centre for Chronic Disease Prevention, James Cook University, Cairns, Queensland, Australia
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Antimicrobial Prophylaxis for Full-Face Laser Resurfacing in Transplant Recipients. Dermatol Surg 2017; 43:599-604. [PMID: 28291061 DOI: 10.1097/dss.0000000000001044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Wernham AGH, Fremlin GA, Verykiou S, Harper N, Chan SA, Stembridge N, Matin RN, Abbott RA. Survey of dermatologists demonstrates widely varying approaches to perioperative antibiotic use: time for a randomized trial? Br J Dermatol 2017; 177:265-266. [PMID: 27589248 DOI: 10.1111/bjd.15025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- A G H Wernham
- Heart of England NHS Foundation Trust, Solihull, U.K
| | - G A Fremlin
- Heart of England NHS Foundation Trust, Solihull, U.K
| | - S Verykiou
- The Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, U.K
| | - N Harper
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, U.K
| | - S A Chan
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, U.K
| | - N Stembridge
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, U.K
| | - R N Matin
- Oxford University Hospitals NHS Foundation Trust, Oxford, U.K
| | - R A Abbott
- Cardiff and Vale University Health Board, Cardiff, U.K
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Saleh K, Sonesson A, Persson K, Riesbeck K, Schmidtchen A. Can dressings soaked with polyhexanide reduce bacterial loads in full-thickness skin grafting? A randomized controlled trial. J Am Acad Dermatol 2016; 75:1221-1228.e4. [PMID: 27692497 DOI: 10.1016/j.jaad.2016.07.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 07/06/2016] [Accepted: 07/10/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Polyhexamethylene biguanide (PHMB)-based antiseptic solutions can reduce bacterial loads in different clinical settings and are believed to lower risk of infections. OBJECTIVE We sought to assess the efficacy of a PHMB-based solution in lowering bacterial loads of full-thickness skin grafting wounds and the risk of surgical site infections (SSIs). METHODS In this double-blinded clinical trial, 40 patients planned for facial full-thickness skin grafting were randomized 1:1 to receive tie-over dressings soaked with either PHMB-based solution or sterile water. Quantitative and qualitative bacterial analysis was performed on all wounds before surgery, at the end of surgery, and 7 days postoperatively. In addition, all patients were screened for nasal colonization of Staphylococcus aureus. RESULTS Analysis of wounds showed no statistically significant difference in bacterial reductions between the groups. The SSI rates were significantly higher in the intervention group (8/20) than in the control group (2/20) (P = .028). Higher postoperative bacterial loads were a common finding in SSIs (P = .011). This was more frequent when S aureus was present postoperatively (P = .034), intraoperatively (P = .03), and in patients with intranasal S aureus colonization (P = .007). LIMITATIONS Assessment of SSIs is largely subjective. In addition, this was a single-center study and the total number of participants was 40. CONCLUSION Soaking tie-over dressings with PHMB solution in full-thickness skin grafting had no effect on postoperative bacterial loads and increased the risk of SSI development. The presence of S aureus intranasally and in wounds preoperatively and postoperatively increased postoperative bacterial loads, which in turn resulted in significantly more SSIs.
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Affiliation(s)
- Karim Saleh
- Division of Dermatology and Venereology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden.
| | - Andreas Sonesson
- Division of Dermatology and Venereology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Kerstin Persson
- Division of Dermatology and Venereology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Kristian Riesbeck
- Clinical Microbiology, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Artur Schmidtchen
- Division of Dermatology and Venereology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden; LKCMedicine, Nanyang Technological University, Singapore
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Zhang S, Heller MM, Plost GR, Blalock TW. Premedication, Sedation, and Pain Medication in Dermatologic Surgery. CURRENT DERMATOLOGY REPORTS 2016. [DOI: 10.1007/s13671-016-0148-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Nuzzi LC, Greene AK, Meara JG, Taghinia A, Labow BI. Surgical Site Infection After Skin Excisions in Children: Is Field Sterility Sufficient? Pediatr Dermatol 2016; 33:136-41. [PMID: 25727412 DOI: 10.1111/pde.12523] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Skin excisions are common procedures in children. They may be performed in the clinic using field sterility or the operating room with strict sterile technique. We compared the effect of these locations and the use of antibiotics on the incidence of surgical site infection (SSI) after skin excisions. Patients ages 0-18 years presenting to our department for the excision of lesions from 2006 to 2010 with complete medical records were included in our study. Records were reviewed for demographic characteristics, presentation, perioperative conditions, and postoperative SSI and other wound complications. Analyses were performed to estimate the costs associated with sterility technique and perioperative antibiotic use. We identified 700 patients with a mean age of 9.1 years. Of 872 lesions excised, 0.3% resulted in SSI and 1.8% had other wound complications. The incidence of SSI did not vary according to sterility technique, antibiotic usage, surgeon, age, or lesion size, type, or location. The equipment costs to excise a lesion in the operating room were 200% greater than in the clinic. The incidence of SSI after excision of benign lesions in children did not differ between those performed using clinic field sterility and those using the standard aseptic sterile technique in the operating room. A considerable cost savings could be realized by adopting field sterility for simple excisions performed in the operating room and avoiding routine perioperative antibiotics in pediatric skin excisions.
