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nfectious Complications andntibiotic Use in Dermatologic Surgery

va A. Hurst, MD, Roy C. Grekin, MD, Siegrid S. Yu, MD, and Isaac M. Neuhaus, MD

Infection rates in dermatologic surgery are low, ranging on average from 1 to 3%. Studieshave shown that many practitioners likely overuse antibiotics, both for prevention of woundinfection and in endocarditis prophylaxis. This article discusses patient and environmentalrisk factors in would infection. Data on wound infection prophylaxis are reviewed, andspecific guidelines set forth with regards to appropriate antibiotic usage, drug selection,dosage, and timing. In addition, recommendations surrounding endocarditis and prostheticjoint infection prophylaxis are presented as they apply to dermatologic surgery.Semin Cutan Med Surg 26:47-53 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS dermatologic surgery, infection, antibiotics, endocarditis, complications

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ermatologists performing cutaneous surgery often arefaced with the decision of whether or not prophylactic

ntibiotics are necessary. The main indications for antibioticrophylaxis are preventing surgical-site infections and re-ucing the risk of endocarditis or contamination of pros-hetic devices in high risk patients. Antibiotic prophylaxis inhese situations often is a source of controversy. Although theurrent trend in medicine is a commitment to evidence-basedpproaches, almost nowhere is this more ignored than in these of prophylactic antibiotics in surgery. Although evi-ence-based data are limited, several authors have reviewedhe available literature and have made recommendations re-arding the use of antibiotics in dermatologic surgery.1-4 Al-hough reducing the incidence of infection is a key objectiven the use of antibiotics, dermatologists should not overlookhe associated risks of antibiotics, such as increased cost,llergic reaction, adverse drug reactions, drug interactions,nd development of resistant strains of bacteria. In this work,e review the current literature and published guidelines

egarding the risk of infection and the role of antibiotic pro-hylaxis when performing dermatologic surgery.

atient Risk Factorshere are several patient characteristics that put a person at

ncreased risk for developing a surgical wound infection.5 Theseisk factors are most often medical conditions specific to the

CSF Dermatologic Surgery and Laser Center, San Francisco, CA.ddress reprint requests to Isaac M. Neuhaus, MD, Assistant Professor,

UCSF Dermatologic Surgery and Laser Center, 1701 Divisadero ST, 3rd

bFloor, San Francisco, CA 94115. E-mail: neuhausi@derm.ucsf.edu

085-5629/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.oi:10.1016/j.sder.2006.12.006

atient and cannot be eliminated before surgery. Diabetes mel-itus has been associated with defects in leukocyte mobilization,hus predisposing diabetics to an increased risk of postoperativeound infection. Additional patient risk factors include im-aired immune status, immunocompromise caused by medica-ion, infectious disease, cancer, smoking, malnutrition, ad-anced age, alcohol use, and long-standing medical conditionsuch as chronic obstructive pulmonary disease or chronic renalailure.6 Patients with concomitant infection at a site distantrom the surgical site (ie, respiratory or urinary tract) have anncreased risk of developing postoperative wound infection, andequire treatment before surgery.

nvironmental Risk Factorseveral exogenous risk factors can play a role in the develop-ent of surgical wound infections. Unlike the patient risk

actors previously described, these can be modified by theatient and physician to reduce the incidence of surgicalound infection.

airreoperative shaving within 24 hours of the procedure haseen associated with a greater incidence of wound infec-ion.6,7 If hair must be removed before surgery, this should beerformed using clippers or scissors, so as not to leave openkin (ie, cuts or scratches), which can serve as a conduit fornfection.

