Risk factors for wound infection after minor surgery in general practice

Evidence-Based Performance Measures for Reconstruction after Skin Cancer Resection: A Multidisciplinary Performance Measure Set

BACKGROUND

The American Society of Plastic Surgeons commissioned the multidisciplinary Performance Measure Development Work Group on Reconstruction after Skin Cancer Resection to identify and draft quality measures for the care of patients undergoing skin cancer reconstruction. Included stakeholders were the American Academy of Otolaryngology-Head and Neck Surgery, the American Academy of Facial Plastic and Reconstructive Surgery, the American Academy of Dermatology, the American Society of Dermatologic Surgery, the American College of Mohs Surgery, the American Society for Mohs Surgery, and a patient representative.

METHODS

Two outcome measures and five process measures were identified. The outcome measures included the following: (1) patient satisfaction with information provided by their surgeon before their facial procedure, and (2) postprocedural urgent care or emergency room use. The process measures focus on antibiotic stewardship, anticoagulation continuation and/or coordination of care, opioid avoidance, and verification of clear margins.

RESULTS

All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the stakeholder societies.

CONCLUSION

The work group recommends the use of these measures for quality initiatives, Continuing Medical Education, Continuous Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.

Surgical site infection in skin surgery-An observational study

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.

Intralesional 5-fluorouracil as a management for cutaneous squamous cell carcinomas: A rural Australian retrospective case series

While the gold standard treatment for cutaneous squamous cell carcinomas (cSCCs) is surgical removal, there is a risk of infection, cosmetic and functional deficits. Intralesional 5-fluorouracil (5-FU) has been shown to be a potential non-surgical treatment modality for cSCCs in the literature. The aim was to investigate the safety and feasibility of using intralesional 5-FU to treat cSCCs. A literature review was conducted and a retrospective case series analysed patients who commenced intralesional 5-FU treatment for at least one cSCC between 1 January 2018 and 1 January 2019 at a private clinic in Orange, Australia. Inclusion criteria include: at least one cSCC was treated; only intralesional 5-FU was used; and treatment was ceased due to complete or inadequate remission, or adverse effects. There were 15 patients (7 female, 8 male, 60-99 years) and 20 out 21 cSCC lesions (82.6%) cleared while one lesion (4.3%) recurred. Six lesions (26.1%) ulcerated, four lesions became infected (17.4%) and one patient had an allergic reaction. The average number of treatments required for clearance was four (range 1-35), and the average 5-FU dose used was 75 mg (range 50-150 mg). Across 25 studies, 656 out of 708 lesions cleared (92.66%). Adverse effects were self-limiting and mostly well-tolerated. Intralesional 5-FU is an affordable and non-invasive non-surgical treatment modality that appears feasible to use for cSCCs and has a relatively low treatment-associated morbidity. Future clinical trials can help develop a protocol to guide clinicians in its use.

Patient-dependent risk factors for wound infection after skin surgery: A systematic review and meta-analysis

Postoperative wound infection in dermatologic surgery causes impaired wound healing, poor cosmetic outcome and increased morbidity. Patients with a high-risk profile may benefit from perioperative antibiotic prophylaxis. The objective of this systematic review was to identify risk factors for surgical site infection after dermatologic surgery. In this article, we report findings on patient-dependent risk factors. The literature search included MEDLINE, EMBASE, CENTRAL and trial registers. We performed meta-analysis, if studies reported sufficient data to calculate risk ratios with 95% confidence intervals. Study quality was assessed according to the Newcastle-Ottawa-Scale. Seventeen observational studies that analysed 31213 surgical wounds were eligible for inclusion. Fourteen studies qualified for meta-analysis. Nine studies showed good, three fair and five poor methodological quality. The reported incidence of surgical site infection ranged from 0.96% to 8.70%. Meta-analysis yielded that male gender and immunosuppression were significantly associated with higher infection rates. There was a tendency towards a higher infection risk for patients with diabetes, without statistical significance. Meta-analysis did not show different infection rates after excision of squamous cell carcinoma or basal cell carcinoma, but studies were substantially heterogenous. There was no significant association between risk for wound infection and smoking, age over 60 years, oral anti-aggregation or anti-coagulation or excision of malignant melanoma. In conclusion, the risk for surgical site infection in dermatologic surgery is low. Infection rates were increased significantly in male as well as immunosuppressed patients and non-significantly in diabetics.

Injectable Platelet-Rich Fibrin as a Drug Carrier Increases the Antibacterial Susceptibility of Antibiotic—Clindamycin Phosphate

The aim of this study was to investigate the change in clindamycin phosphate antibacterial properties against Gram-positive bacteria using the platelet-rich fibrin as a carrier matrix, and evaluate the changes in the antibiotic within the matrix. The antibacterial properties of CLP and its combination with PRF were tested in a microdilution test against reference cultures and clinical isolates of Staphylococcus aureus (S. aureus) or Staphylococcus epidermidis (S. epidermidis). Fourier-transform infrared spectroscopy (FTIR) and scanning electron microscope (SEM) analysis was done to evaluate the changes in the PRF_CLP matrix. Release kinetics of CLP was defined with ultra-performance liquid chromatography (UPLC). According to FTIR data, the use of PRF as a carrier for CLP ensured the structural changes in the CLP toward a more active form of clindamycin. A significant decrease in minimal bactericidal concentration values (from 1000 µg/mL to 62 µg/mL) against reference cultures and clinical isolates of S. aureus and S. epidermidis was observed for the CLP and PRF samples if compared to pure CLP solution. In vitro cell viability tests showed that PRF and PRF with CLP have higher cell viability than 70% after 24 h and 48 h time points. This article indicates that CLP in combination with PRF showed higher antibacterial activity against S. aureus and S. epidermidis compared to pure CLP solution. This modified PRF could be used as a novel method to increase drug delivery and efficacy, and to reduce the risk of postoperative infection.

