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A Comprehensive Review of Guidelines for Antimicrobial Prophylaxis in Plastic Surgery.
Valerie Lemaine, MD, Patrick G Harris, MD, John S Sampalis, PhD, Jean-Paul Brutus, MD, Carlos Cordoba, MD, Hugo E Ciaburro, MD, Andreas Nikolis, MD.
INTRODUCTION: The use of antibiotic prophylaxis in plastic surgery is increasing, and unfortunately based on anecdotal evidence ADDIN EN.CITE Krizek1985636317Krizek, T. J.Gottlieb, L. J.Koss, N.Robson, M. C.The use of prophylactic antibacterials in plastic surgery: a 1980s updatePlast Reconstr SurgPlast Reconstr Surg953-63766Abnormalities/surgeryAnti-Bacterial Agents/administration & dosage/*therapeutic useBacterial Infections/prevention & controlBreast/surgeryBurns/surgeryData CollectionDrug UtilizationEstheticsHand Injuries/surgeryHead/surgeryHumansNeck/surgeryPostoperative Complications/prevention & control*PremedicationQuestionnaires*Surgery, PlasticUnited StatesWound Infection/prevention & control1985Dec4070462http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=4070462 Krizek1975656517Krizek, T. J.Koss, N.Robson, M. C.The current use of prophylactic antibiotics in plastic and reconstructive surgeryPlast Reconstr SurgPlast Reconstr Surg21-32551Anti-Bacterial Agents/*therapeutic useBreast/surgeryBurns/surgeryCleft Lip/surgeryCleft Palate/surgeryHand/surgeryHead/surgeryHumansMaxillofacial Injuries/surgeryNeck/surgeryQuestionnairesResearch Support, U.S. Gov't, P.H.S.RhinoplastySkin Transplantation*Surgery, PlasticTime FactorsTransplantation, Autologous1975Jan1089978http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=1089978 Perrotti2002848417Perrotti, J. A.Castor, S. A.Perez, P. C.Zins, J. E.Department of Plastic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA. jperrottimd@usa.net.Antibiotic use in aesthetic surgery: a national survey and literature reviewPlast Reconstr SurgPlast Reconstr Surg1685-93; discussion 1694-951095*Antibiotic ProphylaxisData CollectionHumans*Reconstructive Surgical ProceduresUnited States2002Apr 15119326191-3 including case series and retrospective reviews, with minimal data from prospective randomized controlled trials (PRCT) in support of their use. This may lead to antimicrobial resistance, adverse medication reactions and increased health care expenditures. The goal of this study was first, to identify existing data on antimicrobial prophylaxis in the plastic surgery literature; second, to provide evidence-based recommendations for primary antimicrobial prophylaxis; and finally, to create the foundation for a prospective evaluation of antibiotic prophylaxis in plastic surgery.
METHOD: An exhaustive review of the plastic surgery literature was conducted using the PubMed and Ovid MEDLINE databases, between 1966 and January 2006. A specific search of non-indexed periodicals was completed, as well as a manual review of the reference list of each article. A total of 145 articles were identified using the following keywords: antibiotic, antimicrobial, prophylaxis, therapy, plastic surgery, plastic or reconstructive surgery. Of these, forty-six articles were identified to be relevant based on the following criteria: 1) category of study evidence 2) study design 3) study characteristics 4) co-morbidities such as diabetes, smoking and radiotherapy 5) definition of infection 6) types of procedures performed and their classification 7) anatomical region 8) lesion and mechanism, when applicable. A committee of three plastic surgeons evaluated each article based on a scoring system created to rate the pertinence of each study based on those eight factors. Ninety-eight articles were rejected for any of the following reasons: 1) the goal of study was not the evaluation of the need of antimicrobial prophylaxis in plastic surgery 2) the study focused on antimicrobial prophylaxis for capsular contracture 3) the study analyzed the treatment of an infectious pathology, such as septic arthritis.
RESULTS: The results were stratified by anatomical category and by level of evidence (Tables 1 and 2). To date, there are ten studies (21,7%) evaluating the use of antimicrobial prophylaxis in large PRCT (n ( 100). Of these, seven trials (70%) evaluate its use in hand surgery. Expert opinion and surveys account for the majority (23,9%) of the published literature on antimicrobial prophylaxis in plastic surgery.
