Medical groups provide clearer anti-infective guidelines

Dr. Rosamilia

State College, Pa. - Perhaps overzealous in the past, leading organizations have simplified guidelines regarding prophylactic use of anti-infective agents before and during skin surgeries, according to an expert.

Lorraine L. Rosamilia, M.D., says prior anti-infective guidelines from groups such as the American Heart Association, the American Dental Association and the American Academy of Orthopaedic Surgeons could be confusing, but directives are now clearer.

“The point that recent literature is trying to make - particularly recommendations from the Mayo Clinic - is that some of it can be simplified, and that our use of antibiotics has probably been overzealous in the past,”^1-4 says Dr. Rosamilia, a dermatologist at Geisinger Medical Center, State College, Pa.

“The bottom line is that to prevent surgical-site infections, you need to know if patients will need prophylaxis when you first decide” on performing a procedure, and much of that decision rests on the surgical site itself and the patient’s comorbidities.

The main factor that determines whether patients should receive prophylaxis is whether the surgical site is clean or infected, Dr. Rosamilia says. However, “‘Clean’ can be a very subjective term, depending on what kind of patient you’re dealing with.” It’s also crucial to determine whether the infection risk pertains to a patient’s heart, joints or only the surgical site itself, she says.

As for the surgical site, she says, traditional Centers for Disease Control classifications include Class 1 (clean), Class 2 (clean/contaminated), Class 3 (contaminated) and Class 4 (infected).

“Rarely are any of our procedures truly sterile,” Dr. Rosamilia says. “They are as clean as they can possibly be, but what the site looks like directs how we classify it. More simply, beyond the strict CDC classification, it’s important to know which surgical sites on the body are going to have the highest risk” and therefore will need prophylaxis. Such sites generally include the lower limbs, groin, a lip or ear wedge excision, a nasal flap, or any site with a skin graft.

“Patient-specific factors to consider include whether the patient has had surgery relating to the heart or joints,” along with the patient’s comorbidities, immune system status and history of certain medications and infections. Other factors include the success of the actual surgical procedures the patient has undergone, as well as instrumentation and perhaps implantable devices used in these procedures, she says.

Considering all factors

Physicians also must consider whether the patient has extensive inflammatory disease, or if nearby skin is infected, Dr. Rosamilia says. Unless it’s a previous biopsy site that has become infected, she adds, dermatologists rarely perform procedures in the latter setting.

High-risk cardiac factors include heart transplants with valvulopathy, placement of any prosthetic cardiac valve and history of infective endocarditis or any congenital heart disease that creates an unrepaired cyanotic defect.

“We’re not talking about atrial or septal defects (ASDs, VSDs), but rather cyanosis” such as that caused by tetralogy of Fallot. Other high-risk patients include those who have had a congenital cardiac defect repaired in the past six months, or an incompletely repaired defect, she says.

In the joints, high-risk hardware includes any joint replacement performed in the past two years or any prosthetic joint that’s been infected, Dr. Rosamilia says. Joint hardware also can provide a fertile site for delayed joint infection related to skin surgery, so dermatologists should ask patients about immunosuppression and other health problems, such as systemic lupus erythematosus, rheumatoid arthritis and HIV.

Prophylaxis decisions

Choosing an oral antimicrobial to prevent endocarditis and joint infection depends on the condition of the surgical site itself, Dr. Rosamilia says.

“If the procedure involves the oral mucosa, or the patient has infected or severely inflamed surgical or nearby skin, then the patient will require prophylaxis,” she says. “Also, if the patient gets an infection afterward, it must be treated very aggressively.”

Patients undergoing oral surgery can take amoxicillin 2 g, she says. For non-oral surgery, current guidelines recommend cephalexin or dicloxacillin 2 g. Penicillin-allergic patients undergoing either oral or non-oral surgery can take clindamycin 600 mg, or azithromycin or clarithromycin 500 mg.

If a patient cannot take oral medication, guidelines recommend cefazolin or ceftriaxone 1 g intramuscularly (IM) or intravenously (IV) for patients undergoing skin grafts or wedge lip/ear excisions or nasal flaps, Dr. Rosamilia says. Penicillin-allergic patients undergoing such surgeries can take clindamycin 600 mg IM/IV, she says.

“Importantly - and I believe the above guidelines will change over time because of increasing bacterial resistance - in a community with an increased risk of methicillin-resistant Staphylococcus aureus (MRSA), you can combine trimethoprim/sulfamethoxazole DS with penicillin VK. Clindamycin 600 mg can be used if a patient is known to be colonized with trimethoprim sulfamethoxazole-resistant or penicillin-resistant S. aureus or if the patient is penicillin-allergic,” she says.

Equally important are dosing schedules, Dr. Rosamilia says. AHA guidelines recommend giving oral prophylaxis 30 to 60 minutes preoperatively. ADA and AAOS guidelines recommend 60 minutes preoperatively.

Surgical planning

With some procedures, however, it’s impossible to predict whether the patient will require a graft or flap before beginning the procedure, Dr. Rosamilia says. “Skin surgery is much different than planned joint or dental procedures.” In such instances, she recommends prophylaxing as closely to the recommended dosing period as possible.

Overall, Dr. Rosamilia says, “We all have our own preferences based on experience and gut feelings about each case. The guidelines are there to standardize and improve care, decrease infection rates and prevent unnecessary use of antibiotics. But sometimes there’s still a gray area.” DT

Disclosures: Dr. Rosamilia reports no relevant financial interests.

1. Messingham MJ, Arpey CJ. Dermatol Surg. 2005;81(8 Pt2):1068-1078.

2. Rosengren H, Dixon A. Am J Clin Dermatol. 2010;11(1):35-44.

3. Shurman DL, Benedetto AV. Clin Dermatol. 2010;28(5):505-510.

4. Wright TI, Baddour LM, Berbari EF, et al. J Am Acad Dermatol. 2008;59(3):464-473.