Prophylactic Antibiotics in Aesthetic Surgery

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

There is a very nice review of this topic in the Nov/Dec 2010 issue of the Aesthetic Surgery Journal (full reference below).

While we want to prevent surgical site infections (SSIs), we don’t want to over utilize antibiotics.   Consequences of which include:   Clostridium difficile infections [CDI] and development of resistant organisms.

The authors note that currently no national guidelines for antibiotic prophylaxis in aesthetic surgery although they do for cardiac, colorectal, neurosurgical, and orthopedic procedures.  “In fact, studies examining the impact of prophylactic antibiotics have produced contradictory results.”

So what should we do:

Until randomized controlled trials examining the efficacy of prophylactic antibiotics in aesthetic surgery are performed, we recommend giving prophylactic antibiotics in accordance with SIP project guidelines.

The ideal antibiotic for surgical prophylaxis should (1) cause minimal toxicity or side effects, (2) be effective against the most likely organisms that will cause an SSI but have a narrow spectrum, (3) achieve adequate tissue concentrations at the surgical site for the duration of the procedure, and (4) be administered for the shortest effective period.

For most patients undergoing aesthetic procedures, the preferred antimicrobial agent is a first-generation cephalosporin such as cefazolin (1 gm IV).  Increase the dose if the patient weighs more than 160 pounds (approximately 80 kg) --  the dose of cefazolin may be increased to 2 g IV.

A second dose of antibiotics should be given IF the surgical procedure lasts more than three to five hours or if the patient has lost a significant amount of blood (greater than or equal to 1500 mL).

Patients with a beta-lactam allergy may receive clindamycin or vancomycin.  If used, remember their longer half-lives if redosing is necessary (clindamycin every four to six hours; vancomycin every six to 12 hours).

Vancomycin may be given for surgical prophylaxis in facilities with a high incidence of methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-resistant coagulase-negative staphylococci. Guidelines recommend against the routine administration of vancomycin for antibiotic prophylaxis.

……

The authors not strategies to prevent MRSA SSI are controversial, but current guidelines from the CDC and the Society for Healthcare Epidemiology of America recommend against routine universal screening for MRSA.

The authors suggest that until more data are available to support routine active surveillance and decolonization among patients undergoing plastic and reconstructive surgery, these interventions should be reserved for patients who are colonized with MRSA or are known to have had an MRSA infection in the past.

As I posted last week, when decolonization is deemed appropriate:

• Nasal decolonization with mupirocin twice daily for 5–10 days.
• Nasal decolonization with mupirocin twice daily for 5–10 days and topical body decolonization regimens with a skin antiseptic solution (eg, chlorhexidine) for 5–14 days or dilute bleach baths. (For dilute bleach baths, 1 teaspoon per gallon of water [or ¼ cup per ¼ tub or 13 gallons of water] given for 15 min twice weekly for 3 months can be considered.)

 

Antibiotic prophylaxis should be given prior to surgery to achieve tissue and serum concentrations that will produce bactericidal levels at the time surgical incision is made.  Most antibiotics should be administered within 60 minutes before incision. If fluoroquinolones or vancomycin is indicated, the infusion should begin 120 minutes before incision. If a proximal tourniquet is required for the surgery, the entire antibiotic dose should be administered before the tourniquet is inflated.

The authors point out that prolonged courses of antibiotics given for prophylaxis have not shown benefit as compared to a single dose of prophylactic antibiotics.  The SIP project endorses cessation of antibiotics within 24 hours of the end of surgery.

What about if a drain(s) is placed?  I, like many surgeons were trained to continue antibiotics for as long as the surgical drains are in place.  The authors point out:  “there is a lack of evidence to support this practice in aesthetic surgery.” 

The SIP project guidelines recommend against continuing antibiotic prophylaxis for the duration of surgical drain placement for orthopedic and cardiothoracic procedures.   It should be noted that antibiotic therapy is appropriate when the surgical drain is placed for therapeutic drainage of an infected space or abscess.

REFERENCE

Prophylactic Antibiotics in Aesthetic Surgery; Lane, Michael A., Young, V.Leroy, Camins, Bernard C.; Aesthetic Surgery Journal November/December 2010 30: 859-871

Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project; Bratzler DW, Houck PM; Clin Infect Dis 2004;38:1706-1715.

Management of multidrug-resistant organisms in health care settings, 2006; Siegel JD, Rhinehart E, Jackson M, Chiarello L;  Am J Infect Control 2007;35(suppl 2):S165-S193.

Fiorina’s Infection Highlights Reconstruction Complications

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

The news report of California Republican U.S. Senate Candidate Carly Fiorina’s recent hospitalization due to an infection related to her breast reconstruction is an opportunity to talk about the risks of complication associated with breast reconstruction surgery.

Fiorina was diagnosed with breast cancer diagnosis in February 2009.  She was treated with chemotherapy, radiation and a double mastectomy.  I found several articles that note she had her reconstructive surgery at Stanford University Medical Center, the San Jose (Calif.) in July 2010, but none mention the reconstruction technique used.

