535802 research-article2014
AESXXX10.1177/1090820X14535802Aesthetic Surgery JournalHunter
Research Commentary
Commentary on: Effectiveness of Prophylactic Antibiotics in Outpatient Plastic Surgery
Aesthetic Surgery Journal 2014, Vol. 34(8) 1259–1260 © 2014 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www. sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X14535802 www.aestheticsurgeryjournal.com
John G. Hunter, MD, MMM, CPE, FACS
Successful prophylaxis requires the adequate delivery of the agent to the operative site before the incision is made. The antimicrobial should be administered within the time frame needed to achieve serum and tissue concentrations that exceed the minimum inhibitory concentration (MIC) for the pathogens likely to be present. Adequate serum and tissue levels should be maintained for the entire time the surgical site is open.7 As the authors indicate, current quality measures and practice guidelines, promulgated by the Surgical Care Improvement Project, Centers for Disease Control and Prevention, and others, recommend administration of the first prophylaxis dose beginning within 60 minutes of surgical incision (120 minutes for vancomycin and fluoroquinolones since they require slow infusion) to achieve ideal serum and tissue concentration levels. As Anigian et al6 reference, recent literature suggests increased prophylaxis effect occurs with antimicrobial administration within 30 minutes before incision, and conflicting data also suggest that administration can be too close to an incision, resulting in a higher infection rate. Bratzler et al,7 in recently updated, authoritative surgical antimicrobial prophylaxis guidelines (developed jointly by the American Society of Health-System Pharmacists [ASHP], the Infectious Disease Society of America, the Surgical Infection Society, and the Society for Healthcare Epidemiology of America) state that the data offered in these reports are “not convincing” or “sufficiently robust” to recommend changing current antimicrobial administration timing recommendations. Interestingly, the updated guidelines report that cefazolin (the most commonly used prophylactic antibiotic in plastic Dr Hunter is an Associate Attending Plastic Surgeon, New YorkPresbyterian Hospital (Weill Cornell Campus), New York, New York, and Vice Chairman, Department of Surgery, and Chief of Plastic Surgery, New York Methodist Hospital, Brooklyn, New York. Corresponding Author: Dr John G. Hunter, 47 East 63rd St, New York, NY 10065, USA. E-mail: [email protected]
Downloaded from http://asj.oxfordjournals.org/ by guest on September 28, 2015
Surgical site infections (SSI) remain the second most common type of hospital-acquired infection (after urinary tract infections). Prophylactic antimicrobial use has been demonstrated to reduce SSI rates for many surgical procedures. Prevention of SSI remains a Joint Commission National Patient Safety Goal.1,2 The indications, efficacy, and proper utilization of systemic prophylactic antimicrobial agents to reduce SSI incidence have been debated in the surgical literature for many years. The appropriate use of prophylactic antibiotics in plastic surgery has been discussed by others in this journal and elsewhere.2-5 With this interesting article evaluating prophylactic antimicrobial use in outpatient plastic surgical procedures, Anigian and colleagues6 contribute to this ongoing conversation. A significant limitation of available literature on antimicrobial prophylaxis is the difficulty in establishing statistically significant differences in efficacy between the prophylactic agent(s) utilized and control groups due to study design issues, as well as a low SSI rate for most surgical procedures. Ideally, a study should be placebo controlled and randomized with a sufficient sample size in each group to avoid type II error. Such publications are uncommon. Furthermore, based on “expert opinion,” antimicrobial prophylaxis is occasionally recommended in some circumstances (ie, consequence of SSI occurrence especially dire, such as after total joint replacement), even though efficacy has not been established.7 The efficacy of antimicrobial prophylaxis in select plastic surgery procedures has been investigated in several clinical trials and cohort studies. Most placebo-controlled and retrospective studies for many clean plastic surgery procedures have found, as Anigian et al6 indicate, that antimicrobial prophylaxis does not reduce SSI incidence. A randomized, double-blind controlled trial of 207 patients undergoing abdominoplasty, however, demonstrated a significantly lower infection rate in those receiving preoperative antibiotic only compared with a placebo group.7,8
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1. Antimicrobial prophylaxis is not recommended for most clean procedures in patients without additional postoperative risk factors (delineated in the publication). 2. Although no studies have demonstrated antimicrobial efficacy in these procedures, expert opinion recommends that patients with risk factors undergoing clean plastic surgery procedures receive antimicrobial prophylaxis (insertion of expanders and implants constitutes a risk factor). 3. Patients undergoing clean-contaminated procedures, breast cancer procedures, or clean procedures with other risk factors should receive a single dose of cefazolin or ampicillin/sulbactam (strength of evidence = C). 4. Alternative agents for patients with allergies to β-lactam include clindamycin and vancomycin.