Table 1. Category A recommendations in favor of the use of antimicrobial prophylaxis in plastic surgery
Strength of evidenceTypes of proceduresCategory A
(Evidence from well-conducted PRCT, controlled clinical trials, meta-analysis and cohort studies)
Hand and upper extremity:
Elective surgery using K-wires, implants or with a length over 2 hours ADDIN EN.CITE Platt1995292917Platt, A.J.Page, R.E.Post-operative infection following hand surgeryJ Hand Surg (Br)J Hand Surg (Br)685-690201995Shapiro1998333317Shapiro, D.B.Postoperative Infection in Hand Surgery, Cause, Prevention, and TreatmentHand ClinHand Clin669-811441998Review4, 5
Emergency surgery: as above, and all dirty wounds, all clean wounds with more than 6 hour delay before surgery, and all open fractures ADDIN EN.CITE Shapiro1998333317Shapiro, D.B.Postoperative Infection in Hand Surgery, Cause, Prevention, and TreatmentHand ClinHand Clin669-811441998ReviewPlatt1995292917Platt, A.J.Page, R.E.Post-operative infection following hand surgeryJ Hand Surg (Br)J Hand Surg (Br)685-690201995Sloan1987353517Sloan, J.P.Dove, A.F.Maheson, M.Cope, A.N.Welsh, K.R.Antibiotics in open fractures of the distal phalanx?J Hand Surg (Br)J Hand Surg (Br)123-241211987Prospective randomized controlled trialFitzgerald1977727217Fitzgerald, R. H., Jr.Cooney, W. P., 3rdWashington, J. A., 2ndVan Scoy, R. E.Linscheid, R. L.Dobyns, J. H.Bacterial colonization of mutilating hand injuries and its treatmentJ Hand Surg [Am]J Hand Surg [Am]85-922Anti-Bacterial Agents/*therapeutic useBacteria/isolation & purificationDrug Resistance, MicrobialHand Injuries/etiology/*microbiology/surgeryHumansProspective StudiesRetrospective StudiesWound HealingWound Infection/microbiology/*prevention & control1977Mar845424http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=845424 4-7
Head and neck:
Oncologic surgery ADDIN EN.CITE Velanovich1991414117Velanovich, C.V.A Meta-Analysis of Prophylactic Antibiotics in Head and Neck SurgeryPlast Reconstr SurgPlast Reconstr Surg429-348731991Bhathena19984417Bhathena, H.M.Kavarana, N.M.Prophylactic Antibiotics Administration in Head and Neck Cancer Surgery with Major Flap Reconstruction: 1-Day Cefoperazone Versus 5-Day CefotaximeActa Chirurgiae PlasticaeActa Chirurgiae Plasticae36-404021998Prospective randomized controlled trial8, 9
Skin cancer surgery ADDIN EN.CITE Bhathena19984417Bhathena, H.M.Kavarana, N.M.Prophylactic Antibiotics Administration in Head and Neck Cancer Surgery with Major Flap Reconstruction: 1-Day Cefoperazone Versus 5-Day CefotaximeActa Chirurgiae PlasticaeActa Chirurgiae Plasticae36-404021998Prospective randomized controlled trial9
Septorhinoplasty ADDIN EN.CITE Rajan2005303017Rajan, G.P.Fergie, N.Fischer, U.Romer, M.Radivojevic, V.Hee, G.K.Antibiotic Prophylaxis in Septorhinoplasty? A Prospective, Randomized StudyPlast Reconstr SurgPlast Reconstr Surg1995-9811672005Prospective randomized controlled trial10
Burns
Skin grafting ADDIN EN.CITE Livingston1990202017Livingston, D.H.Gill Cryer, H.Miller, F.B.Malangoni, M.A.Polk, H.C. JrWeiner, L.J.A Randomized Prospective Study of Topical Antimicrobial Agents on Skin Grafts after Thermal injuryPlast Reconstr SurgPlast Reconstr Surg1059-64; discussion 658661990Prospective randomized controlled trial11
Microsurgery:
Replantation / Revascularisation ADDIN EN.CITE Amland1995606017Amland, P. F.Andenaes, K.Samdal, F.Lingaas, E.Sandsmark, M.Abyholm, F.Giercksky, K. E.Department of Plastic Surgery, Norwegian National Hospital, Oslo, Norway.A prospective, double-blind, placebo-controlled trial of a single dose of azithromycin on postoperative wound infections in plastic surgeryPlast Reconstr SurgPlast Reconstr Surg1378-83966AdultAnti-Bacterial Agents/*therapeutic use*Antibiotic ProphylaxisAzithromycin/administration & dosage/*therapeutic useChildDouble-Blind MethodFemaleHumansMaleProspective StudiesResearch Support, Non-U.S. Gov'tSurgery, PlasticSurgical Wound Infection/*prevention & control1995Nov7480237http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=7480237 12
Free flaps ADDIN EN.CITE Amland1995606017Amland, P. F.Andenaes, K.Samdal, F.Lingaas, E.Sandsmark, M.Abyholm, F.Giercksky, K. E.Department of Plastic Surgery, Norwegian National Hospital, Oslo, Norway.A prospective, double-blind, placebo-controlled trial of a single dose of azithromycin on postoperative wound infections in plastic surgeryPlast Reconstr SurgPlast Reconstr Surg1378-83966AdultAnti-Bacterial Agents/*therapeutic use*Antibiotic ProphylaxisAzithromycin/administration & dosage/*therapeutic useChildDouble-Blind MethodFemaleHumansMaleProspective StudiesResearch Support, Non-U.S. Gov'tSurgery, PlasticSurgical Wound Infection/*prevention & control1995Nov7480237http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=7480237 12
Breast:
Reconstruction ADDIN EN.CITE Franchellil1993909017Franchellil, S.Leone, M.S.Rainero, M.L.Gipponi, M.Cafiero, F.Capuzzo, R.Costantini, M.Santi, P.L.Antibiotic prophylaxis with teicoplanin in patients undergoing breast reconstruction with the transverse rectus abdominis myocutaneous flapEur J Plast SurgEur J Plast Surg204-207164-5199313
Table 2. Category A evidence against the use of antimicrobial prophylaxis in plastic surgery
Strength of evidenceTypes of proceduresCategory A
(Evidence from well-conducted PRCT, controlled clinical trials, meta-analysis and cohort studies)
Hand and upper extremity:
Elective surgery not using K-wires or implants ADDIN EN.CITE Platt1995292917Platt, A.J.Page, R.E.Post-operative infection following hand surgeryJ Hand Surg (Br)J Hand Surg (Br)685-690201995Shapiro1998333317Shapiro, D.B.Postoperative Infection in Hand Surgery, Cause, Prevention, and TreatmentHand ClinHand Clin669-811441998Review4, 5
Open fractures of the phalanx ADDIN EN.CITE Stevenson2003373717Stevenson, J.McNaughton, G.Riley, J.The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: A double-blind randomized placebo-controlled trialJ Hand Surg (Br)J Hand Surg (Br)388-3942852003Prospective randomized controlled trialSuprock1990393917Suprock, M.D.Hood, J.M.Lubahn, J.D.Role of antibiotics in open fractures of the fingerJ Hand Surg (Am)J Hand Surg (Am)761-7641551990Prospective randomized controlled trialPeacock1988242417Peacock, K.C.Hanna, D.P.Kirkpatrick, K.Breidenbach, W.C.Lister, G.D.Firrell, J.Efficacy of perioperative cefamandole with postoperative cephalexin in the primary outpatient treatment of open wounds of the handJ Hand Surg (Am)J Hand Surg (Am)198814-16
Lacerations excluding fractures ADDIN EN.CITE Cassell19975517Cassell, O.C.S.Ion, L.Are antibiotics necessary in the surgical management of upper limb lacerations?Br J Plast SurgBr J Plast Surg523-529501997Prospective randomized controlled trialHoffman1998676717Hoffman, R. D.Adams, B. D.Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA.The role of antibiotics in the management of elective and post-traumatic hand surgeryHand ClinHand Clin657-66144Anti-Bacterial Agents/administration & dosage*Antibiotic ProphylaxisHand/*surgeryHand Injuries/*surgeryHumans*Surgical Procedures, Elective1998Nov9884902http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9884902 Whittaker2005666617Whittaker, J. P.Nancarrow, J. D.Sterne, G. D.West Midlands Regional Plastic Surgery Unit, Wordsley Hospital, Stourbridge, West Midlands, UK. jpwhittaker@onetel.net.ukThe role of antibiotic prophylaxis in clean incised hand injuries: a prospective randomized placebo controlled double blind trialJ Hand Surg [Br]J Hand Surg [Br]162-7302AdolescentAdultAgedAnti-Bacterial Agents/*therapeutic use*Antibiotic ProphylaxisDouble-Blind MethodDrug Administration ScheduleFemaleFloxacillin/*therapeutic useGram-Positive Bacteria/isolation & purificationHand Injuries/*surgeryHumansMaleMiddle AgedPreoperative CareProspective StudiesResearch Support, Non-U.S. Gov'tSurgical Wound Infection/microbiology/*prevention & control2005May15757769http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15757769 Shapiro1998333317Shapiro, D.B.Postoperative Infection in Hand Surgery, Cause, Prevention, and TreatmentHand ClinHand Clin669-811441998ReviewPeacock1988242417Peacock, K.C.Hanna, D.P.Kirkpatrick, K.Breidenbach, W.C.Lister, G.D.Firrell, J.Efficacy of perioperative cefamandole with postoperative cephalexin in the primary outpatient treatment of open wounds of the handJ Hand Surg (Am)J Hand Surg (Am)1988Peacock1988242417Peacock, K.C.Hanna, D.P.Kirkpatrick, K.Breidenbach, W.C.Lister, G.D.Firrell, J.Efficacy of perioperative cefamandole with postoperative cephalexin in the primary outpatient treatment of open wounds of the handJ Hand Surg (Am)J Hand Surg (Am)1988Cassell19975517Cassell, O.C.S.Ion, L.Are antibiotics necessary in the surgical management of upper limb lacerations?Br J Plast SurgBr J Plast Surg523-529501997Prospective randomized controlled trialPeacock1988242417Peacock, K.C.Hanna, D.P.Kirkpatrick, K.Breidenbach, W.C.Lister, G.D.Firrell, J.Efficacy of perioperative cefamandole with postoperative cephalexin in the primary outpatient treatment of open wounds of the handJ Hand Surg (Am)J Hand Surg (Am)19885, 16-19
Head and neck:
Cleft lip and palate ADDIN EN.CITE Amland1995606017Amland, P. F.Andenaes, K.Samdal, F.Lingaas, E.Sandsmark, M.Abyholm, F.Giercksky, K. E.Department of Plastic Surgery, Norwegian National Hospital, Oslo, Norway.A prospective, double-blind, placebo-controlled trial of a single dose of azithromycin on postoperative wound infections in plastic surgeryPlast Reconstr SurgPlast Reconstr Surg1378-83966AdultAnti-Bacterial Agents/*therapeutic use*Antibiotic ProphylaxisAzithromycin/administration & dosage/*therapeutic useChildDouble-Blind MethodFemaleHumansMaleProspective StudiesResearch Support, Non-U.S. Gov'tSurgery, PlasticSurgical Wound Infection/*prevention & control1995Nov7480237http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=7480237 12
Publications were further classified as category B (evidence from well-conducted retrospective studies, case-control-studies; evidence from uncontrolled studies that were not well conducted) and category C (expert opinion) for and against the use of antibiotic prophylaxis. The scientific evidence shown in the above tables clearly demonstrates the lack of category A evidence in aesthetic surgery, as well as the controversy in the literature concerning the need for antimicrobial prophylaxis in the management of open hand fractures.
CONCLUSION: We present the first review of primary antimicrobial prophylaxis in plastic surgery. Evaluation demonstrates a significant lack of evidence-based data in antibiotic prophylaxis use, and a need for PRCT in establishing future guidelines.