Are Specific Body Sites Prone for Wound Infection After Skin Surgery? A Systematic Review and Meta-Analysis

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.

Skin lesion assessment and management model: optimising existing resources in the management of non-melanoma skin cancer

Abstract Background Skin cancer is a relatively common cancer in Australia, with early, simple treatment conferring a high likelihood of cure. Early diagnosis and treatment are important to reduce morbidity and mortality. A see-and-treat clinic seeks to offer earlier diagnosis and treatment as compared with a traditional model of care. The aim was to implement this model using pre-existing infrastructure with a hypothesis that this service will reduce wait times with reduced costs and high levels of patient satisfaction    Methods Referrals were screened and those suitable underwent consultation with a Plastic and Reconstructive Surgeon and same-day operative management with their choice of anaesthesia. Patients were reviewed 1 week and 4 weeks postoperatively.   Results 206 patients had 286 skin lesions removed over 23 operating lists. Over 75% of excisions were on the face. Local anaesthetic with sedation was the most popular anaesthetic technique There were 22 complications and the incomplete excision rate was 4.2%. Average wait time for SLAM-suitable patients reduced by 76%, and category 1 outpatient waitlists were reduced by 100%. An estimated gross saving of $1,339 per patient was calculated. A survey of patients post-operatively showed all patients would recommend this model.   Conclusion This see-and-treat model was shown to reduce wait times and cost, along with high levels of patient satisfaction. It was also easily implemented using pre-existing infrastructure. It is a service that continues to be offered and expanded, with ongoing patient satisfaction.

Risk Factors for Infection After Noncultured Melanocyte Keratinocyte Transplantation for Vitiligo

BACKGROUND

Noncultured autologous melanocyte keratinocyte transplantation is considered a safe and effective treatment option in stable vitiligo. Factors associated with risk of infection are still poorly explored.

OBJECTIVE

To search for factors associated with the risk of infection after noncultured autologous melanocyte keratinocyte transplantation (MKTP).

METHOD

This was a retrospective multicentric study including all patients with vitiligo who had undergone noncultured autologous MKTP between January 2010 and December 2020. Data included age, sex, site, and size of the treated area, recipient area preparation method, and antibiotic prescription preceding the procedure. Univariate and multivariate analyses to search for factors associated with infection after MKTP were conducted.

RESULTS

A total of 672 patients were included. Infection was present in 39 of the patients (6%) (95% confidence interval [CI]: 4.2%-7.7%). The following factors were independently associated with higher rate of infection: cryotherapy for recipient area preparation (OR 19.76, 95% CI: 3.21-121.74) and treated lesions on the trunk (OR 2.67, 95% CI: 1.21-5.90), lower extremity (OR 5.99, 95% CI: 2.49-14.40), and foot (OR 13.15, 95% CI: 4.37-39.62).

CONCLUSION

Infection after noncultured autologous MKTP is not uncommon. Cryotherapy for recipient area preparation and lesions on the trunk, lower extremity, or foot was independently associated with an increased risk of infection.

From Blood to Regenerative Tissue: How Autologous Platelet-Rich Fibrin Can Be Combined with Other Materials to Ensure Controlled Drug and Growth Factor Release

The purpose of this review is to examine the latest literature on the use of autologous platelet-rich fibrin as a drug and growth factor carrier system in maxillofacial surgery. Autologous platelet-rich fibrin (PRF) is a unique system that combines properties such as biocompatibility and biodegradability, in addition to containing growth factors and peptides that provide tissue regeneration. This opens up new horizons for the use of all beneficial ingredients in the blood sample for biomedical purposes. By itself, PRF has an unstable effect on osteogenesis: therefore, advanced approaches, including the combination of PRF with materials or drugs, are of great interest in clinics. The main advantage of drug delivery systems is that by controlling drug release, high drug concentrations locally and fewer side effects within other tissue can be achieved. This is especially important in tissues with limited blood supply, such as bone tissue compared to soft tissue. The ability of PRF to degrade naturally is considered an advantage for its use as a "warehouse" of controlled drug release systems. We are focusing on this concentrate, as it is easy to use in manipulations and can be delivered directly to the surgical site. The target audience for this review are researchers and medical doctors who are involved in the development and research of PRFs further studies. Likewise, surgeons who use PRF in their work to treat patients and who advice patients to take the medicine orally.

Health utilities for non-melanoma skin cancers and pre-cancerous lesions: A systematic review

BACKGROUND

Non-melanoma skin cancers (NMSCs) are common and consume many healthcare resources. A health utility is a single preference-based value for assessing health-related quality of life, which can be used in economic evaluations. There are scarce data on health utilities for NMSCs.

OBJECTIVES

Using a systematic review approach, we synthesized the current data on NMSC-related health utilities.

METHODS

A systematic review of studies of NMSC-related health utilities was conducted in Medline, Embase, and Cochrane databases. Data were extracted based on the protocol and a quality assessment was performed for each study.

