WILLIAMSBURG, VA. Patients with prosthetic cardiac valves and recently implanted joint prostheses are among the few who should receive prophylactic antibiotics before surgical procedures, according to a dermatologic surgeon.
Prosthetic devices sometimes grow coagulase-negative Staphylococcus aureus, which can cause a life-threatening endocarditis or, in the case of joint prostheses, an intra-articular infection that can necessitate replacement of the device. "If a patient [in these categories] comes to me for surgery and has not been prophylaxed, I will not do the procedure," said Dr. Stephen Spencer of Port Charlotte, Fla.
Neither of the guidelines that address prophylactic antibioticsthe 2007 guidelines for preventing infective carditis and the 2003 guidelines for preventing hematogenous total joint infectionsspecifically deal with dermatologic surgery, but dermatologists can rationally extrapolate the recommendations to their own patients, Dr. Spencer said at a meeting of the American Society for Mohs Surgery.
For patients with prosthetic cardiac valves, the American Heart Association guidelines recommend 2 g of amoxicillin orally 30-60 minutes before the procedure. Penicillin-allergic patients can take cephalexin, clindamycin, or azithromycin (Circulation 2007;116:1736-54).
Patients who have had a total joint replacement in the past 2 years should take 2 g of cephalexin, cephradine, or amoxicillin 60 minutes before surgery. Penicillin-allergic patients can take clindamycin. Choices for injected antibiotics include clindamycin, cefazolin, or ampicillin, according to guidelines issued by the American Dental Association and the American Academy of Orthopedic Surgeons (J. Am. Dent. Assoc. 2003;134:895-9).
For most other patients, including healthy individuals with joint replacements more than 2 years old, the risks of adverse events associated with antibiotic treatment probably outweigh any potential benefit it might have in preventing infective complications, including infective endocarditis, said Dr. Spencer.
"Very few healthy people need these preoperative antibiotics," he said, citing a 2006 study from Australia that found an extremely low rate of wound infection after dermatologic surgery in the absence of prophylactic antibiotics (Dermatol. Surg. 2006;32:819-26).
The 3-year study included 5,091 lesions treated on 2,424 patients, none of whom received preoperative antibiotics. The overall infection incidence was 1.5%, and many individual procedures had similarly low rates: curettage (0.7%); skin flap repairs (3%); simple excision and closure (0.5%). Skin grafts and wedge excisions had higher rates (9% each).
The investigators concluded that surgery to the nose, ear, fingers, and lips; skin flap surgery; and surgery on diabetics, smokers, and those on anticoagulants did not warrant prophylactic antibiotic treatment. They did recommend antibiotics for procedures below the knee, wedge excisions of lip and ear, all skin grafts, and lesions in the groin, Dr. Spencer noted.