reoperative Antisepsislcohol is commonly used for minor, clean procedures (ie,

iopsies). It is inexpensive, quick-acting, and effective

47

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gainst many bacteria, fungi, and viruses. However, it is flam-able and has only weak antimicrobial activity, thus limiting

ts role for more extensive sterile procedures.Chlorhexidine has a broad spectrum of activity against

oth Gram-positive and Gram-negative bacteria. In addition,t has a rapid onset of activity, is nonstaining, and is notnactivated by blood. It binds to the stratum corneum and hasrolonged antimicrobial activity, even after being wiped off.hlorhexidine has been reported to cause both ototoxicitynd keratitis from direct, prolonged tympanic membrane orcular contact.8,9 However, it mainly has been observed inatients under general anesthesia who cannot respond to

mmediate irritation from ocular contact, a problem that isvoided with most dermatologic procedures performed un-er local anesthesia.Betadine and all iodine-containing products have an excel-

ent bactericidal activity within several minutes of applica-ion. However, it must be dry for efficacy, is often irritating tohe skin, leaves a residual color, is inactivated by contact withlood, and loses its activity when wiped from the skin. It haslso been associated with newborn hypothyroidism withhronic maternal use.10

Hexachlorophene is not bactericidal against many Gram-egative organisms and has the potential for neurotoxicity inhildren and teratogenicity in pregnant women.11,12 Hydro-en peroxide has no significant antiseptic properties and isot suitable for skin preparation.Skin should be prepped in an enlarging circular fashion,

tarting from the operative site and extending well beyondhe placement of the sterile drapes. All patients should benstructed to shower the evening before surgery with regularr antibacterial soap to reduce the rate of infection.13

andwashingntiseptic handwashing before surgery can significantly re-uce the incidence of surgical wound infection. Either use ofcrub and water or alcohol-based products can be effective,ith the latter becoming increasingly popular due to ease ofse.14

terile or Clean Techniquehe sterile standards used in an operating room are typicallyot used in outpatient dermatologic surgery. However,clean” or “sterile” technique that is used in cutaneous sur-ery results in very low infection rates (1-3%) comparable tohose of an operating room. Studies have shown that thenfection rate in Mohs surgery is not affected by the use ofterile versus nonsterile gloves, with both methods having a.7% to 1.8% risk of infection.15

ntibioticrophylaxis for Wound Infectionound Classificationdiscussion of the use of antibiotics to prevent wound in-

ection in dermatologic surgery requires an understanding of d

he various types of wounds that a physician will encounter.ounds have been classically categorized into 4 groups1:

1. Clean wounds (class I) are created on normal skin usingclean or sterile technique. Examples include excision ofneoplasms, noninflamed cysts, biopsies, and mostcases of Mohs surgery. The majority of dermatologicsurgery fall into this category. The infection rate ofthese wounds is �5%. Of note, this is a percentagegenerated from general surgery cases, which are oftenof longer duration and greater extent than dermatologicsurgery cases. Thus, this rate is probably higher thanactual infection rates in dermatologic surgery, whichhave been found to range from 1% to 3%.16

2. Clean-contaminated wounds (class II) are created oncontaminated skin or any mucosal or moist intertrigi-nous surface such as the oral cavity, upper respiratorytract, axilla, or perineum. The infection rate of thesewounds is approximately 10%.

3. Contaminated wounds (class III) involve visibly in-flamed skin with or without nonpurulent dischargeand have an infection rate in the range of 20% to 30%.Examples include inflamed cysts or traumatic wounds.

4. Infected wounds (class IV) have contaminated foreignbodies, purulent discharge, or devitalized tissue. Exam-ples included necrotic tumors, ruptured cysts, or activehidradenitis suppurativa. These wounds have an infec-tion rate of approximately 40%.

ultiple issues need to be considered when decidinghether prophylactic antibiotics are indicated. The risk-ben-

fit ratio of preventing infection must be balanced against theossibility of allergic reaction, adverse drug reactions, drug

nteraction, antibiotic resistance, and cost.Antibiotics are not required in class I wounds. These

ounds account for the majority of dermatologic surgicalrocedures, and multiple studies have demonstrated a very

ow (�5%) infection rate for these cases.Although antibiotic prophylaxis in Class II wounds is aore controversial issue, most cases probably do not require

ntibiotics. Their use probably is beneficial when oral-nasalr anogenital mucosae are breached, or for larger wounds inhe axillary and inguinal regions.

