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Topical antibiotics
Topical antibiotics
Postoperative topical antibiotics are not recommended for routine dermatologic surgery cases.47 Numerous studies have evaluated whether the use of topical antibiotic ointment in the postoperative period is associated with a reduction in the already very low baseline risk of SSI in dermatologic surgery procedures, and results have generally suggested that for the majority of wounds, the use of topical antibiotics does not confer a significant advantage. A wide range of topical antibiotic preparations have been explored, including fusidic acid,48 gentamicin,49 mupirocin,50 tobramycinโ
dexamethasone (combination preparation),51 bacitracin,52โ54 neomycinโpolymyxin (and in combination),53 and chloramphenicol.55 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.
The use of topical antibiotics may confer a risk to patients as well, since neomycin (11%) and bacitracin (8%) are the two most common causes of allergic contact dermatitis in a general patch-tested US population.50 Inflammation risk may similarly be higher in patients treated with topical antibiotics rather than petrolatum.56
While the routine use of topical antibiotics is inadvisable, selected surgical sites at increased risk of infection may benefit from the use of topical antibiotic therapy. One study examining the infection rate in a tropical Australian region found that a single dose of topical chloramphenicol (a topical antibiotic rarely used in the United States but popular in the United Kingdom and elsewhere) resulted in a statistically significant reduction in wound infection rate.55 That study, however, evaluated wounds that were treated by general practitioners in Australia with a baseline infection rate in the control group of 11%, surgical sites that were possibly prepped with normal saline, and wounds that were closed with a single layer of nonabsorbable sutures; therefore, the generalizability of these findings to the generally low-risk dermatologic surgery population is unknown.
While there is little evidence to support the practice, many dermatologic surgeonsโ while eschewing the blanket use of topical antibiotic ointment in all surgical casesโ will use these agents on select high-risk cases. Thus, wounds on the ears, nose, genitalia, lower extremities, and some flaps may benefit from the use of topical antibiotic preparations. In the United States, mupirocin is generally favored for its broad coverage and lack of significant risk of contact dermatitis. The effect on wound care compliance of providing patients with a prescription topical ointment has not been explored, though this may arguably represent an additional benefit of topical antibiotic use in select cases. As noted above, intranasal topical mupirocin may be useful preoperatively in order to temporarily decrease the nasal carriage of staphylococcal species.