5. For procedures in which SSI has been associated with gram-negative organisms, consider combining clindamycin or vancomycin with another agent— cefazolin—if the patient is not allergic to β-lactam; if he or she is allergic to β-lactam, consider aztreonam, gentamicin, or fluoroquinolone. 6. Postoperative duration of antimicrobial prophylaxis should be limited to 24 hours, regardless of the presence of indwelling drains (or implants). Anigian and colleagues6 have added to the growing literature supporting rational use of prophylactic antibiotics in plastic surgery.
Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
References 1. Burke JP. Infection control: a problem for patient safety. N Engl J Med. 2003;348:651-656. 2. Hunter JG. Appropriate prophylactic antibiotic use in plastic surgery: the time has come. Plast Reconstr Surg. 2007;120:1732-1734. 3. Lyle WG, Outlaw K, Krizek TJ, et al. Prophylactic antibiotics in plastic surgery: trends of use over 25 years of an evolving specialty. Aesthetic Surg J. 2003;23:177-183. 4. Rohrich RJ, Rios JL. The role of prophylactic antibiotics in plastic surgery: whom are we treating? Plast Reconstr Surg. 2003;112:617-618. 5. Perrotti JA, Castor SA, Perez PC, Zins JE. Antibiotic use in aesthetic surgery: a national survey and literature review. Plast Reconstr Surg. 2002;109:1685-1693. 6. Anigian KT, Miller T, Constantine RS, et al. Prophylactic antibiotic use in plastic surgery outpatient cases. Aesthetic Surg J. 2014;34(8) 1252–1258. 7. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guideline for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70:195-283. 8. Sevin A, Senen D, Sevin K, et al. Antibiotic use in abdominoplasty: prospective analysis of 207 cases. J Plast Reconstr Aesthetic Surg. 2007;60:379-382. 9. Khan UD. Breast augmentation, antibiotic prophylaxis and infection: comparative analysis of 1628 primary augmentation mammaplasties assessing the role and efficacy of antibiotic prophylaxis duration. Aesthetic Plast Surg. 2010;34:42-47.
Downloaded from http://asj.oxfordjournals.org/ by guest on September 28, 2015
surgery), under widely accepted dosing practices, may not achieve sufficient serum and tissue levels to exceed the MIC for the most common pathogens encountered at surgery. The latest ASHP recommendation for cefazolin calls for administration of 2 g for patients weighing >80 kg and 3 g for those weighing >120 kg. A 1-g cefazolin dose is no longer considered adequate prophylaxis for almost any adult patient.7 Bratzler et al7 also state that multiple studies do not support the extended continuation of prophylactic antibiotics when drains or implants are inserted. Multiple studies have found no significant differences in SSI rates after breast surgery with single-dose preoperative cephalosporin administration compared with regimens continuing prophylaxis for 1 to 5 days postoperatively.7,9 The findings by Anigian et al6 also support the belief that there is little if any justification for extended-duration prophylaxis antibiotic use. Anigian and colleagues6 are to be commended for thoughtfully analyzing the University of Texas Southwestern Medical Center’s prophylactic antibiotic utilization practices and patterns for outpatient plastic surgical procedures and the impact on outcomes. Hopefully, the findings led the group to minimize the variance in its prophylaxis practices evident in the study. A minor criticism, acknowledged by the authors, was the decision to aggregate a number of wound-related complications in the analysis rather than just infectious complications. The 2013 ASHP Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery,7 specifically for plastic surgery procedures, include the following:
Aesthetic Surgery Journal 34(8)
AESXXX10.1177/1090820X14535802Aesthetic Surgery JournalHunter
Research Commentary
Commentary on: Effectiveness of Prophylactic Antibiotics in Outpatient Plastic Surgery
Aesthetic Surgery Journal 2014, Vol. 34(8) 1259–1260 © 2014 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www. sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X14535802 www.aestheticsurgeryjournal.com
John G. Hunter, MD, MMM, CPE, FACS