RESULTS

The protocol resulted in 16 studies, involving 121 621 participants. Mean utility values across the studies ranged from 0.56 to 1 for undifferentiated NMSC, 0.84 to 1 for actinic keratosis, 0.45 to 1 for squamous cell carcinoma, and 0.67 to 1 for basal cell carcinoma. There was considerable variability in utilities by type of cancer, stage of diagnosis, time to treatment, treatment modality, and quality of life instrument or method. Utility values were predominantly based on the EuroQol 5-dimension instrument and ranged from 0.45 to 0.96, while other measurement methods produced values ranging from 0.67 to 1. Lower utility values were observed for advanced cancers and for the time period during and immediately after treatment, after which values gradually returned to pre-treatment levels.

CONCLUSIONS

Most utility values clustered around relatively high values of 0.8 to 1, suggesting small decrements in quality of life associated with most NMSCs and their precursors. Variability in utilities indicates that careful characterization is required for measures to be used in economic evaluations.

Risk Factors for Surgical Site Infection after Minor Dermatologic Surgery

BACKGROUND

Surgical site infection (SSI) after dermatologic surgery is associated with poor outcomes including increased recovery time, poor cosmesis, and repeat visits to doctors. Prophylactic antibiotics are prescribed to reduce these adverse outcomes. Identifying risk factors for SSI will facilitate judicious antibiotic prophylaxis.

OBJECTIVE

To identify risk factors for SSI after minor dermatologic surgery.

METHODS

Individual patient data from four large randomized controlled trials were combined to increase statistical power. A total of 3,819 adult patients requiring minor skin procedures at a single facility were recruited over a 10-year period. The main outcome measure was SSI.

MAIN RESULTS

A total of 298 infections occurred, resulting in an overall incidence of 7.8% (95% confidence interval [CI], 5.8-9.6), although the incidence varied across the four studies (P = .042). Significant risk factors identified were age (relative risk [RR], 1.01; 95% CI, 1.001-1.020; P = .008), excisions from the upper limbs (RR, 3.03; 95% CI, 1.76-5.22; P = .007) or lower limbs (RR, 3.99; 95% CI, 1.93-8.23; P = .009), and flap/two-layer procedures (RR, 3.23; 95% CI, 1.79-5.85; P = .008). Histology of the excised lesion was not a significant independent risk factor for infection.

CONCLUSIONS

This study demonstrated that patients who were older, underwent complex excisions, or had excisions on an extremity were at higher risk of developing an SSI. An awareness of such risk factors will guide evidence-based and targeted antibiotic prophylaxis.

Is Surgical Site Infection (SSI) after skin surgery affected by home municipal versus non-municipal water supply?

PURPOSE

SSI represent one of the most common sources of morbidity and escalated healthcare costs in skin cancer management. It has been shown that exposing wounds to treated water does not increase SSIs, however a large proportion of Australasian patients reside in rural areas dependant on roof or bore collected water for their primary water supply, and no data exist regarding the association between tank water supply and SSI following skin surgery.

METHODOLOGY

A nine-month retrospective analysis of patients undergoing skin cancer surgery at the Auckland Regional Plastic Surgery Unit was performed. Wounds assessed using a validated wound infection scoring system. Rates of SSI analysed against various clinical factors (water supply, smoking status, immunocompromise, glucose intolerance) and surgical factors (type of reconstruction, ulceration, lesion site, surface area of lesion).

RESULTS

857 lesions were excised from 357 patients over the period studied. 718 lesions (83.7%) had municipal and 139 lesions (16.3%) had non-municipal water as their primary supply. Overall rate of clinically significant SSI was 15.6%, with no difference between municipal and non-municipal water groups (15.6% vs. 15.8% P = 0.946). Further subgroup analysis did not reveal any difference in rate of SSI based on type of surgical closure (direct closure, skin graft vs. flap).

CONCLUSION

Non-municipal water supply was not associated with change in SSI relative to home municipal water supply in patients receiving skin cancer surgery. Our data supplements existing literature that water exposure does not influence SSI following skin surgery irrespective of primary home water supply.

Postoperative complications in dermatological patients undergoing microscopically controlled surgery in inpatient setting (next-day surgery): A single-center epidemiological study

BACKGROUND

Surgical site infections (SSI), bleeding, and necrosis are possible complications of dermatological surgery, and their rates are well described for Mohs surgery (same-day surgery). However, there are only limited data on their occurrence in microscopically controlled surgery of the form in which it is practiced in German hospitals (next-day surgery).

MATERIALS AND METHODS

We performed a retrospective analysis of patient records of patients hospitalized for microscopically controlled surgery during the year 2017 (12 months) in the Department of Dermatology and Allergology at the University Hospital of the RWTH Aachen (Aachen, Germany). The investigation addressed postoperative outcomes.

RESULTS

319 patients underwent 528 dermatosurgical procedures in the defined period. Bleeding and necrosis occurred in 3.8 % (20/528) and 1.7 % (9/528) of the procedures, respectively. SSI occurred in 5.1 % (27/528) of the cases. The occurrence of bleeding was a statistically significant risk factor for SSI (p  =  0.01). Furthermore, bleeding, SSI, and wound closure with a full-thickness graft were statistically significant risk factors for the development of necrosis (p < 0.05). Diabetes or immunosuppression were not found to be statistically significant risk factors for the development of SSI or necrosis after dermatologic surgery (p > 0.05).

CONCLUSIONS

Complication rates in microscopically controlled surgery (next-day surgery) are generally low and similar to those reported for Mohs surgery (same-day surgery). Therefore, it appears that some evidence-based perioperative recommendations that have been developed for Mohs surgery could be applied to German inpatient dermatosurgery. However, prospective studies with larger patient numbers are required to offer concrete recommendations specifically for microscopically controlled surgery (next-day surgery).

