Thursday, January 13, 2011

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Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.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

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.

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