Antibiotics serve a therapeutic (rather than a prophylactic)ole in class III and IV wounds and should be used routinelyn these cases.

ntibiotic Selection and Timingo achieve optimal prophylaxis, antibiotics ought to be in theloodstream and at the surgical site at the time of the initial

ncision.17 Antibiotics that are administered at the conclusionf the procedure are not incorporated into the coagulum ofhe wound and are not as effective in preventing infection.nce the wound is closed, there is generally no longer any

isk of contamination. As the majority of dermatologic pro-edures are of short duration, a single preoperative antibiotic

ose 1 hour before surgery is sufficient. In rare circumstances

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Infectious complications and antibiotic use in dermatologic surgery 49

f an extended surgical case, a second dose of antibiotics cane administered 6 hours postoperatively.The choice of antibiotic is based on the most likely caus-

tive organism (Table 1). The most common pathogen inutaneous wound infection is Staphylococcus aureus.16 Otherathogens that need to be considered in certain situations (ie,pecific surgical locations) include Streptococcus viridans (oralavity) and Escherichia coli (perianal, perineal, and genitalegions). Staphylococcus epidermidis, which comprises morehan 50% of the resident staphylococcal species of the skin, ishe most common bacteria on the skin. It is not a commonathogen in cutaneous wound infections but has been re-orted in sternal incision wound infections after cardiotho-acic surgery.18,19

A first-generation cephalosporin is a good choice given itsroad coverage against Gram-positive organisms, such as. aureus, and common Gram-negative organisms, including. coli. Cephalosporins are absorbed rapidly from the gastro-

ntestinal tract when taken orally and have good tissue pen-tration, making this class of antibiotics excellent prophylac-ic choices. The estimated cross-reactivity in penicillinllergic patients is 5% to 10%.

Penicillins can be used safely in patients with no prioristory of hypersensitivity. Isoxazolyl penicillins, such as di-loxacillin and nafcillin, provide excellent coverage againstost strains of streptococci and S. aureus because they treat-lactamase-producing bacterial strains. Aminopenicillins,uch as ampicillin and amoxicillin, have better Gram-nega-ive, enterococcal, and group A streptococcal coverage.moxicillin has an advantage over ampicillin because of itsreater oral absorption and decreased incidence of diarrhea.he aminopenicillins are susceptible to �-lactamase-produc-

ng bacteria and are not effective against most strains of. aureus. In addition, they don’t achieve high skin concen-rations. Therefore, they are more commonly used in proce-

able 1 Antibiotic Prophylaxis for Wounds Based on Site

SiteAntibiotic

Choice

Regimen(1 Hour

PreoperativeDose)

kin First-generationcephalosporin

1 g by mouth (po)

Dicloxicillin 1 g poClindamycin 300 mg poVancomycin 500 mg

intravenouslyral First-generation

cephalosporin1 gram po

Amoxicillin 1 gram poClindamycin 300 mg po

astrointentinal/Genitounnary

First-generationcephalosporin

1 gram po

Trimethaprim-sulfamethoxasoleDS

1/2 tablet po

Ciprofloxacin 250 mg po

ures involving the oral cavity. t

Clindamycin is an alternative for patients with allergy toenicillin or cephalosporins. It can be used for both skin andral cavity wounds. Although the use of this drug has beenssociated with colitis, this adverse effect is generally not aroblem during the short courses used for wound infectionrophylaxis. Nonetheless, it should be discontinued if signif-

cant diarrhea occurs. Macrolides, such as erythromycin andzithromycin, also are alternatives for penicillin-allergic pa-ients. Penicillin allergic patients with perianal, perineal, andenital surgical wounds can be treated with trimethoprim-ulfamethoxazole or ciprofloxacin.

Vancomycin generally is limited to those cases in whichethicillin resistant S. aureus (MRSA) is suspected as a patho-

en. It is administered intravenously and dosage must bedjusted in patients with impaired renal function. Doxycy-ine can be considered in communities where bacteria areusceptible.

opical and Incisional Antibioticsopical antibiotics frequently are used in wound care after aariety of dermatologic procedures. Although this practiceas been based on early studies showing a marked reduction

n infection rates, the infection rates reported in these studiesre much higher than the current predicted infection in cleanclass I) wounds in most dermatologic surgery proce-ures.20-23 As such, the reported reduction in infection rate isot likely to correlate to current practice standards, thusaising questions as to the efficacy of topical antibiotics.

In contrast, Smack and coworkers randomized 922 pa-ients undergoing dermatologic surgery to wound care withacitracin or white petrolatum.24 Surgical procedures in-luded biopsy, curettage and electrodesiccation, excision,ohs micrographic surgery, flaps, grafts, and dermabrasion.he infection rate for both groups was less than 2% and notatistical difference was noted. In addition, there has been anncreasing incidence of allergic reactions associated with bac-tracin.25 The North American Contact Dermatitis Group re-orts an incidence of contact dermatitis to bacitracin ofearly 8%.26 Given the insignificant reduction in the infec-ion rate, high incidence of allergic contact dermatitis, andncreased cost of bacitracin as compared with white petrola-um, the routine use of topical antibiotics for postoperativeare of clean surgical wounds does not appear to be indi-ated.

The use of intraincisional antibiotics also has been re-orted as a way to prevent wound infections. Griego anditelli report in a randomized controlled double blind study

hat a single intraincisional dose of nafcillin mixed with buff-red lidocaine solution resulted in significantly lower rates ofostoperative wound infections as compared with placebo0.2% in the nafcillin group versus 2.5% in the controlroup).27 In a follow-up study of single dose intraincisionallindamycin with buffered lidocaine in 1172 surgicalounds, 29 postoperative wound infections occurred. Six

1.0%) occurred in the clindamycin group as compared with3 (4%) in the control group (P � 0.02).28 However, given

he low baseline infection rate in these cases and associated

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isks and costs of the antibiotic intervention, intraincisionalntibiotic prophylaxis as a standard treatment in all surgicalases does not appear warranted.

aser resurfacingost dermatologists consider full face laser resurfacing to beclass I wound as it is performed on clean skin and usuallyot involving mucosal surfaces. Therefore, most authors doot recommend antibiotic prophylaxis for any patients.2,29,30

ome dermatologic surgeons do report prescribing antibiot-cs in high-risk patients.30 Gaspar and coworkers published arospective study of 31 patients undergoing full-face laseresurfacing and concluded that antibiotic prophylaxis against. aureus is “not essential,” because meticulous wound carend close clinical monitoring of patients daily with routineacterial swabs can detect infection early.”29 A 1998 caseeport of MRSA infection after carbon dioxide laser resurfac-ng advocates preoperative nares cultures before laser resur-acing, followed by preoperative antibiotic treatment if theulture is positive.31 However, this single case report of annusual adverse event does not reflect our personal experi-nce in laser resurfacing.

At the University of California, San Francisco, we do notoutinely culture laser resurfacing patients and prophylacticacterial antibiotics are not administered. Prophylactic her-etic antivirals are prescribed routinely for all cases given theotential morbidity and severity of herpetic infection in thislinical setting, which outweighs the low-incidence of sideffects, low rates of resistance, and low cost of antivirals.ntiviral agents are started the day of the procedure andontinued for 10 days afterward. Patients are followed closelyn the days following resurfacing, and bacterial cultures arebtained before initiation of antibiotics if any clinical evi-ence of bacterial infection develops.