Bacterial Profile, Antimicrobial Susceptibility Pattern, and Associated Risk Factors Among Patients With Wound Infections at Debre Markos Referral Hospital, Northwest, Ethiopia

Wound infections are associated with morbidity and mortality in developing countries. Thus, this study aimed to assess bacterial profile, antimicrobial susceptibility pattern and risk factors among wound infection suspected patients. A hospital-based cross-sectional study was conducted on 201 participants at Debre Markos referral hospital from January to May 2019. Sociodemographic data were collected using pre-designed questionnaire and swabs from different types of wounds were collected, and inoculated onto mannitol salt agar, blood and MacConkey agar plate for isolation and identification. Antimicrobial susceptibility tests were done using modified Kirby-Bauer disk diffusion technique. Out of 201 swabs analyzed, 72.6% were culture positive and 10.9% of them had co-infections, and 162 bacterial isolates obtained from 146 swab samples. Staphylococcus aureus was the most frequently isolated which accounted for 32.1% of isolates followed by Pseudomonas aeruginosa, 15.4%. The susceptibility patterns of ciprofloxacin, gentamycin and ceftriaxone were 77.8%, 69.1%, and 68.5%, respectively. The MDR rate of gram positive and gram negative isolates were 69.7% and 82.3%, respectively. Anatomically located wounds near a site of potential contamination, inadequate management of moisture, exudate or edema, mechanism of wound production, presence of predisposing condition and being urban in residence significantly associated with wound infections. S. aureus and P. aeruginosa were the predominant causes of wound infections. Ciprofloxacin, gentamycin and ceftriaxone were the most effective antimicrobials. Periodic surveillance of isolates involved in wound infection and their antimicrobial susceptibility is recommended for effective management of patients.

Surgical site infections after microscopically controlled skin surgery in immunocompromised patients: a retrospective two-center cohort study

The data on the risk of surgical site infections (SSI) after skin surgery in patients undergoing immunosuppressive treatment are limited and the results of the existing single-center studies are controversial. At the same time, perioperative antibiotic prophylaxis (PAP) for immunocompromised patients seems to be overused. We performed a retrospective analysis of the SSI rates after extensive dermatosurgical procedures performed from January 2017 to December 2017 in patients with impaired immune status due to a hematological disorder or immunosuppressive treatment at two German dermatosurgical centers. The SSI rate in immunocompromised patients was 6.7%. The independent risk factors for SSI found in the studied population were the occurrence of bleeding after one of the surgical stages and the use of oral anticoagulation with two different agents (the combination of acetylsalicylic acid and a direct oral anticoagulant). 44.4% (4/9) of the procedures complicated with an SSI involved wound closure with a skin flap, which was statistically significant (p = 0.041). Other risk factors identified were older age of the patients and increased duration of hospitalization (p < 0.05). Localization of the surgical site, number of surgical stages required for tumor clearance, and diabetes mellitus were not found to be statistically significant risk factors for occurrence of SSI in the studied population. SSI rates in immunocompromised patients undergoing skin surgery are low; therefore, we recommend against routine use of PAP for this cohort.

Radiation for below the knee skin cancers: a single institution experience

Background: Historically, radiation to skin cancers for the lower legs has been avoided due to the perceived increased risk of radiation toxicity (poor wound healing, radiation necrosis). However, there is a paucity of published data regarding this perceived risk.Purpose: The objective was to review the risk of poor wound healing/radiation necrosis occurring post radiation and to determine rates of complete response (CR), partial response (PR), and progressive disease after radiation therapyMaterials and methods: A retrospective review of patients treated with radiation for skin cancer below the knee was undertaken from January 1, 2013 to May 31, 2018.Results: A total of 25 patients with 39 below the knee skin sites were treated with radiation. Mean follow-up time was 19 months (range 3 months-7.2 years). Crude CR, PR and progression rates for the treated lesions were 65%, 19%, and 16% respectively. Four out of 23 (17%) patients developed Grade 3 skin toxicity. There were no grades 4 or 5 toxicities.Conclusions: For patients not eligible for surgery, radiation therapy is an option with a moderate chance of complete response (65%) and a 17% risk of poor wound healing/radiation necrosis.

Analysis of the status quo of perioperative antibiotic prophylaxis in dermatosurgery in Germany: results of the DESSI-study

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.

Surgical Site Infections After Dermatologic Surgery in Immunocompromised Patients: A Single-Center Experience

BACKGROUND

Immunosuppression is often considered as an indication for antibiotic prophylaxis to prevent surgical site infections (SSI) while performing skin surgery. However, the data on the risk of developing SSI after dermatologic surgery in immunosuppressed patients are limited.

PATIENTS AND METHODS

All patients of the Department of Dermatology and Allergology at the University Hospital of RWTH Aachen in Aachen, Germany, who underwent hospitalization for a dermatologic surgery between June 2016 and January 2017 (6 months), were followed up after surgery until completion of the wound healing process. The follow-up addressed the occurrence of SSI and the need for systemic antibiotics after the operative procedure. Immunocompromised patients were compared with immunocompetent patients. The investigation was conducted as a retrospective analysis of patient records.

RESULTS

The authors performed 284 dermatologic surgeries in 177 patients. Nineteen percent (54/284) of the skin surgery was performed on immunocompromised patients. The most common indications for surgical treatment were nonmelanoma skin cancer and malignant melanomas. Surgical site infections occurred in 6.7% (19/284) of the cases. In 95% (18/19), systemic antibiotic treatment was needed. Twenty-one percent of all SSI (4/19) were seen in immunosuppressed patients.

