A Comprehensive Review of Guidelines for Antimicrobial ...



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 evidence1-3 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 evidence |Types of procedures |

|Category A |Hand and upper extremity: |

|(Evidence from well-conducted PRCT, |Elective surgery using K-wires, implants or with a length over 2 hours4, 5 |

|controlled clinical trials, meta-analysis |Emergency surgery: as above, and all dirty wounds, all clean wounds with more than 6 hour delay before |

|and cohort studies) |surgery, and all open fractures4-7 |

| |Head and neck: |

| |Oncologic surgery8, 9 |

| |Skin cancer surgery9 |

| |Septorhinoplasty10 |

| |Burns |

| |Skin grafting11 |

| |Microsurgery: |

| |Replantation / Revascularisation12 |

| |Free flaps12 |

| |Breast: |

| |Reconstruction13 |

Table 2. Category A evidence against the use of antimicrobial prophylaxis in plastic surgery

|Strength of evidence |Types of procedures |

|Category A |Hand and upper extremity: |

|(Evidence from well-conducted PRCT, controlled |Elective surgery not using K-wires or implants4, 5 |

|clinical trials, meta-analysis and cohort studies) |Open fractures of the phalanx14-16 |

| |Lacerations excluding fractures5, 16-19 |

| |Head and neck: |

| |Cleft lip and palate12 |

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

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.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download