Antimicrobial Prophylaxis Prior to Dermatologic Surgery

ABSTRACT

With many more dermatologists now actively involved in carrying out surgical and cosmetically related procedures, it is time to focus on some of the difficult questions surrounding prophylaxis in dermatologic surgery. Antibiotic prophylaxis aims to prevent wound infections and provide adequate antibiotic cover for patients with prostheses or at risk for endocarditis. Most recommendations are based on studies in general surgery patients, where the range of procedures and spread of risk factors may not accurately predict the risks for patients undergoing outpatient cutaneous surgery. 

Key Words: orthopedic prosthesis, ventriculoatrial, peritoneal shunts, dicloxacillin, arterial graft

Haas and Grekin, San Francisco, feel that in dermatologic surgery units, the overall incidence of infection of clean-contaminated wounds is probably much lower than the 10% figure quoted for general surgery.¹ Their unit has an annual infection rate of less than 1% and they feel that prophylaxis is not usually required for this type of procedure.¹ Exceptions which may require prophylaxis are patients undergoing dermatologic surgical procedures involving areas that are considered contaminated, such as nose and mouth, genital and peri-anal areas and the axilla.¹The type and length of procedure, contamination level and overall patient health are additional risk factors that need to be considered and may at times trigger the use of antibiotic prophylaxis.¹

Routine dermatologic surgery in high-risk patients

There are no uniformly agreed upon recommendations, most are loosely based on American Heart Association (AHA) guidelines.² “High-risk” patients, as defined by the AHA, are those with prosthetic heart valves, congenital cardiac malformations, rheumatic valve disease, hypertrophic cardiomyopathy, or mitral valve prolapse with valvular regurgitation. It is probably advisable to seek guidance from an appropriate infectious disease consultant prior to carrying out surgery on unusually “high-risk” patients.

• The commonly held belief that antimicrobial prophylaxis, given before procedures that can cause transient bacteremia, can prevent endocarditis in patients with valvular heart disease, prosthetic heart valves or other cardiac abnormalities has never been established by controlled clinical trials.3 However, antibiotic doses pre- and post-operatively have been recommended for patients with high-risk cardiac lesions who are undergoing surgical manipulation of eroded skin, manipulation of infected skin, and for those with a distant skin infection.¹
• Antibiotic doses pre- and post-operatively have also been recommended for patients with an orthopedic prosthesis or ventriculoatrial or peritoneal shunts, who are undergoing surgical manipulation of eroded skin, or manipulation of infected, or abscessed skin, and for those with a distant skin infection.¹
• “High-risk” patients undergoing prolonged procedures (i.e Moh’s), or any surgical procedure on eroded or infected skin require prophylaxis which covers coagulase positive staphylococci and streptococci. Give one pre-operative dose of antibiotic one hour before the procedure.^{1, 4, 5} The most commonly used antibiotics are dicloxacillin, amoxicillin or a first generation cephalosporin⁵ (e.g. Keflex® 1 gm PO, one hour pre-op. followed by 500 mg six hours later ^1,2). Erythromycin is an effective alternative in patients allergic to penicillin or its derivatives.⁵

Other precautions prior to skin resurfacing⁶

• Identify what prescription and non-prescription products are being used by the patient.
• Peel first, laser second! This avoids getting peeling solution on denuded skin.
• For patients with type III and higher skin types, consider starting treatment with daily use of tretinoin and sunscreens six weeks before the procedure.

Patients NOT usually requiring prophylaxis

• Minor procedures (biopsies, small excisions, ED/C, etc.) on intact skin.^1,4,5
• High-risk patients undergoing surgery of intact skin in a low-risk skin region are not considered to need antibiotic prophylaxis for minor procedures when the excision can be closed quickly.¹
• The organisms that reside on noninfected skin are not commonly associated with endocarditis, and bacteremia following procedures performed through scrubbed skin is not likely. For these reasons we do not recommend prophylaxis under these circumstances. Dajani, Bolger, Taubert.⁷
• Patients with indwelling cardiac pacemakers, genitourinary prostheses or breast implants do not usually require any extra precautions.¹
• Patients undergoing hemodialysis, or those with an indwelling catheter do not need antibiotic prophylaxis routinely, except when excising eroded or contaminated skin directly above the graft.1
• When more than one month has elaped following an arterial graft, routine antibiotic prophylaxis is not required.¹

Herpes infections and other special concerns

Prior to undertaking an “abrasive” procedure (mediumdepth chemical peel, laser resurfacing, dermabrasion) it is essential to determine whether or not the patient has a history of facial herpes. If this is the case, initiate prophylactic use of acyclovir,^1,2 or one of the newer analogues, famciclovir or valaciclovir.

Complications resulting from viral infections

Complications such as prolonged healing times, and without appropriate wound care atrophic or hypertrophic scarring, occur predictably in patients with a known history of recurrent labial herpes. These complications may be seen in greater than 50% of untreated patients, 6-9% of patients receiving standard prophylactic regimens, and in less than 5% of patients receiving high dose (e.g. acyclovir 800 mg TID) prophylactic regimens.⁵ Herpes simplex virus infections have been reported in up to 2% of patients undergoing cutaneous laser resurfacing without prophylaxis. Herpetic infections are more uncommon in patients on a prophylactic regimen.⁵

Bear in mind that 80% of the population has antibodies to the virus – that’s why some practitioners give the drugs to all patients regardless of their clinical history.⁸
Dr. Stephen Tyring,
University of Texas Medical Branch at Galveston

Herpes simplex infections after skin resurfacing appears primarily on denuded skin and antiviral prophylaxis should be continued until re-epithelialization is complete.^5,6

Appropriate prophylactic use of systemic and topical antibiotics is important if we are to safeguard patients undergoing dermatological procedures and maximise the post-operative cosmetic result.
Dr. Stuart Maddin, Editor

Antiviral dosage regimen recommended prior to dermatologic surgical procedures

This antiparasitic drug has been widely used and effective against tropical filarial diseases such as strongyloidiasis and onchocerciasis. In some parts of the world it is being trialed or used in the treatment of scabies. During an outbreak of scabies in a Canadian long-term care facility, 47 residents with an mean age of 73 years, were treated with a single oral dose of ivermectin, 150-200 mcg/kg of body weight. Treatment was effective within five days, but over the next six months, 15 of the 47 treated patients died, compared with five of an age-matched and sex-matched cohort. In the treated patients, although final causes of death varied, a sudden change in behaviour with lethargy, anorexia and listlessness preceded death. The authors suggest that in the face of what appears to be a highly significant statistical association between the use of ivermectin in the elderly, and increased risk of death, ivermectin should not be used for treating scabies in this age group. Confounding factors such as underlying medical condition and the effect of earlier treatments with other drugs such as lindane and psychoactive drugs need further study before this adverse effect of ivermectin is established, but this report should serve as an early warning signal. Barkwell R, Shields S. Deaths associated with ivermectin treatment of scabies. Lancet 1997; 349: 1144-1145.

References

1. Haas AF, Grekin RC. Antibiotic prophylaxis in dermatologic surgery. J Am Acad Dermatol 1995; 32: 155-176.
2. Dajani AS, Taubert KA, Wilson W et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA 1997; 277: 1794-1801.
3. Antimicrobial prophylaxis in surgery. The Medical Letter 1997, 39: 97-102.
4. Haas AF. Personal communication, November 1997.
5. Stratigos AJ, Dover JS. Personal communication, November 1997.
6. Zloty D. Personal communication, March 1997.
7. Dajani AS, Bolger AF, Taubert KA. [letter]. JAMA 1997; 278: 1233
8. Tyring S. Personal communication, November 1997.