Perioperative use of antibiotics: preventing and treating perioperative infections

Prevention of postoperative wound infection in dermatologic surgery and appropriate use of antibiotics to prevent endocarditis and joint-replacement infections are controversial issues. Dermatologists often may misunderstand the use of antibiotics to prevent endocarditis, surgical site infections, and prosthesis infections. In order to prevent endocarditis associated with surgical procedures, the American Heart Association (AHA) has developed clinical practice guidelines that apply to surgical patients with prosthetic cardiac valves, previous bacterial endocarditis, mitral valve prolapse with valvular regurgitation, or thickened leaflets. For these patients, the AHA recommends that antistaphylococcal antibiotics (eg, cephalosporins) be given before surgery only when the procedure involves significant risk of bacteremia (eg, incision into infected tissues). Routine dermatologic surgery of intact skin with sterile technique usually does not require prophylaxis. Antibiotic prophylaxis may also be justified in surgical patients who are at moderate to high risk for wound site infection. Patients should be given prophylactic antibiotics shortly before surgery or as soon as the risk is recognized. In patients allergic to penicillin, cross reactions are unlikely for most second- and third-generation agents (cefdinir, cefuroxime, cefixime, ceftibuten), because these agents lack a side chain similar to penicillin. By identifying the risk of infection, being aware of the risks of antibiotic therapy, and weighing the risks and benefits of each option, dermatologists can devise individualized treatments, thus optimizing outcomes of their patients.