My guess would be implant based reconstruction considering how quickly she returned to campaigning.  Recovery time for a TRAM flap (free or pedicle) or any other flap based reconstruction would have been much longer.

The chemotherapy and radiation put her at increased risk of surgical complications.  It’s all a balancing act.  Weighing the need/desire for reconstruction against the risks.  Treatment of the breast cancer is always the first priority.

As noted by in the eMedicine article (1st reference below)

The occurrence of complications using expander-implants can exceed 40% in published studies. However, despite a significant rate, the complications themselves are usually minor and do not prevent completion of a satisfactory reconstruction. In experienced hands, good to excellent aesthetic outcomes can be obtained in more than 80% of patients.

The 40% includes every little complication that can occur:  capsular contracture, infection, wound healing issues, seroma/hematoma, assymetry, poor implant position, etc.

Breaking it down better is the table found from the Mentor Large Simple Trial data that lists the complications that occur within 3 years.

Additional Operation (Reoperation)	40%
Loss of Nipple Sensation	35%
Capsular Contracture III/IV or grade unknown	30%
Asymmetry	28%
Implant Removal	27%
Wrinkling	20%
Breast Pain	17%
Infection	9%
Leakage/Deflation	9%
Irritation/Inflammation	8%
Delayed Wound Healing	6%
Seroma	6%
Scarring	5%
Extrusion	2%
Necrosis	2%
Hematoma	1%
Position Change	1%

What these numbers don’t do is individualize the risk.  You can’t tell from these numbers who had only radiation, who had only chemotherapy, who had both, which ones smoked, who had diabetes, etc.  All of these things increase the risk to the individual.

Related Post:

Infected or Exposed Breast Prosthesis (Sept 1, 2010)

Patient Satisfaction Following Breast Reconstruction Using Implants (June 7, 2010)

REFERENCES

Breast Reconstruction, Expander-Implant; eMedicine article, October 2009; Jorge I de la Torre, MD, FACS, Luis O Vasconez, MD, FACS

Breast Reconstruction Overview; eMedicineHealth

About Breast Reconstruction; Cancer Help UK

Adherence to Surgical Care Improvement Project Measures

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. 

An article in the June 23/30 issue of JAMA features an analysis of the reported adherence to Surgical Care Improvement Project measures (SCIPs) and the reduction of postoperative infections.

There are 9 publicly reported SCIP measures, 6 of which focus on postoperative infection prevention.

• INF-1: patients who received prophylactic antibiotics within 1 hour prior to surgical incision (2 hours if receiving vancomycin).
• INF-2: patients who received prophylactic antibiotics recommended for their specific surgical procedure.
• INF-3: patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours for coronary artery bypass graft surgery or other cardiac surgery).
• INF-4: cardiac surgery patients with controlled 6 AM postoperative blood glucose level (200 mg/dL [11.1 mmol/L]).
• INF-6: surgery patients with appropriate surgical site hair removal with clippers or depilatory or those not requiring surgical site hair removal.
• INF-7: colorectal surgery patients with immediate postoperative normothermia (first recorded temperature was 96.8°F within first 15 minutes after leaving the operating room).

The intention of CMS in collecting this data and publicly reporting it is "to assist patients in selecting centers of excellence" for receipt of their surgical care.  CMS also ties it to payment for services.

Hospital participation in these data collection efforts is voluntary. However, the Centers for Medicare & Medicaid Services (CMS) reduces hospital reimbursement by 2% if they fail to report their performance on these measures.    After validation and cleanup of the data, the results are reported on the Hospital Compare Web site (http://www.hospitalcompare.hhs.gov).

The authors of the paper point out “Developers of the SCIP measurement process are hoping to demonstrate a 25% reduction in complication rates over 5 years; however, our findings are unable to suggest that the improvements in SCIP compliance have been associated with a reduction in infection rates. According to our estimates, increasing adherence to 100% would result in less than a 25% decrease in these rates.”

The results of their analysis:

There were 3996 documented postoperative infections (out of 405 720 patients).

The S-INF composite process-of-care measure predicted a decrease in postoperative infection rates from 14.2 to 6.8 per 1000 discharges (adjusted odds ratio, 0.85; 95% confidence interval, 0.76-0.95).

The S-INF-Core composite process-of-care measure predicted a decrease in postoperative infection rates from 11.5 to 5.3 per 1000 discharges (adjusted odds ratio, 0.86; 95% confidence interval, 0.74-1.01), which was not a statistically significantly lower probability of infection.

None of the individual SCIP measures were significantly associated with a lower probability of infection.

For me, the point that stood out (even with the limitations of the study) is that NONE of the individual SCIP measures were associated with lower infection.  It took (takes) a combination of good practices to lower and or prevent infection.

REFERENCE

Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections; Jonah J. Stulberg, MD, PhD, MPH; Conor P. Delaney, MD, PhD; Duncan V. Neuhauser, PhD; David C. Aron, MD, MS; Pingfu Fu, PhD; Siran M. Koroukian, PhD; JAMA. 2010;303(24):2479-2485

The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery; Bratzler DW, Hunt DR.;  Clin Infect Dis. 2006;43(3):322-330.