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Affiliation(s)
- Laura C Nuzzi
- Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - John G Meara
- Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Amir Taghinia
- Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian I Labow
- Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Patel J, Bota J, Salkey K. The Role of Preoperative Antibiotic Prophylaxis for Dermatologic Surgery in Patients With Left Ventricular Assist Devices. Dermatol Surg 2015; 41:1337-9. [PMID: 26458040 DOI: 10.1097/dss.0000000000000470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jigar Patel
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, Virginia
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Surgical site infections in dermatologic surgery: etiology, pathogenesis, and current preventative measures. Dermatol Surg 2015; 41:537-49. [PMID: 25888316 DOI: 10.1097/dss.0000000000000364] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) after dermatologic surgery continue to represent undesirable complications that affect patients in several aspects. The etiology and pathogenesis of SSIs are not completely understood, and as a result, current preventative measures are debatable. OBJECTIVE To review and summarize the current available literature specific to SSIs in dermatologic surgery. The pathogenesis of SSIs, factors contributing to SSIs, current preventative guidelines, and evidence supporting their use are explored. METHODS A review of the medical literature. RESULTS AND CONCLUSIONS Most measures used to prevent SSIs in dermatologic surgery are based on studies of wounds in general surgery. Evidence specific to dermatologic surgery is scarce. More research related to the pathogenesis of SSIs is needed to establish effective preventative measures that are key to reducing incidences of SSIs.
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Rieck B, Bates D, Zhang K, Escott N, Mougenot C, Pichardo S, Curiel L. Focused ultrasound treatment of abscesses induced by methicillin resistant Staphylococcus aureus: feasibility study in a mouse model. Med Phys 2015; 41:063301. [PMID: 24877838 DOI: 10.1118/1.4875692] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To study the therapeutic effect of focused ultrasound on abscesses induced by methicillin-resistant Staphylococcus aureus (MRSA). MRSA is a major nosocomial pathogen where immunocompromised patients are prone to develop infections that are less and less responsive to regular treatments. Because of its capability to induce a rise of temperature at a very precise location, the use of focused ultrasound represents a considerable opportunity for therapy of localized MRSA-related infections. METHODS 50 μl of MRSA strain USA400 bacteria suspension at a concentration of 1.32 ± 0.5 × 10(5) colony forming units (cfu)/μl was injected subcutaneously in the left flank of BALB/c mice. An abscess of 6 ± 2 mm in diameter formed after 48 h. A transducer operating at 3 MHz with a focal length of 50 mm and diameter of 32 mm was used to treat the abscess. The focal point was positioned 2 mm under the skin at the abscess center. Forty-eight hours after injection four ultrasound exposures of 9 s each were applied to each abscess under magnetic resonance imaging guidance. Each exposure was followed by a 1 min pause. These parameters were based on preliminary experiments to ensure repetitive accurate heating of the abscess. Real-time estimation of change of temperature was done using water-proton resonance frequency and a communication toolbox (matMRI) developed inhouse. Three experimental groups of animals each were tested: control, moderate temperature (MT), and high temperature (HT). MT and HT groups reached, respectively, 52.3 ± 5.1 and 63.8 ± 7.5 °C at the end of exposure. Effectiveness of the treatment was assessed by evaluating the bacteria amount of the treated abscess 1 and 4 days after treatment. Myeloperoxidase (MPO) assay evaluating the neutrophil amount was performed to assess the local neutrophil recruitment and the white blood cell count was used to evaluate the systemic inflammatory response after focused ultrasound treatment. RESULTS Macroscopic evaluation of treated abscess indicated a diminution of external size of abscess 1 day after treatment. Treatment did not cause open wounds. The median (lower to upper quartile) bacterial count 1 day after treatment was 6.18 × 10(3) (0.76 × 10(3)-11.18 × 10(3)), 2.86 × 10(3) (1.22 × 10(3)-7.07 × 10(3)), and 3.52 × 10(3) (1.18 × 10(3)-6.72 × 10(3)) cfu/100 μl for control, MT and HT groups, respectively; for the 4-day end point, the count was 1.37 × 10(3) (0.67 × 10(3)-2.89 × 10(3)), 1.35 × 10(3) (0.09 × 10(3)-2.96 × 10(3)), and 0.07 × 10(3) (0.03 × 10(3)-0.36 × 10(3)) cfu/100 μl for control, MT and HT, showing a significant reduction (p = 0.002) on the bacterial load four days after focused ultrasound treatment when treating at high temperature (HT). The MPO amount remained unchanged between groups and days, indicating no change on local neutrophil recruitment in the abscess caused by the treatment. The white blood cell count remained unchanged between groups and days indicating that no systemic inflammatory response was caused by the treatment. CONCLUSIONS Focused ultrasound induces a therapeutic effect in abscesses induced by MRSA. This effect is observed as a reduction of the number bacteria without significantly altering the amount of MPO at the site of a MRSA-induced abscess. These initial results suggest that focused ultrasound is a viable option for the treatment of localized MRSA-related infections.
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Affiliation(s)
- Birgit Rieck
- Thunder Bay Regional Research Institute, Thunder Bay, Ontario P7B6V4, Canada
| | - David Bates
- Thunder Bay Regional Research Institute, Thunder Bay, Ontario P7B6V4, Canada and Lakehead University, Thunder Bay, Ontario P7B6V4, Canada
| | - Kunyan Zhang
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta T2N 1N4, Canada
| | - Nicholas Escott
- Department of Pathology, Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ontario P7B 6V4, Canada
| | | | - Samuel Pichardo
- Thunder Bay Regional Research Institute, Thunder Bay, Ontario P7B6V4, Canada and Lakehead University, Thunder Bay, Ontario P7B6V4, Canada
| | - Laura Curiel
- Thunder Bay Regional Research Institute, Thunder Bay, Ontario P7B6V4, Canada and Lakehead University, Thunder Bay, Ontario P7B6V4, Canada
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