Antibacterial prophylaxis in dermatologic surgery: an evidence-based review.

Clean, non-contaminated skin surgery is associated with low rates of surgical site infection (SSI), bacterial endocarditis, and joint prosthesis infection. Hence, antibacterial prophylaxis, which may be associated with adverse effects, the emergence of multidrug-resistant pathogens, and anaphylaxis, is generally not recommended in dermatologic surgery. Some body sites and surgical reconstructive procedures are associated with higher infection rates, and guidelines for SSI antibacterial prophylaxis have been proposed for these cases. Large prospective, controlled trials are needed to ascertain the role of oral SSI prophylaxis for these surgical sites and procedures especially in patients with diabetes mellitus who are intrinsically at greater risk of SSI. Topical antibacterial ointment and sterile paraffin appear to make no difference to healing or the incidence of SSIs in clean wounds. Although further research is needed, preliminary studies have shown that intraincisional antibacterials, which may be associated with fewer adverse effects and a lower risk of multidrug-resistant bacteria, could potentially be helpful for SSI prophylaxis. Trials using honey- and silver-impregnated dressings have found no advantage in the healing of chronic wounds. However, several case studies, which need corroboration in larger studies, suggest that these dressings may be helpful in preventing and treating SSIs. Bacterial endocarditis and joint prosthesis infection prophylaxis are not routinely recommended in cutaneous surgery. The updated 2007 American Heart Association guidelines now advocate bacterial endocarditis prophylaxis for high-risk cardiac patients having surgery involving the oral mucosa or infected skin. The latest American Dental Association/American Academy of Orthopaedic Surgery guidelines recommend considering antibacterial prophylaxis for oral procedures where bleeding is anticipated and for surgery involving acute orofacial skin infections if the patient has had a total joint replacement within 2 years or is in a high-risk group and has had a joint replacement at any time.

Education in skin cancer management--assessing knowledge and safety.

BACKGROUND: General practitioners manage the majority of skin cancers in Australia. There are a range of training opportunities for, and certifications in, skin cancer management. METHOD: Between 15 June and 25 June 2008, an online examination was placed on the Australasian College of Skin Cancer Medicine website. Two hundred and forty-five college affiliated doctors were invited by email to complete the examination. Thirty questions were asked pertaining to the management of a hypothetical case study including melanoma, basal cell carcinoma and squamous cell carcinoma. RESULTS: Of 187 doctors who had an active responding email address, 140 (75%) took the examination. From a possible score of 100, the mean score was 84 +/- 16. The median score was 80. DISCUSSION: Some trends emerged. Longer and more detailed training programs correlated with better subsequent knowledge retention and safety. Two days of training may not make doctors sufficiently safe in skin cancer management; it appeared to improved knowledge, but not to a point where unsafe practice was eliminated.

Effect of a Single Preoperative Dose of Oral Antibiotic to Reduce the Incidence of Surgical Site Infection Following Below-Knee Dermatological Flap and Graft Repair.

BACKGROUND: Surgical site infection (SSI) rates for below-knee dermatological surgery are unacceptably high, particularly following complex flap and graft closures. The role of antibiotic prophylaxis for these surgical cases is uncertain. OBJECTIVE: To determine whether SSI following complex dermatological closures on the leg could be reduced by antibiotic prophylaxis administered as a single oral preoperative dose. METHODS: A total of 115 participants were randomized to 2 g of oral cephalexin or placebo 40-60 minutes prior to surgical incision in a prospective, randomized, double-blind, placebo-controlled trial at a primary care skin cancer clinic in North Queensland, Australia. RESULTS: Overall 17/55 (30.9%) controls and 14/55 (25.5%) intervention participants developed infection (P = 0.525). There was no difference between the study groups in adverse symptoms that could be attributed to high-dose antibiotic administration (P = 1). CONCLUSION: A single oral 2-g dose of cephalexin given before complex below-knee dermatological closure did not reduce SSI.

Effect of a single prophylactic preoperative oral antibiotic dose on surgical site infection following complex dermatological procedures on the nose and ear: a prospective, randomised, controlled, double-blinded trial.

OBJECTIVES: There is limited published research studying the effect of antibiotic prophylaxis on surgical site infection (SSI) in dermatological surgery, and there is no consensus for its use in higher-risk cases. The objective of this study was to determine the effectiveness of a single oral preoperative 2 g dose of cephalexin in preventing SSI following flap and graft dermatological closures on the nose and ear. DESIGN: Prospective double-blinded, randomised, placebo-controlled trial testing for difference in infection rates. SETTING: Primary care skin cancer clinics in North Queensland, Australia, were randomised to 2 g oral cephalexin or placebo 40-60 min prior to skin incision. PARTICIPANTS: 154 consecutive eligible patients booked for flap or graft closure following skin cancer excision on the ear and nose. INTERVENTION: 2 g dose of cephalexin administered 40-60 min prior to surgery. RESULTS: Overall 8/69 (11.6%) controls and 1/73 (1.4%) in the intervention group developed SSI (p=0.015; absolute SSI reduction 10.2%; number needed to treat (NNT) for benefit 9.8, 95% CI 5.5 to 45.5). In males, 7/44 controls and 0/33 in the intervention group developed SSI (p=0.018; absolute SSI reduction 15.9%; NNT for benefit 6.3, 95% CI 3.8 to 19.2). SSI was much lower in female controls (1/25) and antibiotic prophylaxis did not further reduce this (p=1.0). There was no difference between the study groups in adverse symptoms attributable to high-dose antibiotic administration (p=0.871). CONCLUSION: A single oral 2 g dose of cephalexin given before complex skin closure on the nose and ear reduced SSI. TRIAL REGISTRATION NUMBER: ANZCTR 365115; Post-results.

Does taping torso scars following dermatologic surgery improve scar appearance?

BACKGROUND: Studies show that patients are significantly less satisfied with torso scars than scars elsewhere. Though not an uncommon practice, it is unknown if application of adhesive tapes following dermatological surgery help improve cosmesis. OBJECTIVE: To determine the effect of taping sutured torso wounds on overall scar appearance, scar width and patient satisfaction with the scar. PATIENTS/METHODS: Participants having elliptical torso skin excisions in a primary care setting in regional Australia were randomized in a single-blinded, controlled trial to 12 weeks taping (intervention) or usual care (control) following deep and subcuticular suturing. A blinded assessor reviewed scars at three and six months. RESULTS: Of 195 participants recruited, 136 (63 taped, 73 controls) completed six months of follow-up. Independent blinded assessment of overall scar appearance was significantly better in taped participants (p= 0.004). Taping reduced median scar width by 1 mm (p=0.02) and when stratified by gender, by 3.0 mm in males (p=0.04) and 1.0 mm in females (p=0.2). High participant scar satisfaction was not further improved by taping. CONCLUSION: Taping elliptical torso wounds for 12 weeks after dermatologic surgery improved scar appearance at six months.