Successful prophylaxis requires the adequate delivery of the agent to the operative site before the incision is made. The antimicrobial should be administered within the time frame needed to achieve serum and tissue concentrations that exceed the minimum inhibitory concentration (MIC) for the pathogens likely to be present. Adequate serum and tissue levels should be maintained for the entire time the surgical site is open.7 As the authors indicate, current quality measures and practice guidelines, promulgated by the Surgical Care Improvement Project, Centers for Disease Control and Prevention, and others, recommend administration of the first prophylaxis dose beginning within 60 minutes of surgical incision (120 minutes for vancomycin and fluoroquinolones since they require slow infusion) to achieve ideal serum and tissue concentration levels. As Anigian et al6 reference, recent literature suggests increased prophylaxis effect occurs with antimicrobial administration within 30 minutes before incision, and conflicting data also suggest that administration can be too close to an incision, resulting in a higher infection rate. Bratzler et al,7 in recently updated, authoritative surgical antimicrobial prophylaxis guidelines (developed jointly by the American Society of Health-System Pharmacists [ASHP], the Infectious Disease Society of America, the Surgical Infection Society, and the Society for Healthcare Epidemiology of America) state that the data offered in these reports are “not convincing” or “sufficiently robust” to recommend changing current antimicrobial administration timing recommendations. Interestingly, the updated guidelines report that cefazolin (the most commonly used prophylactic antibiotic in plastic Dr Hunter is an Associate Attending Plastic Surgeon, New YorkPresbyterian Hospital (Weill Cornell Campus), New York, New York, and Vice Chairman, Department of Surgery, and Chief of Plastic Surgery, New York Methodist Hospital, Brooklyn, New York. Corresponding Author: Dr John G. Hunter, 47 East 63rd St, New York, NY 10065, USA. E-mail: [email protected]
Downloaded from http://asj.oxfordjournals.org/ by guest on September 28, 2015
Surgical site infections (SSI) remain the second most common type of hospital-acquired infection (after urinary tract infections). Prophylactic antimicrobial use has been demonstrated to reduce SSI rates for many surgical procedures. Prevention of SSI remains a Joint Commission National Patient Safety Goal.1,2 The indications, efficacy, and proper utilization of systemic prophylactic antimicrobial agents to reduce SSI incidence have been debated in the surgical literature for many years. The appropriate use of prophylactic antibiotics in plastic surgery has been discussed by others in this journal and elsewhere.2-5 With this interesting article evaluating prophylactic antimicrobial use in outpatient plastic surgical procedures, Anigian and colleagues6 contribute to this ongoing conversation. A significant limitation of available literature on antimicrobial prophylaxis is the difficulty in establishing statistically significant differences in efficacy between the prophylactic agent(s) utilized and control groups due to study design issues, as well as a low SSI rate for most surgical procedures. Ideally, a study should be placebo controlled and randomized with a sufficient sample size in each group to avoid type II error. Such publications are uncommon. Furthermore, based on “expert opinion,” antimicrobial prophylaxis is occasionally recommended in some circumstances (ie, consequence of SSI occurrence especially dire, such as after total joint replacement), even though efficacy has not been established.7 The efficacy of antimicrobial prophylaxis in select plastic surgery procedures has been investigated in several clinical trials and cohort studies. Most placebo-controlled and retrospective studies for many clean plastic surgery procedures have found, as Anigian et al6 indicate, that antimicrobial prophylaxis does not reduce SSI incidence. A randomized, double-blind controlled trial of 207 patients undergoing abdominoplasty, however, demonstrated a significantly lower infection rate in those receiving preoperative antibiotic only compared with a placebo group.7,8
1260
1. Antimicrobial prophylaxis is not recommended for most clean procedures in patients without additional postoperative risk factors (delineated in the publication). 2. Although no studies have demonstrated antimicrobial efficacy in these procedures, expert opinion recommends that patients with risk factors undergoing clean plastic surgery procedures receive antimicrobial prophylaxis (insertion of expanders and implants constitutes a risk factor). 3. Patients undergoing clean-contaminated procedures, breast cancer procedures, or clean procedures with other risk factors should receive a single dose of cefazolin or ampicillin/sulbactam (strength of evidence = C). 4. Alternative agents for patients with allergies to β-lactam include clindamycin and vancomycin.
