Antibiotic prophylaxis revisited

Abstract

Antibiotic prophylaxis for cutaneous surgery is a controversial but important area for dermatologists. Five key issues are addressed: why prophylax, whom to prophylax, when to prophylax, how to prophylax, and why NOT to prophylax. The goal of prophylaxis is to prevent infection. Infection can manifest as localized (limited to wound) or systemic (bacteremia leading to endocarditis or prosthesis infection). Guidelines for prophylaxis to prevent wound infection come from the general surgery literature and may not be applicable to cutaneous surgery. Dermatologic procedures are generally short in duration and have a low rate of wound infection (2–4%). Many factors contribute to the development of wound infection, including anatomic location, variations in practice of aseptic technique, characteristics of the lesion to be excised, surgical technique, and overall status of the patient. Similarly, some patients are at higher risk of developing endocarditis following a bacteremia-producing procedure than others. The gold standard guidelines for antibiotic prophylaxis come from the American Heart Association (AHA). Joint guidelines from the American Dental Association and the American Academy of Orthopaedic Surgeons were reviewed as well. Cutaneous surgery is not specifically addressed by any of these guidelines but AHA guidelines state that “incision into surgically scrubbed skin does not require antibiotic prophylaxis.” Various studies have shown that the incidence of bacteremia after surgical procedures on non-infected skin is low (0–7%). Antibiotic prophylaxis should be initiated just prior to surgery and need not be continued for an extended period. Antibiotic use is not without risk; potential side effects range from GI distress to anaphylaxis. Methods to decrease reliance on oral antibiotics include increased use of sterile technique, meticulous wound care, and intra-incisional antibiotics. In general, management of each patient should be considered on a case-by-case basis.