iposuctionumescent liposuction is increasingly being performed in anutpatient setting. The safety profile of this procedure is ex-remely favorable, with a low incidence of overall complica-ions (less than 1%), including postoperative infection.32,33

iven this fact, the authors do not routinely prescribe anti-iotic prophylaxis for these cases.

reatment of Wound Infectionn the 1% to 2% of cases in which postoperative infections doccur, they generally present within the first 4 to 7 days afterurgery with increased erythema, tenderness, warmth, pain,nd the appearance of purulent drainage at the surgical site.utures should be removed to allow drainage of any exu-ates. In cases where infection leads to dehiscence, woundsan be packed with sterile gauze or be allowed heal by secondntention. If necessary, scar revisions can be performed at aater date. Wound culture should always be obtained beforenitiation of empiric antibiotics due to emerging resistanceatterns.

S. aureus is the most common pathogen and cephalexin or

icloxacillin 2 g daily in divided doses is an appropriatenitial therapy. Patients with penicillin allergy and suspectedram-positive infection can be treated with clindamycin. Inommunities or hospitals with a high incidence of MRSA,mpiric treatment with an appropriate antibiotic may be usedased on the community flora (ie, doxycylcine or tri-ethoprim-sulfamethoxazole). For those infections with aigher likelihood of Gram-negative or pseudomonas infec-ion (ie, ear), initial treatment with ciprofloxacin 500 to 1000g daily is advised. All antibiotic choices should be adjusted

ased on culture results.

ndocarditis Prophylaxisacterial endocarditis is defined as an infection of the heartalves or endocardial lining. This occurs when blood bornerganisms are deposited on abnormal valves or damaged car-iac tissue. Endocarditis carries a significant mortality forhose that do not receive prompt, adequate treatment. Endo-arditis prophylaxis is based on the concept of predicting thencidence of bacteremia after medical procedures in at riskatients, and treating these patients with antibiotics at anppropriate time to reduce the incidence of infection. In re-lity, however, only a very small number of reported cases ofndocarditis are iatrogenic, related to an invasive medicalrocedure. In addition, no studies have demonstrated thatntibiotic prophylaxis is effective, or that the antibiotics com-only used actually cover the most common pathogens.

ndocarditis Riskhe American Heart Association (AHA) updated its guide-

ines in 1997 regarding endocarditis prophylaxis.34 Cardiaconditions are divided into high, moderate, and negligibleisk (Table 2). Endocarditis prophylaxis is recommended forigh-risk and moderate-risk disorders, while it is not recom-ended for negligible risk patients.In addition to categorizing the risk of a patient’s underly-

ng cardiac condition, physician must stratify the risk of therocedure being performed. The AHA guidelines state that

able 2 Endocarditis Risk

igh-risk categoryProsthetic cardiac valvesPrevious bacterial endocarditisComplex cyanotic congenital heart diseaseSurgically constructed systemic pulmonary shunts or

conduitsoderate-risk categoryAcquired valvular dysfunctionHypertrophic cardiomyopathyMitral valve prolapse with valvular regurgitation

ow-risk categoryPhysiologic heart murmursMitral valve prolapse without valvular regurgitationCardiac pacemakersIsolated secundum atrial septal defect

Previous rheumatic fever without valvular dysfunction

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Infectious complications and antibiotic use in dermatologic surgery 51

he “incision or biopsy of surgically scrubbed skin” does notequire antibiotic prophylaxis, even in the setting of a high-isk cardiac condition. Despite these recommendations, spe-ific information as to what constitutes surgically scrubbedkin is lacking. However, most experts suggest that surgicallycrubbed skin implies proper cleaning (see the section “Pre-perative Antisepsis”) before a procedure.35 Skin cannot beterilized and, therefore, the setting of the procedure (oper-ting room versus outpatient procedure) does not play a fac-or in the decision of whether to prescribe antibiotics. Addi-ionally, the normal skin flora are not usually the bacteria thatause endocarditis. When these facts are combined with theHA guidelines, most experts agree that dermatologic proce-ures, even when performed in high risk patients, do notequire prophylactic antibiotics.