Pre-Hospital Surgical Prep

 Updated 3/2017 --  all links (except to my own posts) removed as many no longer active.

The June 2010 issue of the Surgical Products magazine has an article by Amanda McGowan focusing on the prep in preventing surgical site infections – Preventing SSI: It Starts in the Prep.

What really caught my attention was the pre-hospital prep described for one hospital.  Currently, (as most of my patients exhibit good hygiene) I haven’t begun anything more than taking a shower (with basic soap), washing their hair, and brushing their teeth pre-op.  My SSI rate is less than 0.5% over 20 years.  The bold is my emphasis.

As Beth Beck, director of infection prevention and control/employee health at Springhill Medical Center in Mobile, AL, explains, her facility follows specific steps in the prep process to help reduce infection risk.

“We ask the surgeons to have the patients bathe with chlorhexidine the night before,” she says.

“Then, once they arrive to the hospital, we wipe them down with a CHG-impregnated cloth and we instruct patients to brush their teeth twice. We have them rinse with a CHG oral rinse. Then, we give them skin and nasal antiseptic.”

Now remember this is a surgical products magazine, so the focus on the article may be to sell me the skin and nasal antiseptic product which the article mentions is marketed by 3M and is meant to reduce Staphylococcus aureus (Staph aureus) colonization, a leading cause of SSI.

The article quotes Joe Gillis, marketing manager for the skin and nasal antiseptic product at 3M:

According to Gillis, approximately thirty percent of surgical patients today are colonized with Staph aureus in the nares. In turn, a study published in The Lancet in 2004 revealed that eighty percent of Staph aureus infections are caused by the patient’s own nasal flora. Additionally, one percent of the surgical population carries methicillan-resistant Staphylococcus aureus (MRSA).

The article goes on to explain that Beck’s facility is in the trial phase of using the skin and nasal antiseptic product on orthopedic patients who are undergoing an operation involving implants.  The hospital added the nasal antiseptic part of the routine after seeing an increase in surgical site infections in orthopedic patients.

What is your or your hospital’s routine “prep before the prep?”

Recommended:
How-to Guide: Prevent Surgical Site Infection
How-to Guide: Reduce Surgical Complications

Preoperative Skin Cleanser

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Looks like it’s time for me to rethink my preference for preoperative skin cleanser. This past week there were two new prospective studies published in the Jan. 7 issue of the New England Journal of Medicine, along with an accompanying editorial.

The Centers for Disease Control and Prevention estimates that in American hospitals alone, there are 1.7 million healthcare-associated infections each year. Of these infections, 22% are surgical site infections (SSIs). So if simply changing the preop skin cleanser will reduce my patient’s SSI risk, then I will do so.

Rabih Darouiche, MD and colleagues found using chlorhexidine as the preoperative skin cleanser reduced infections by 41% compared with povidone-iodine. Their study involve randomly assigning 897 adults undergoing clean-contaminated surgery to preoperative skin preparation with chlorhexidine gluconate (CHG) and alcohol or with povidone-iodine (P-I). Patients were assessed for occurrence of SSIs within 30 days postoperatively.

CHG-alcohol use was associated with a lower overall rate of SSIs (9.5% vs. 16.1% for P-I), lower rates of superficial (4.2% vs. 8.6%) and deep (1.0% vs. 3.0%) incisional SSIs. There was no significant difference between the two groups where organ-space infections (4.4% and 4.6%, respectively) or sepsis from SSIs (2.7% and 4.3%) was involved.

Lonneke G.M. Bode, M.D and colleagues found that screening and decolonizing patients who are nasal carriers of S. aureus, combined with washing with chlorhexidine soap reduced the risk of SSIs by 58%.

"The weight of evidence suggests that chlorhexidine–alcohol should replace povidone–iodine as the standard for preoperative surgical scrubs," Dr. Wenzel writes. "The use of intranasal mupirocin and chlorhexidine baths for carriers of S. aureus who have been identified preoperatively by means of a real-time [PCR] assay could be reserved primarily for patients who are undergoing cardiac surgery, all patients receiving an implant, and all immunosuppressed surgical candidates. Currently, the incremental value of preoperative baths with chlorhexidine alone for all surgical patients is unclear, but this relatively straightforward procedure could be examined critically in future studies."

REFERENCES
Minimizing Surgical-Site Infections; N Engl J Med. 2010;362:9-17, 75-77; Richard P. Wenzel, M.D.
Chlorhexidine–alcohol versus povidone–iodine for surgical-site antisepsis; N Engl J Med 2010 Jan 7; 362:18; Darouiche RO et al.
Preventing surgical-site infections in nasal carriers of Staphylococcus aureus; N Engl J Med 2010 Jan 7; 362:9; Bode LGM et al.
Advances in Preventing Surgical-Site Infections. JWatch Infect. Diseases 2010: 1-1