Why Are Antibiotics Given Before Cutaneous Surgery?

What are prophylactic antibiotics?

Prophylactic or preemptive antibiotic treatments are administered prior to skin surgery in people who have compromised immunity or other conditions that make them prone to infection.

Prophylactic antibiotics are antimicrobial medications administered to prevent possible infection that may result from exposure to microorganisms during certain medical procedures. Prophylactic antibiotics are administered as a preemptive measure, mostly to people who are at a high risk for a potential infection.

When should antibiotics be given for cutaneous surgery?

Prophylactic antibiotics are usually given as a single intravenous dose approximately an hour before the procedure so that the tissues are adequately infiltrated with the antibiotic when surgery begins. Surgeries that take longer than four hours may require additional antibiotic doses.

Prophylactic antibiotics are generally discontinued within 24 hours after completion of surgery. Some patients may, however, require postoperative treatment with antibiotics if the surgical wound develops an infection.

Why are antibiotics given before skin (cutaneous) surgery?

Antibiotics are given before a dermatologic surgery because the tissue and blood vessels under the skin are exposed to microbes when a skin incision is made. Use of antibiotics before a cutaneous surgery is particularly important for patients who are immune-compromised or otherwise face a high risk from infections.

Skin is the first-line defense against germs and forms a barrier against harmful pathogens from the environment. Skin harbors several bacteria species (skin flora), both resident and transient. Even though antiseptic scrubbing can reduce the skin flora, approximately 20% remain on the skin. These otherwise harmless microbes — some are even beneficial in normal circumstances — may become deadly when they enter exposed tissue and the bloodstream.

Are antibiotics necessary before cutaneous surgery?

Not everyone requires antibiotics before a clean cutaneous surgery. Most dermatologic procedures are of short duration and have a low infection risk in healthy people.

When prophylactic antibiotics are used for skin surgery in mostly healthy people, it’s usually because an incision is necessary in the mucous membranes of the mouth, throat or sinuses. It is not possible to adequately sterilize these tissues with topical antibacterial agents.

The use of antibiotics in cutaneous surgery should be individualized and given after evaluating the potential for infection and the risk for development of antibiotic-resistant organisms.

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Who should be given antibiotics before a cutaneous surgery?

Antibiotics are essential for certain patients who are at a higher risk for developing infections from bacteria in the bloodstream (bacteremia). Following are the primary reasons for antibiotic use before cutaneous surgery:

Prevention of infective endocarditis

Endocarditis is the infection of the inner heart tissue (endocardium), which is an uncommon but potentially life-threatening condition that can result from a surgical site infection. People at risk for infective endocarditis include patients who have:

Prosthetic heart valves
Had a cardiac repair surgery with prosthetic material
Congenital heart disease
History of infective endocarditis
History of cardiac transplantation

Prevention of hematogenous total joint infection

Some patients who have total joint replacements are at high risk for developing infection in the prosthetic joints from bacteremia. Patients with prosthetic joints who are at high risk include those who also:

Have a history of inflammatory arthropathies (joint diseases)
Have a history of prosthetic joint infection

People who are immune compromised

Some diseases make it easier to contract an infection, conditions such as:

Malignancy
Human immunodeficiency virus (HIV) infection
Are under immunosuppression for treatment of a disease
Have type I diabetes
Are malnourished
Have a bleeding disorder (hemophilia)

Prevention of surgical site infection

The chances of surgical site infection from a cutaneous surgery is very low in most people if rigorous hygiene is followed during and after the procedure. Still, some bacteria may still enter the wound through skin cells or aerosolized water droplets, but a healthy immune system can fight these bacteria successfully.

The risk factors for surgical site infections include the following:

Patient-related risks
Skin condition and location of the procedure
Pre-existing bacterial infection
Obesity
Malnutrition
Advanced age
Diabetes mellitus
Kidney disease
Immunosuppression
Corticosteroid use
Tobacco use
Alcohol use
Concurrent other infections
Transfusion of blood products
Environment-related risks
Length of the procedure
Complexity of skin reconstruction
Preoperative antiseptic showering and hair removal
Surgical technique used
History of hospitalization prior to surgery
Treatment of wound infection

Antibiotics are used after a cutaneous procedure usually only if an infection develops. The symptoms of wound infection include:

Redness
Swelling
Pain and/or warmth
Pus formation (purulence)

Treatment of wound infection usually requires antibiotics that are also active against methicillin-resistant Staphylococcus aureus (MRSA).

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Are antibiotics necessary after Mohs surgery?

Mohs micrographic surgery is a procedure to remove cancerous lesions in the skin. Mohs surgery is a sterile procedure and is safe for most people, but patients with high risk for infection may require antibiotics.

Risk factors from Mohs surgery include:

Area of procedure: Some areas on the skin carry a higher infection risk, which include:
- Nose
- Ears
- Mucous membrane
- Below the knees
Complexity of procedure: Infection risks can go up in procedures that involve:
- Large lesions
- Multiple stages of tissue excision
- Multiple lesion sites
- Prolonged duration
- Wound closure with flap or graft

What antibiotics are given before cutaneous surgery?

The selection of antibiotic prophylaxis before a cutaneous surgery is based on the most likely organisms that can cause an infection from the specific procedure. Infections after a cutaneous surgery are most often from Staphylococcus or Streptococcus species which are usually found on the skin, though not restricted to those.

First-line antibiotics are usually penicillin or cephalosporin:
- Penicillin
  - Amoxicillin
  - Ampicillin
  - Dicloxacillin
- Cephalosporin
  - Cephalexin
  - Cefazolin
  - Ceftriaxone
  - Trimethoprim–sulfamethoxazole
Following are some of the antibiotics that may be used for penicillin-allergic patients:
- Clindamycin
- Erythromycin
- Azithromycin
- Ciprofloxacin
- Vancomycin (intravenous for MRSA)