CONCLUSION

According to the authors' data, immunosuppression does not represent a significant risk factor for SSI after dermatologic surgery. However, larger prospective studies are needed to make specific recommendations on the use of antibiotic prophylaxis while performing skin surgery in these patients.

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

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.

Diabetes and the occurrence of infection in primary care: a matched cohort study

Background

People with diabetes may be at higher risk for acquiring infections through both glucose-dependent and biologic pathways independent of glycemic control. Our aim was to estimate the association between diabetes and infections occurring in primary care.

Methods

Using the Newfoundland and Labrador Sentinel of the Canadian Primary Care Sentinel Surveillance Network, patients with diabetes ≥18 years between 1 January 2008 and 31 March 2013 were included with at least 1-year of follow-up. We randomly matched each patient with diabetes on the date of study entry with up to 8 controls without diabetes. Primary outcome was the occurrence of ≥1 primary care physician visits for any infectious disease. Secondary outcomes included primary visits for head & neck, respiratory, gastrointestinal, genitourinary, skin and soft tissue, musculoskeletal, and viral infections. Using multivariable conditional logistic regression analysis, we measured the independent association between diabetes and the occurrence of infections.

Results

We identified 1779 patients with diabetes who were matched to 11,066 patients without diabetes. Patients with diabetes were older, had a higher prevalence of comorbidities, and were more often referred to specialists. After adjusting for potential confounders, patients with diabetes had an increased risk of any infection compared to patients without diabetes (adjusted odds ratio = 1.21, 95% confidence interval 1.07–1.37). Skin and soft tissue infections had the strongest association, followed by genitourinary, gastrointestinal, and respiratory infections. Diabetes was not associated with head and neck, musculoskeletal, or viral infections.

Conclusion

Patients with diabetes appear to have an increased risk of certain infections compared to patients without diabetes.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-2975-2) contains supplementary material, which is available to authorized users.

Do perioperative antibiotics reduce the risk of surgical-site infections following excision of ulcerated skin cancers? A Critically Appraised Topic

AIM

To review the efficacy of perioperative antibiotics in reducing the risk of surgical-site infections (SSIs) following excision of ulcerated skin cancers.

SETTING AND DESIGN

Study selection, data extraction and analysis were carried out independently by four authors. Only randomized controlled trials (RCTs) reported in the English language were included.

INCLUDED STUDIES

RCTs in the English language in which patients received perioperative topical, intralesional or oral antibiotics for dermatological surgery, including Mohs micrographic surgery in general practice, dermatology or plastic surgery departments, were included.

OUTCOME

The proportion of participants developing SSI following excision of skin lesions.

RESULTS

Thirteen RCTs were identified from our literature search of PubMed and Embase, which evaluated SSI following use of topical (n = 5), oral (n = 3), intramuscular (n = 2), intravenous (n = 1) and intralesional antibiotics (n = 2) in dermatological surgery. Two RCTs specifically investigated SSIs in ulcerated skin cancer excisions; one RCT investigated the SSI rate following surgical treatment specifically for ulcerated skin cancers in individuals randomized to topical antibiotics vs. oral cephalexin; and one RCT compared intravenous cefazolin with no antibiotic, demonstrating significant reduction in SSI rates for ulcerated tumours (P = 0·04).

CONCLUSIONS

The heterogeneity of the RCTs included in this study makes it difficult to make a direct comparison of the outcomes measured. High-quality evidence demonstrating a beneficial effect of the use of perioperative antibiotics to prevent SSI following excision of ulcerated skin cancers is lacking. In the absence of an evidence base, we propose that a well-designed multicentre RCT could evaluate the effect of perioperative antibiotics following excision of ulcerated tumours, and potentially reduce inappropriate antibiotic prescription.

Topical antibiotics to prevent surgical site infection after minor surgery in primary care

Background

Surgical site infection (SSI) after minor surgery in primary care can compromise cosmetic outcomes, delay wound healing and increase costs. In addition to efficacy, adverse effects must be considered when considering antibiotic prophylaxis. There is no prior published literature regarding the proportion of general practitioners (GPs) who use topical antibiotics as SSI prophylaxis following minor surgery.

Objectives

To identify the proportion of GPs in a regional center in Queensland, Australia who apply topical antibiotics to wounds prevent SSIs after minor surgery.

Method

A database of 90 GPs was established, and they were invited to complete a questionnaire.

Results

The response rate was 62% (56/90). Topical antibiotics prophylaxis was reported as being used always or sometimes in routine practice by 18% (10/56) of participants after both skin lesion excision and repair of lacerations. In the context of high-risk situations, on the other hand, use was higher. They were more likely to be used in high-risk situations, most frequently in diabetic patients (41.0% [23/56]) and immunocompromised patients (46.5% [26/56]).

Conclusions

Evidence-based prescribing of antibiotics is vital. Topical antibiotic prophylaxis is often prescribed excessively after clean dermatological surgery, however, in our sample of GPs, only 18% used topical antibiotics always or sometimes in their practice.

Alcoholic versus aqueous chlorhexidine for skin antisepsis: the AVALANCHE trial

BACKGROUND

Preoperative skin antisepsis is routine practice. We compared alcoholic chlorhexidine with aqueous chlorhexidine for skin antisepsis to prevent surgical site infection after minor skin excisions in general practice.