Many dermatologists prescribe antibiotics before proce-ures in high-risk patients and are reluctant to changeheir current practices.36 However, according to the AHAuidelines, more invasive procedures (ie, cesarean deliv-ry, sterilization procedures, implantation of cardiac defibril-ators, therapeutic abortion) in high-risk patients do not requirentibiotics. This emphasizes the concept that not every high riskatient needs antibiotic prophylaxis before any medical proce-ure.

able 3 Endocarditis Prophylaxis Regimens

Situation

ontaminated or infected skin Cephale

Dicloxac

Clindam

Vancom

rocedures involving oral or respiratory mucosatandard general prophylaxis Amoxicil

Ampicilli

llergic to penicillin Clindam

Cephale

Azithrom

rocedures Involving GI or GU mucosaigh-risk patients Ampicilli

Vancom

oderate-risk patients Amoxicil

Ampicilli

Vancom

The AHA guidelines consider procedures with a bactere-ia incidence of greater than 10% as posing a significant

ndocarditis risk. Multiple studies have demonstrated thatatients undergoing dermatologic procedures have a rate ofacteremia (ranging from 0.7% to 7%) similar to the sponta-eous rate of healthy adults (2.1%).37-40 Furthermore, theacteremia generally occurred within the first 15 minutesfter the procedure and was short lived. This rate of bactere-ia associated with dermatologic procedures is quite lowhen compared with that found in routine daily activities,

uch as brushing teeth, mastication, and defacation17-40%). These facts further support the recommendationhat endocarditis prophylaxis is not necessary for most der-atologic procedures on clean, noninflamed skin, even inigh risk patients.Exceptions do exist and endocarditis prophylaxis is in-

icated in specific situations, including procedures thatiolate respiratory, oral, intestinal, or genitourinary mu-osa. Procedures performed on obviously inflamed or po-entially infected skin in high risk patients should havendocarditis prophylaxis. Incision and drainage of ab-cesses is associated with a high incidence of bacteremia38%) and endocarditis prophylaxis is indicated in highisk patients.41

bioticRegimen

(1 Hour Preopereative Dose)

Adults: 2 gChildren: 50 mg/kgAdults: 2 gChildren: 50 mg/kgAdults: 600 mgChildren: 20 mg/kgAdults: 1 g intravenously (IV)Children: 20 mg/kg IV

Adults: 2 gChildren: 50 mg/kgAdults: 2 g intramuscularly (IM) or IVChildren: 50 mg/kg IM or IVAdults: 600 mgChildren: 20 mg/kg

cefadroxil Adults: 2 gChildren: 50 mg/kg

r clarithromycin Adults: 500 mgChildren: 15 mg/kg

entamicin Adults: 2 g � 1.5 mg/kg IM/IVChildren: 50 mg/kg � 1.5 mg/kg IM/IV

gentamicin Adults: 1 g IV � 1.5 mg/kg IM/IVChildren: 20 mg/kg � 1.5 mg/kg IM/IVAdults: 2 gChildren: 50 mg/kgAdults: 2 g IM or IVChildren: 50 mg/kg IM or IVAdults: 1 g IV

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ntibiotic Selectionn Endocarditis Prophylaxisn the infrequent setting wherein prophylaxis for endocardi-is is indicated in dermatologic surgery, AHA guidelines statehat the antibiotic should be administered one hour beforehe procedure. A second postoperative dose is no longer rec-mmended, consistent with the short and transient nature ofacteremia associated with various cutaneous surgical proce-ures. Antibiotic recommendations are listed in Table 3. Theecommendations take into account both the area of surgerynd the most likely resident flora, as well as the bacteriaapable of attaching to cardiac tissue or prostheses.