REFERENCES
ADDIN EN.REFLIST 1. Krizek TJ, Gottlieb LJ, Koss N, Robson MC. The use of prophylactic antibacterials in plastic surgery: a 1980s update. Plast Reconstr Surg 1985;76(6):953-63.
2. Krizek TJ, Koss N, Robson MC. The current use of prophylactic antibiotics in plastic and reconstructive surgery. Plast Reconstr Surg 1975;55(1):21-32.
3. Perrotti JA, Castor SA, Perez PC, Zins JE. Antibiotic use in aesthetic surgery: a national survey and literature review. Plast Reconstr Surg 2002;109(5):1685-93; discussion 94-95.
4. Platt AJ, Page RE. Post-operative infection following hand surgery. J Hand Surg (Br) 1995;20:685-90.
5. Shapiro DB. Postoperative Infection in Hand Surgery, Cause, Prevention, and Treatment. Hand Clin 1998;14(4):669-81.
6. Sloan JP, Dove AF, Maheson M, Cope AN, Welsh KR. Antibiotics in open fractures of the distal phalanx? J Hand Surg (Br) 1987;12(1):123-24.
7. Fitzgerald RH, Jr., Cooney WP, 3rd, Washington JA, 2nd, Van Scoy RE, Linscheid RL, Dobyns JH. Bacterial colonization of mutilating hand injuries and its treatment. J Hand Surg [Am] 1977;2(2):85-9.
8. Velanovich CV. A Meta-Analysis of Prophylactic Antibiotics in Head and Neck Surgery. Plast Reconstr Surg 1991;87(3):429-34.
9. Bhathena HM, Kavarana NM. Prophylactic Antibiotics Administration in Head and Neck Cancer Surgery with Major Flap Reconstruction: 1-Day Cefoperazone Versus 5-Day Cefotaxime. Acta Chirurgiae Plasticae 1998;40(2):36-40.
10. Rajan GP, Fergie N, Fischer U, Romer M, Radivojevic V, Hee GK. Antibiotic Prophylaxis in Septorhinoplasty? A Prospective, Randomized Study. Plast Reconstr Surg 2005;116(7):1995-98.
11. Livingston DH, Gill Cryer H, Miller FB, Malangoni MA, Polk HCJ, Weiner LJ. A Randomized Prospective Study of Topical Antimicrobial Agents on Skin Grafts after Thermal injury. Plast Reconstr Surg 1990;86(6):1059-64; discussion 65.
12. Amland PF, Andenaes K, Samdal F, et al. A prospective, double-blind, placebo-controlled trial of a single dose of azithromycin on postoperative wound infections in plastic surgery. Plast Reconstr Surg 1995;96(6):1378-83.
13. Franchellil S, Leone MS, Rainero ML, et al. Antibiotic prophylaxis with teicoplanin in patients undergoing breast reconstruction with the transverse rectus abdominis myocutaneous flap. Eur J Plast Surg 1993;16(4-5):204-7.
14. Stevenson J, McNaughton G, Riley J. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: A double-blind randomized placebo-controlled trial. J Hand Surg (Br) 2003;28(5):388-94.
15. Suprock MD, Hood JM, Lubahn JD. Role of antibiotics in open fractures of the finger. J Hand Surg (Am) 1990;15(5):761-4.
16. Peacock KC, Hanna DP, Kirkpatrick K, Breidenbach WC, Lister GD, Firrell J. Efficacy of perioperative cefamandole with postoperative cephalexin in the primary outpatient treatment of open wounds of the hand. J Hand Surg (Am) 1988.
17. Cassell OCS, Ion L. Are antibiotics necessary in the surgical management of upper limb lacerations? Br J Plast Surg 1997;50:523-9.
18. Hoffman RD, Adams BD. The role of antibiotics in the management of elective and post-traumatic hand surgery. Hand Clin 1998;14(4):657-66.
19. Whittaker JP, Nancarrow JD, Sterne GD. The role of antibiotic prophylaxis in clean incised hand injuries: a prospective randomized placebo controlled double blind trial. J Hand Surg [Br] 2005;30(2):162-7.
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