METHODS

We conducted this prospective, multicentre, randomized controlled trial in 4 private general practices in North Queensland, Australia, from October 2015 to August 2016. Consecutive adult patients presenting for minor skin excisions were randomly assigned to undergo preoperative skin antisepsis with 0.5% chlorhexidine in 70% ethanol (intervention) or 0.5% chlorhexidine aqueous solution (control). Our primary outcome was surgical site infection within 30 days of excision. We also measured the incidence of adverse reactions.

RESULTS

A total of 916 patients were included in the study: 454 underwent antisepsis with alcoholic chlorhexidine and 462 with aqueous chlorhexidine. Of these, 909 completed follow-up. In the intention-to-treat analysis of cases available at follow-up, there was no significant difference in the incidence of surgical site infection between the alcoholic chlorhexidine arm (5.8%, 95% confidence interval [CI] 3.6% to 7.9%) and the aqueous chlorhexidine arm (6.8%, 95% CI 4.5% to 9.1%). The attributable risk reduction was 0.010 (95% CI -0.021 to 0.042), the relative risk was 0.85 (95% CI 0.51 to 1.41), and the number needed to treat to benefit was 100. Per protocol and sensitivity analyses produced similar results. The incidence of adverse reactions was low, with no difference between groups (p = 0.6).

INTERPRETATION

There was no significant difference in efficacy between alcoholic and aqueous chlorhexidine for the prevention of surgical site infection after minor skin excisions in general practice. Trial registration: https://www.anzctr.org.au, no. ACTRN12615001045505.

Protocol for a randomised controlled trial comparing aqueous with alcoholic chlorhexidine antisepsis for the prevention of superficial surgical site infection after minor surgery in general practice: the AVALANCHE trial

INTRODUCTION

Surgical site infection (SSI) after minor skin excisions has a significant impact on patient morbidity and healthcare resources. Skin antisepsis prior to surgical incision is used to prevent SSI, and is performed routinely worldwide. However, in spite of the routine use of skin antisepsis, there is no consensus regarding which antiseptic agents are most effective. The AVALANCHE trial will compare Aqueous Versus Alcoholic Antisepsis with Chlorhexidine for Skin Excisions.

METHODS AND ANALYSIS

The study design is a prospective, randomised controlled trial (RCT) with the aim of investigating the impact of two different antiseptic preparations on the incidence of superficial SSI in patients undergoing minor skin excisions. The intervention of 0.5% chlorhexidine gluconate (CHG) in 70% alcohol will be compared with that of 0.5% CHG in aqueous solution. The trial will be conducted in four Australian general practices over a 9-month period, with 920 participants to be recruited. Consecutive patients presenting for minor skin excisions will be eligible to participate. Randomisation will be on the level of the patient. The primary outcome is superficial SSI in the first 30 days following the excision. Secondary outcomes will be adverse effects, including anaphylaxis, skin irritation, contact dermatitis and rash and patterns of antibiotic resistance.

ETHICS AND DISSEMINATION

The study has been approved by the James Cook University Human Research Ethics Committee (HREC). Findings will be disseminated in conference presentations and journals and through online electronic media.

DISCUSSION

RCTs conducted in general practice differ from hospital-based projects in terms of feasibility, pragmatism and funding. The success of this trial will be cemented in the fact that the research question was established by a group of general practitioners who identified an interesting question which is relevant to their clinical practice and not answered by current evidence.

TRIAL REGISTRATION NUMBER

ACTRN12615001045505; Pre-results.

Factors associated with infection following anterior cruciate ligament reconstruction

BACKGROUND

Although rare, infection can be devastating after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to test the association between infection after ACL reconstruction and potential risk factors such as age, body mass index (BMI), smoking, diabetes, and graft choice.

METHODS

We reviewed the Multicenter Orthopaedic Outcomes Network (MOON) cohort from 2002 to 2005 to identify patients with a postoperative infection. The age, BMI, smoking status, history of diabetes, and graft choice were recorded for each patient. A multivariable regression analysis was constructed to examine which baseline risk factors were independently associated with postoperative infection after ACL reconstruction requiring surgical intervention.

RESULTS

There were 2198 eligible patients in the cohort, with seventeen (0.8%) reporting a postoperative infection. Diabetes was found to be a significant risk factor for infection (odds ratio [OR] = 18.8; 95% confidence interval [CI] = 3.8 to 94.0; p < 0.001). Compared with bone-tendon-bone autograft, both hamstring autograft and other grafts (e.g., the majority of allografts, with some that were both autograft and allograft) also increased the risk of infection (OR = 4.6 [95% CI = 1.2 to 17.9; p = 0.026] for hamstrings and 4.3 [95% CI = 1.0 to 18.1; p = 0.047] for other grafts). Although the OR for infection in smokers was 2.5, this finding did not reach significance.

CONCLUSIONS

Patients with diabetes undergoing ACL reconstruction have a significantly elevated risk of postoperative infection (18.8-times higher odds) compared with that for patients without diabetes. Use of bone-tendon-bone autograft is associated with a lower risk of infection after ACL reconstruction.

Prophylactic antibiotics in dermatological surgery

This is a review of the common pathogens of surgical site infections, antibiotic coverage for particular anatomical sites, mechanisms by which surgical site infections occur and the latest data and recommendations for prophylactic antibiotics in the prevention of surgical site infections, infective endocarditis and haematogenous joint infections. Recent evidence-based guidelines on surgical prophylaxis is for restricted indications and a shorter duration of antibiotic prophylaxis in situations where no clinical benefit of prolonged therapy has been proven, in order to minimise the potential adverse ecological and clinical effects associated with antibiotic therapy. This review recommends the cautious use of prophylactic antibiotics in dermatological surgery to help prevent the growing problem of bacterial resistance as well as other morbidity and health-care costs.

