Active Ingredients: Azithromycin
Prophylaxis was more effective for subgroups commenced on antibiotics pre- rather than post-operatively. In a recent retrospective review of 8850 elective hand surgery cases, the low 0.
Given the low infection rate and relatively small patient numbers in subgroups, the effectiveness of AP cannot be discounted for specific risk factors associated with DSSI.
The use of prophylactic antibiotics was the only predictor of successful graft take. Dermatologic surgery rarely causes bacteraemia, and AP is therefore not indicated even in patients at highest risk of adverse outcome from IE unless the surgical site is already infected or involves incision of the oral mucosa.
Conditions such as valvular heart disease, aortic stenosis, and stable congenital heart disease no longer require AP. Table 2 Risk factors for IE and PJI that require antibiotic prophylaxis if dermatological surgery involves infected skin or incision of oral mucosa Full size table The AHA has clarified that simply injecting local anaesthetic via the oral mucosa does not require prophylaxis.
Optimal oral health and hygiene is more important than AP for a dental procedure to reduce the risk of IE. Despite new AHA guidelines being evidence-based, there has been resistance among dentists, cardiologists, and patients to comply with the changes.
Barriers to implementation include difficulty explaining to patients previously requiring AP for IE that this recommendation is now obsolete for future procedures ; fear of criticism from colleagues and lack of trust in the evidence also prevents compliance.
Patients habituated to taking AP before certain procedures expressed concern that the updated guidelines were incorrect. Our own experience mirrors this with many patients remaining on AP to prevent IE following dermatologic surgery because their cardiologists still recommend it.
Vancomycin or clindamycin can also be given. For those with penicillin allergy, azithromycin, clindamycin, or clarithromycin are now advocated.
The data showed that most late onset PJI was related to bacteraemia. Consequently, patients susceptible for PJI should receive AP for incision of infected skin or the oral mucosa. AP is not indicated for patients with pins, plates, or screws.
Additionally, a previous prosthetic joint infection, being immunocompromised, or having certain co-morbidities warrant AP for PJI regardless of when the joint was replaced.
High risk co-morbidities include insulin-dependent type 1 diabetes, malignancy, HIV infection, malnourishment, and hemophilia.
Conclusions Many host- and procedure-related factors influence the risk of DSSI, and in the absence of clear updated guidelines reflecting emerging evidence, the decision to give prophylactic antibiotics should be on a case-by-case basis with systematic attention to multiple risk factors.
Prophylactic prescribing of antibiotics could result in unnecessary troublesome side effects, allergy, anaphylaxis, and drug resistance.
On the other hand, a high-risk, complex dermatological procedure complicated by infection can result in delayed healing and poor cosmesis.
RCTs have shown that topical antibiotics applied immediately after dermatologic surgery do not prevent infection and they should therefore not be used. Intravenous AP has been found to reduce infection rates following skin grafts but not hand surgery.
We know of no RCT that has specifically studied the effect of intranasal mupirocin alone in dermatological surgery, but as the impact on SSI has been universally beneficial in other studies we would recommend checking for and treating S.
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