5. For procedures in which SSI has been associated with gram-negative organisms, consider combining clindamycin or vancomycin with another agent— cefazolin—if the patient is not allergic to β-lactam; if he or she is allergic to β-lactam, consider aztreonam, gentamicin, or fluoroquinolone. 6. Postoperative duration of antimicrobial prophylaxis should be limited to 24 hours, regardless of the presence of indwelling drains (or implants). Anigian and colleagues6 have added to the growing literature supporting rational use of prophylactic antibiotics in plastic surgery.
Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
References 1. Burke JP. Infection control: a problem for patient safety. N Engl J Med. 2003;348:651-656. 2. Hunter JG. Appropriate prophylactic antibiotic use in plastic surgery: the time has come. Plast Reconstr Surg. 2007;120:1732-1734. 3. Lyle WG, Outlaw K, Krizek TJ, et al. Prophylactic antibiotics in plastic surgery: trends of use over 25 years of an evolving specialty. Aesthetic Surg J. 2003;23:177-183. 4. Rohrich RJ, Rios JL. The role of prophylactic antibiotics in plastic surgery: whom are we treating? Plast Reconstr Surg. 2003;112:617-618. 5. Perrotti JA, Castor SA, Perez PC, Zins JE. Antibiotic use in aesthetic surgery: a national survey and literature review. Plast Reconstr Surg. 2002;109:1685-1693. 6. Anigian KT, Miller T, Constantine RS, et al. Prophylactic antibiotic use in plastic surgery outpatient cases. Aesthetic Surg J. 2014;34(8) 1252–1258. 7. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guideline for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70:195-283. 8. Sevin A, Senen D, Sevin K, et al. Antibiotic use in abdominoplasty: prospective analysis of 207 cases. J Plast Reconstr Aesthetic Surg. 2007;60:379-382. 9. Khan UD. Breast augmentation, antibiotic prophylaxis and infection: comparative analysis of 1628 primary augmentation mammaplasties assessing the role and efficacy of antibiotic prophylaxis duration. Aesthetic Plast Surg. 2010;34:42-47.
Downloaded from http://asj.oxfordjournals.org/ by guest on September 28, 2015
surgery), under widely accepted dosing practices, may not achieve sufficient serum and tissue levels to exceed the MIC for the most common pathogens encountered at surgery. The latest ASHP recommendation for cefazolin calls for administration of 2 g for patients weighing >80 kg and 3 g for those weighing >120 kg. A 1-g cefazolin dose is no longer considered adequate prophylaxis for almost any adult patient.7 Bratzler et al7 also state that multiple studies do not support the extended continuation of prophylactic antibiotics when drains or implants are inserted. Multiple studies have found no significant differences in SSI rates after breast surgery with single-dose preoperative cephalosporin administration compared with regimens continuing prophylaxis for 1 to 5 days postoperatively.7,9 The findings by Anigian et al6 also support the belief that there is little if any justification for extended-duration prophylaxis antibiotic use. Anigian and colleagues6 are to be commended for thoughtfully analyzing the University of Texas Southwestern Medical Center’s prophylactic antibiotic utilization practices and patterns for outpatient plastic surgical procedures and the impact on outcomes. Hopefully, the findings led the group to minimize the variance in its prophylaxis practices evident in the study. A minor criticism, acknowledged by the authors, was the decision to aggregate a number of wound-related complications in the analysis rather than just infectious complications. The 2013 ASHP Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery,7 specifically for plastic surgery procedures, include the following:
Aesthetic Surgery Journal 34(8)