A study of Basal cell carcinoma in South asians for risk factor and clinicopathological characterization: a hospital based study

Objectives. Although the incidence of skin cancers in India (part of South Asia) is low, the absolute number of cases may be significant due to large population. The existing literature on BCC in India is scant. So, this study was done focusing on its epidemiology, risk factors, and clinicopathological aspects. Methods. A hospital based cross-sectional study was conducted in Punjab, North India, from 2011 to 2013. History, examination and histopathological confirmation were done in all the patients visiting skin department with suspected lesions. Results. Out of 36 confirmed cases, 63.9% were females with mean ± SD age being 60.9 ± 14.2 years. Mean duration of disease was 4.7 years. Though there was statistically significant higher sun exposure in males compared to females (P value being 0.000), BCC was commoner in females, explainable by intermittent sun exposure (during household work in the open kitchens) in women. Majority of patients (88.9%) had a single lesion. Head and neck region was involved in 97.2% of cases, with nose being the commonest site (50%) with nodular/noduloulcerative morphology in 77.8% of cases. Pigmentation was evident in 22.2% of cases clinically. Nodular variety was the commonest histopathological variant (77.8%). Conclusions. This study highlights a paradoxically increasing trend of BCC with female preponderance, preferential involvement of nose, and higher percentage of pigmentation in Indians.

Prevention of surgical site infection in lower limb skin lesion excisions with single dose oral antibiotic prophylaxis: a prospective randomised placebo-controlled double-blind trial

OBJECTIVES

To determine the effectiveness of a single perioperative prophylactic 2 g dose of cephalexin in preventing surgical site infection (SSI) following excision of skin lesions from the lower limb.

DESIGN

Prospective double-blinded placebo-controlled trial testing for difference in infection rates.

SETTING

Primary care in regional North Queensland, Australia.

PARTICIPANTS

52 patients undergoing lower limb skin lesion excision.

INTERVENTIONS

2 g dose of cephalexin 30-60 min before excision.

MAIN OUTCOME MEASURES

Incidence of SSI.

RESULTS

Incidence of SSI was 12.5% (95% CI 2.7% to 32.4%) in the cephalexin group compared with 35.7% (95% CI 18.6% to 55.9%) in the placebo group (p=0.064). This represented an absolute reduction of 23.21% (95% CI -0.39% to 46.82%), relative reduction of 65.00% (95% CI -12.70% to 89.13%) and number-needed-to-treat of 4.3.

CONCLUSIONS

Administration of a single 2 g dose of cephalexin 30-60 min before skin lesion excision from the lower limb may produce a reduction in the incidence of infection; however, this study was underpowered to statistically determine this.

TRIAL REGISTRATION NUMBER

ACTRN12611000595910.

The halo split skin graft in the management of non-melanoma skin cancer of the leg: a retrospective study

Background:

The purpose of this study was to compare the results of the halo split skin graft (HSSG) by two primary care skin cancer practitioners at one clinic at the Gold Coast, Queensland, Australia, to the results of the only previous study while adding to the body of evidence regarding use of the HSSG following excision of non-melanoma skin cancer on the leg.

Method:

A retrospective review of the notes (Jan 2010–Aug 2012) was performed of all cases of nonmelanoma skin cancer (NMSC) excisions in which split skin graft (SSG) closure with the HSSG was utilized on the leg.

Results:

There were a total of 68 HSSGs included over the 31 months of the study. Average lesion size was 19.4 mm (range 9–75 mm) and the average age of patients was 78 years (range 49–95 years) with 49% of patients being male. The average healing time was 4 weeks with 35/68 (51%) healing within 14 to 21 days. The overall infection rate was 8/68 (11.8%), which decreased to 4/53 (7.5%) when the ankle grafts were excluded. The graft failure rate was 7/68 (10%) with 3/68 (4.4%) having both infection and graft failure.

Limitations:

This was a retrospective study.

Conclusion:

The HSSG confines the surgical wounds to a single site, does not require specialized equipment and it is an economical and effective option for managing NMSC on the leg in situations where skin graft is indicated.

Surgical Site Infections in Ear Surgery

Objective

(1) To compare the rate of surgical site infections in ear surgery between groups with and without hair removal and (2) to study factors associated with surgical site infections.

Study Design

A preliminary, randomized, controlled trial.

Setting

University hospital.

Subjects and Methods

The study was conducted in a group of 136 patients who underwent surgery for external or middle ear disease via the post-auricular approach at Chiang Mai University Hospital from May 2010 to May 2011. Demographic data, surgical site infection within 30 days postoperatively, and associated factors were recorded.

Results

Fifty-eight cases were men and 78 cases women. Demographic data between the 2 groups were compared. Age, gender, the side of operated ear, types of anesthesia, emergency or elective setting, body mass index, history of alcohol and/or tobacco use, underlying diseases, operative time, and the length of hospital stay revealed no significant differences. A postoperative surgical site infection developed in 5 patients: 3 in the group with hair removal (4.5%) and 2 in the group without hair removal (2.8%) ( P value = 0.674, Fisher’s exact test). All infected cases had undergone mastoidectomy.

