Perioperative antibiotic prophylaxis in plastic surgery: A prospective study of 1100 adult patients

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Summary

Background

Although guidelines for antibiotic prophylaxis to prevent surgical site infections (SSIs) exist, specific guidelines for plastic surgery are missing and there is a tendency towards excessive administration of antibiotics.

A total of 1100 patients were prospectively studied according to an evidence-based protocol to investigate if limiting antibiotic prophylaxis to high-risk cases does increase the infection rate.

Methods

Between April 2009 and April 2010, 1100 consecutive patients undergoing elective reconstructive or cosmetic procedures were enrolled.

Procedures were classified into four groups, and prophylactic antibiotics were only administered perioperatively in 23.4% of cases, according to patient-related and procedure-related risk factors.

Results

The overall SSI incidence was 1.4% (1.1% for clean surgery and 3.8% for clean-contaminated surgery). Oral oncologic surgery showed the highest infection rate (5.3%).

Conclusions

Specific guidelines are provided to encourage judicious use of antibiotics.

Antibiotic prophylaxis is administered based on the type of operation and the patient’s characteristics. No prophylaxis was carried out in superficial skin surgery and simple mucosal excisions.

Antibiotic prophylaxis is always indicated in microsurgery, prosthetic surgery, incisional hernias, clean non-prosthetic osteoarticular surgery and clean-contaminated procedures such as oral cavity or genitourinary system.

In clean surgery and rhinoplasty, antibiotic prophylaxis is only indicated when the operation lasts more than 3 h and/or the American Society of Anesthesiologists (ASA) score is 3 or more.

With the protocol reported, the risk of infection can be kept very low, avoiding the negative effects of indiscriminate use of antibiotics.

Section snippets

Patients and methods

Between April 2009 and April 2010, a prospective study was conducted in the plastic surgery department of the University Hospital Paolo Giaccone in Palermo. A total of 1100 consecutive patients undergoing an elective clean or clean-contaminated surgical procedure (according to Culver’s definition)21 were enrolled (Table 1). Contaminated or dirty procedures, patients under antibiotic therapy and patients requiring postoperative recovery in an intensive care unit were excluded, and 978 patients

Results

The overall incidence of SSI was 1.4% (14/978 infections). The infection rate was 1.1 for clean surgery (9/816) and 3.8 for clean-contaminated surgery (5/132). Oral oncologic surgery showed the highest rate of infection (5.3%). All infections were superficial. No deep or organ/space SSI was observed. Two patients (14.3%) needed re-hospitalisation and further surgical intervention because of their SSI.

Staphylococcus aureus was responsible for 65% of infections (n = 9), Pseudomonas aeruginosa for

Discussion

Most elective plastic surgery procedures are clean and clean-contaminated.

The population studied is representative of the average activity of an elective plastic surgery department. Contaminated or dirty procedures represent less than 10% of the cases and antibiotic administration is decided case by case.

Infection risk is generally low, and indications for antibiotic prophylaxis include clean-contaminated procedures,9, 23 prosthetic surgery12, 24 and clean procedures with a high infection risk.

Conclusions

Elective plastic surgical procedures must be differentiated based on the risk of infection and antibiotic prophylaxis must be administered accordingly.

Based on our data the protocol described in this article is safe.

Selection of patients who need antibiotic prophylaxis is based on patient-related and procedure-related criteria and can be summarised as follows:

  • •

    No prophylaxis in superficial skin surgery and simple mucosal excisions, regardless of the co-morbidities.

  • •

    Antibiotic prophylaxis is

Conflicts of interest/funding statement

None.

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