ntibiotic Prophylaxis forrthopedic Prosthetic Devices

he morbidity associated with infection of prosthetic joints isigh, requiring revision of the joint and extensive medicalanagement. However, there are currently no published

uidelines on antibiotic prophylaxis in patients with ortho-edic prosthetic devices undergoing cutaneous surgery. Allecommendations are extrapolated from data related to oralnd dental procedures in patients with prosthetic devices.aution must be employed given the vast differences in the

isk of bacteremia between dental and cutaneous procedures.The American Dental Association (ADA) and the American

cademy of Orthopedic Surgeons (AAOS) issued a jointtatement in 1997, with a 2003 update, on the need forntibiotic prophylaxis during dental procedures in patientsith artificial joints.42 Given the low incidence of infection,

he panel recommended that antibiotic prophylaxis is notndicated for patients with pins, plates, and screws, or for

ost patients with total joint replacement. However, a subsetf high-risk patients should be treated with antibiotic pro-hylaxis when undergoing higher-risk dental proceduresuch as extractions, periodontal surgery, root canal, and pro-hylactic dental cleaning. These high-risk patients includehose with certain underlying medical conditions, or thoseithin the first 2 years after joint replacement (Table 4).However, as previously described in this review, the inci-

ence of bacteremia with cutaneous surgery on clean intactkin is quite low compared with dental procedures, wherestimates of bactermia with routine cleaning range from 18%o 20%. Thus, the risk of hematogenous total joint infection isuch lower in dermatologic surgery cases that do not violate

able 4 Patients with Higher Risk of Hematogenous Totaloint Infection

nflammatory arthropathies (ie, rheumatoid arthritis,systemic lupus erythematosus)isease-, drug-, or radiation-induced immunosuppression

nsulin-dependent (type 1) diabetesirst 2 years after joint replacementrior history of prosthetic joint infectionalnourishment

emophilia

he oral mucosa, and antibiotics are not routinely indicated inatients who have cutaneous surgery on clean, intact skin.hen surgery involves the oral or anogenital mucosa in the

igh-risk patients described, we feel that a conservative ap-roach would be to follow the ADA/AAOS guidelines and usentibiotic prophylaxis.

ntibiotic Selection Prostheticoint Infection Prophylaxishe antibiotic regimen for prosethetic joint infection prophy-

axis is similar to that proposed by the AHA for endocarditisrophylaxis. A single preoperative dose 1 hour before sur-ery is recommended. No postoperative dose is necessary.ecommendations for high-risk patients undergoing invasiveental procedures include cephalexin, cephradine, amoxicil-

in (2-g dose, 1 hour preoperatively), or clindamycin600-mg dose, 1 hour preoperatively) if the patient is allergico penicillin. A similar regimen is appropriate for those spe-ific cutaneous surgery cases in which antibiotic prophylaxisas been deemed necessary by the dermatologist and ortho-edic surgeon, typically in those patients within the first twoears following prosthesis placement or with other high-riskonditions as listed in Table 4. Because no published guide-ines or data exist other than for dental procedures, we wouldecommend using prophylaxis regimens similar to those forndocarditis, as listed in Table 3. A conservative approachould be to use the regimen of ampicillin plus gentamicin orancomycin plus gentamicin in procedures involving gastro-ntestinal or genitourinary mucosa, just as in high-risk endo-arditis patients.

onclusionhe prevention of surgical site infection, endocarditis, andematogenous prosthetic joint infection is an important goalhen performing dermatologic surgery. However, updateduidelines and data suggest that almost all situations in der-atologic surgery do not require antibiotic prophylaxis.iven the low baseline infection and bacteremia rates in der-atologic surgery combined with the consideration of ad-

erse events associated with antibiotic use, it is clear thathere are only a very few specific instances in which derma-ologic surgery patients are likely to benefit from antibioticse.

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Infectious complications and antibiotic use in dermatologic surgery 53

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