Conclusions

Surgical site infection rates between the 2 groups (with and without hair removal) demonstrated no difference. Hair removal prior to ear surgery via post-auricular incision had no effect on the rate of surgical site infection.

Algorithm for the management of antibiotic prophylaxis in onychocryptosis surgery

BACKGROUND

Antibiotic prophylaxis in nail surgery is not clearly established, and there is scant scientific evidence regarding the need for its use in preventing surgical site infection, hematogenous total joint infection, and infective endocarditis.

OBJECTIVES

To propose an algorithm based on the evidence for the management of antibiotic prophylaxis in onychocryptosis surgery.

METHODS

A literature review was performed in Medline, Pubmed, Cochrane database and Scopus and recent prospective studies were examined. The most-current authoritative guidelines together with new classification system of the pathology have been taken into account.

RESULTS

In non-risk patients with onychocryptosis stage II or III phenol technique can be used without the need for antibiotics. In stages IV and V, specific antibiotic treatment should be administered before surgery together with partial ablation of nail until the infection is resolved and the process remits to stage II or III. In the case of long-developing onychocryptosis, osteomyelitis should be ruled out, and specific antibiotic treatment besides the preoperative dose should be administered. In high-risk cardiac patients with infective onychocryptosis, the need for prophylaxis for bacterial endocarditis should be considered.

CONCLUSION

Current evidence does not support the use of preoperative antibiotic prophylaxis in onychocrytosis surgery except in special patients with infective onychocryptosis.

Prophylactic antibiotics in aesthetic surgery

Improvements in infection prevention practices over the past several decades have enhanced outcomes following aesthetic surgery. However, surgical site infections (SSI) continue to result in increased morbidity, mortality, and cost of care. The true incidence rate of SSI in aesthetic surgery is unknown due to the lack of a national surveillance system, but studies of SSI across surgical specialties have suggested that many of these infections are preventable. Patient-related factors-including obesity, glycemic control, and tobacco use-may contribute to the development of SSI following aesthetic surgery. In terms of SSI prevention, proper handwashing and surgical skin preparation are integral. Furthermore, the administration of prophylactic antibiotics has been shown to reduce SSI following many types of surgical procedures. Unfortunately, there are few large, randomized studies examining the role of prophylactic antibiotics in aesthetic surgery. The authors review the medical literature, discuss the risks of antibiotic overutilization, and detail nonpharmacological methods for reducing the risk of SSI.

Antibacterial prophylaxis in dermatologic surgery: an evidence-based review

Clean, non-contaminated skin surgery is associated with low rates of surgical site infection (SSI), bacterial endocarditis, and joint prosthesis infection. Hence, antibacterial prophylaxis, which may be associated with adverse effects, the emergence of multidrug-resistant pathogens, and anaphylaxis, is generally not recommended in dermatologic surgery. Some body sites and surgical reconstructive procedures are associated with higher infection rates, and guidelines for SSI antibacterial prophylaxis have been proposed for these cases. Large prospective, controlled trials are needed to ascertain the role of oral SSI prophylaxis for these surgical sites and procedures especially in patients with diabetes mellitus who are intrinsically at greater risk of SSI. Topical antibacterial ointment and sterile paraffin appear to make no difference to healing or the incidence of SSIs in clean wounds. Although further research is needed, preliminary studies have shown that intraincisional antibacterials, which may be associated with fewer adverse effects and a lower risk of multidrug-resistant bacteria, could potentially be helpful for SSI prophylaxis. Trials using honey- and silver-impregnated dressings have found no advantage in the healing of chronic wounds. However, several case studies, which need corroboration in larger studies, suggest that these dressings may be helpful in preventing and treating SSIs. Bacterial endocarditis and joint prosthesis infection prophylaxis are not routinely recommended in cutaneous surgery. The updated 2007 American Heart Association guidelines now advocate bacterial endocarditis prophylaxis for high-risk cardiac patients having surgery involving the oral mucosa or infected skin. The latest American Dental Association/American Academy of Orthopaedic Surgery guidelines recommend considering antibacterial prophylaxis for oral procedures where bleeding is anticipated and for surgery involving acute orofacial skin infections if the patient has had a total joint replacement within 2 years or is in a high-risk group and has had a joint replacement at any time.

Does single application of topical chloramphenicol to high risk sutured wounds reduce incidence of wound infection after minor surgery? Prospective randomised placebo controlled double blind trial

OBJECTIVE

To determine the effectiveness of a single application of topical chloramphenicol ointment in preventing wound infection after minor dermatological surgery.

DESIGN

Prospective randomised placebo controlled double blind multicentre trial.

SETTING

Primary care in a regional centre in Queensland, Australia.

PARTICIPANTS

972 minor surgery patients.

INTERVENTIONS

A single topical dose of chloramphenicol (n=488) or paraffin ointment (n=484; placebo).

MAIN OUTCOME MEASURE

Incidence of infection.

RESULTS

The incidence of infection in the chloramphenicol group (6.6%; 95% confidence interval 4.9 to 8.8) was significantly lower than that in the control group (11.0%; 7.9 to 15.1) (P=0.010). The absolute reduction in infection rate was 4.4%, the relative reduction was 40%, and the relative risk of wound infection in the control group was 1.7 (95% confidence interval 1.1 to 2.5) times higher than in the intervention group. The number needed to treat was 22.8.

CONCLUSION

Application of a single dose of topical chloramphenicol to high risk sutured wounds after minor surgery produces a moderate absolute reduction in infection rate that is statistically but not clinically significant. Trial registration Current Controlled Trials ISRCTN73223053.