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Introduction
CHAPTER 7 Antibiotics:
Preoperative and Postoperative Considerations
Allen F. Shih Jonathan Kantor
SUMMARY
The rate of infection after skin surgery is likely between 1% and 4%.
Antibiotic use in dermatologic surgery has declined markedly over the past
several decades, as studies highlighting the baseline low rate of wound infections, coupled with the individual and societal risks associated with widespread antibiotic use, have made the routine prescribing of perioperative antibiotics no longer the standard of care.
Beginner Pearls
The differential diagnosis of postoperative infection includes irritant or allergic
contact dermatitis, suture reactions/suture abscesses, filler reactions (if relevant), and inflammatory chondritis.
Contact dermatitis should be considered, particularly when topical antibiotics or
adhesives were used, or when the involved area is geometric.
Expert Pearls
Risk factors for infection include patient factors, surgical factors, and surgical site
factors.
One study demonstrated a statistically significant benefit to local intraincisional
clindamycin injection for Mohs micrographic surgery cases; the solution was prepared by adding 0.15 mL of clindamycin (150 mg/mL) to a 50-cc bottle containing lidocaine (1%) with epinephrine (1:100,000) buffered with sodium bicarbonate (5 mL of an 8.4% solution)
Donโt Forget!
Cephalexin or dicloxacillin can be used as prophylaxis for wedge excisions of the lip
or ear, flaps on the nose, and grafts.
Clarithromycin, levofloxacin, TMP-SMX, metronidazole, and ciprofloxacin are
associated with a higher risk of hypoglycemia in diabetic patients taking sulfonylurea medications.
Pitfalls and Cautions
While antibiotics are typically given the hour before the procedure, there is ambiguous
data about whether prophylactic antibiotic timing affects the risk of SSI.
Given the high rate of warfarin and sulfonylurea use in the patient population
undergoing dermatologic surgery, systemic antibiotics should be prescribed with extreme caution and an eye to minimizing the risk of drugโdrug interactions.
Patient Education Points
No rigorous study has demonstrated a robust statistically significant benefit to utilizing
any single topical antibiotic preparation, and the American Academy of Dermatology has, therefore, warned against the routine use of topical antibiotics after clean surgical procedures as part of its Choosing Wisely campaign.
Patients often request perioperative antibiotics under the assumption that these will
decrease their risk of developing an infection; therefore, adequate education may be valuable in dissuading patients from this practice and increasing their comfort level.
It may be helpful to explain to patients that bacteremia is more likely after brushing
their teeth than it is postoperatively.
CHAPTER 7 Antibiotics: