American Journal of Clinical Dermatology

, Volume 11, Issue 1, pp 35–44 | Cite as

Antibacterial Prophylaxis in Dermatologic Surgery

An Evidence-Based Review
Review Article Antibacterial Prophylaxis in Dermatologic Surgery


Clean, non-contaminated skin surgery is associated with low rates of surgical site infection (SSI), bacterial endocarditis, and joint prosthesis infection. Hence, antibacterial prophylaxis, which may be associated with adverse effects, the emergence of multidrug-resistant pathogens, and anaphylaxis, is generally not recommended in dermatologic surgery. Some body sites and surgical reconstructive procedures are associated with higher infection rates, and guidelines for SSI antibacterial prophylaxis have been proposed for these cases. Large prospective, controlled trials are needed to ascertain the role of oral SSI prophylaxis for these surgical sites and procedures especially in patients with diabetes mellitus who are intrinsically at greater risk of SSI. Topical antibacterial ointment and sterile paraffin appear to make no difference to healing or the incidence of SSIs in clean wounds. Although further research is needed, preliminary studies have shown that intraincisional antibacterials, which may be associated with fewer adverse effects and a lower risk of multidrug-resistant bacteria, could potentially be helpful for SSI prophylaxis. Trials using honey- and silver-impregnated dressings have found no advantage in the healing of chronic wounds. However, several case studies, which need corroboration in larger studies, suggest that these dressings may be helpful in preventing and treating SSIs.

Bacterial endocarditis and joint prosthesis infection prophylaxis are not routinely recommended in cutaneous surgery. The updated 2007 American Heart Association guidelines now advocate bacterial endocarditis prophylaxis for high-risk cardiac patients having surgery involving the oral mucosa or infected skin. The latest American Dental Association/American Academy of Orthopaedic Surgery guidelines recommend considering antibacterial prophylaxis for oral procedures where bleeding is anticipated and for surgery involving acute orofacial skin infections if the patient has had a total joint replacement within 2 years or is in a high-risk group and has had a joint replacement at any time.


  1. 1.
    Maragh SL, Otley CC, Roenigk RK, et al. Antibiotic prophylaxis in dermatologic surgery: updated guidelines. Dermatol Surg 2005; 31: 83–91PubMedCrossRefGoogle Scholar
  2. 2.
    Wright TI, Baddour LM, Berbari EF, et al. Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008. J Am Acad Dermatol 2008; 59: 464–73PubMedCrossRefGoogle Scholar
  3. 3.
    Messingham MJ, Arpey CJ. Update on the use of antibiotics in cutaneous surgery. Dermatol Surg 2005; 31: 1068–78PubMedCrossRefGoogle Scholar
  4. 4.
    Hirschmann JV. Antimicrobial prophylaxis in dermatologic surgery. Cutis 2007; 79: 43–51PubMedGoogle Scholar
  5. 5.
    Moorhead C, Torres A. I PREVENT bacterial resistance: an update on the use of antibiotics in dermatologic surgery. Dermatol Surg 2009 Oct; 35 (10): 1532–8PubMedCrossRefGoogle Scholar
  6. 6.
    Scheinfeld N, Struach S, Ross B. Antibiotic prophylaxis guideline awareness and antibiotic prophylaxis use among New York State dermatologic surgeons. Dermatol Surg 2002; 28: 841–4PubMedCrossRefGoogle Scholar
  7. 7.
    George PM. Dermatologists and antibiotic prophylaxis: a survey. J Am Acad Dermatol 1995; 33: 418–21PubMedCrossRefGoogle Scholar
  8. 8.
    Peled IJ, Dvir G, Berger J, et al. Prophylactic antibiotics in aesthetic and reconstructive surgery. Aesthetic Plast Surg 2000; 24: 299–302PubMedCrossRefGoogle Scholar
  9. 9.
    Rabb DC, Lesher Jr JL. Antibiotic prophylaxis in cutaneous surgery. Dermatol Surg 1995; 21: 550–4PubMedCrossRefGoogle Scholar
  10. 10.
    Campbell RM, Perlis CS, Fisher E, et al. Gentamicin ointment versus petrolatum for management of auricular wounds. Dermatol Surg 2005; 31: 664–9PubMedCrossRefGoogle Scholar
  11. 11.
    Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki DiseaseCommittee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 116: 1736–54PubMedCrossRefGoogle Scholar
  12. 12.
    Antibiotic prophylaxis for dental patients with total joint replacements. J Am Dent Assoc 2003; 134: 895–9Google Scholar
  13. 13.
    Berbari EF, Hanssen AD, Duffy MC, et al. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis 1998; 27: 1247–54PubMedCrossRefGoogle Scholar
  14. 14.
    Maderazo EG, Judson S, Pasternak H. Late infections of total joint prostheses: a review and recommendations for prevention. Clin Orthop Relat Res 1988; (229): 131–42PubMedGoogle Scholar
  15. 15.
    Ainscow DA, Denham RA. The risk of haematogenous infection in total joint replacements. J Bone Joint Surg Br 1984; 66: 580–2PubMedGoogle Scholar
  16. 16.
    Lacassin F, Hoen B, Leport C, et al. Procedures associated with infective endocarditis in adults: a case control study. Eur Heart J 1995; 16: 1968–74PubMedGoogle Scholar
  17. 17.
    Strom BL, Abrutyn E, Berlin JA, et al. Risk factors for infective endocarditis: oral hygiene and nondental exposures. Circulation 2000; 102: 2842–8PubMedCrossRefGoogle Scholar
  18. 18.
    Dixon AJ, Dixon MP, Askew DA, et al. Prospective study of wound infections in dermatologic surgery in the absence of prophylactic antibiotics. Dermatol Surg 2006; 32: 819–26; discussion 826-7PubMedCrossRefGoogle Scholar
  19. 19.
    Rogues AM, Lasheras A, Amici JM, et al. Infection control practices and infectious complications in dermatological surgery. J Hosp Infect 2007; 65: 258–63PubMedCrossRefGoogle Scholar
  20. 20.
    Futoryan T, Grande D. Postoperative wound infection rates in dermatologic surgery. Dermatol Surg 1995; 21: 509–14PubMedCrossRefGoogle Scholar
  21. 21.
    Sticha RS, Swiriduk D, Wertheimer SJ. Prospective analysis of postoperative wound infections using an early exposure method of wound care. J Foot Ankle Surg 1998; 37: 286–91PubMedCrossRefGoogle Scholar
  22. 22.
    Murphy PG, Tadros E, Cross S, et al. Skin closure and the incidence of groin wound infection: a prospective study. Ann Vasc Surg 1995; 9: 480–2PubMedCrossRefGoogle Scholar
  23. 23.
    Heal C, Buettner P, Raasch B, et al. Can sutures get wet? Prospective randomised controlled trial of wound management in general practice. BMJ 2006; 332: 1053–6PubMedCrossRefGoogle Scholar
  24. 24.
    Cook JL, Perone JB. A prospective evaluation of the incidence of complications associated with Mohs micrographic surgery. Arch Dermatol 2003; 139: 143–52PubMedCrossRefGoogle Scholar
  25. 25.
    Zitelli JA. Secondary intention healing: an alternative to surgical repair. Clin Dermatol 1984; 2: 92–106PubMedCrossRefGoogle Scholar
  26. 26.
    Lawson C, Juliano L, Ratliff CR. Does sterile or nonsterile technique make a difference in wounds healing by secondary intention? Ostomy Wound Manage 2003; 49: 56–8, 60PubMedGoogle Scholar
  27. 27.
    Smack DP, Harrington AC, Dunn C, et al. Infection and allergy incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment: a randomized controlled trial. JAMA 1996; 276: 972–7PubMedCrossRefGoogle Scholar
  28. 28.
    Heal C, Buettner P, Browning S. Risk factors for wound infection after minor surgery in general practice. Med J Aust 2006; 185: 255–8PubMedGoogle Scholar
  29. 29.
    Sylaidis P, Wood S, Murray DS. Postoperative infection following clean facial surgery. Ann Plast Surg 1997; 39: 342–6PubMedCrossRefGoogle Scholar
  30. 30.
    Wasserberg N, Tulchinsky H, Schachter J, et al. Sentinel-lymph-node biopsy (SLNB) for melanoma is not complication-free. Eur J Surg Oncol 2004; 30: 851–6PubMedCrossRefGoogle Scholar
  31. 31.
    Horan TC, Gaynes RP, Martone WJ, et al. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992; 13: 606–8PubMedCrossRefGoogle Scholar
  32. 32.
    Garner JS. CDC guideline for prevention of surgical wound infections, 1985. Infect Control 1986; 7: 193–200PubMedGoogle Scholar
  33. 33.
    Hirschmann JV. Antimicrobial prophylaxis in dermatology. Semin Cutan Med Surg 2000; 19: 2–9PubMedCrossRefGoogle Scholar
  34. 34.
    Haas AF, Grekin RC. Antibiotic prophylaxis in dermatologic surgery. J Am Acad Dermatol 1995; 32: 155–76; quiz 177-80PubMedCrossRefGoogle Scholar
  35. 35.
    Garner JS, Jarvis WR, Emori TG, et al. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988; 16: 128–40PubMedCrossRefGoogle Scholar
  36. 36.
    Bruce J, Russell EM, Mollison J, et al. The quality of measurement of surgical wound infection as the basis for monitoring: a systematic review. J Hosp Infect 2001; 49: 99–108PubMedCrossRefGoogle Scholar
  37. 37.
    Mangram AJ, Horan TC, Pearson ML, et al. Guideline for Prevention of Surgical Site Infection, 1999: Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999; 27: 97–132; quiz 133-4; discussion 96PubMedCrossRefGoogle Scholar
  38. 38.
    Roth RR, James WD. Microbiology of the skin: resident flora, ecology, infection. J Am Acad Dermatol 1989; 20: 367–90PubMedCrossRefGoogle Scholar
  39. 39.
    National Nosocomial Infections Surveillance (NNIS) report, data summary from October 1986-April 1997, issued May 1997. A report from the NNIS System. Am J Infect Control 1997; 25: 477–87Google Scholar
  40. 40.
    Malone DL, Genuit T, Tracy JK, et al. Surgical site infections: reanalysis of risk factors. J Surg Res 2002; 103: 89–95PubMedCrossRefGoogle Scholar
  41. 41.
    Bumpous JM, Johnson JT. The infected wound and its management. Otolaryngol Clin North Am 1995; 28: 987–1001PubMedGoogle Scholar
  42. 42.
    Olsen MA, Lock-Buckley P, Hopkins D, et al. The risk factors for deep and superficial chest surgical-site infections after coronary artery bypass graft surgery are different. J Thorac Cardiovasc Surg 2002; 124: 136–45PubMedCrossRefGoogle Scholar
  43. 43.
    Dixon AJ, Dixon MP, Dixon JB, et al. Prospective study of skin surgery in smokers vs. nonsmokers. Br J Dermatol 2000 Feb; 160 (2): 365–7CrossRefGoogle Scholar
  44. 44.
    Dixon AJ, Dixon MP, Dixon JB. Prospective study of skin surgery in patients with and without known diabetes. Dermatol Surg 2009 Jul; 35: 1035–40PubMedCrossRefGoogle Scholar
  45. 45.
    Demir F. A survey on prevention of surgical infections in operating theatres. Worldviews Evid Based Nurs 2009; 6 (2): 102–13PubMedCrossRefGoogle Scholar
  46. 46.
    Astagneau P, L’Hériteau F, Daniel F, et al. Reducing surgical site infection incidence through a network: results from the French ISO-RAISIN surveillance system. J Hosp Infect 2009 Jun; 72 (2): 127–34PubMedCrossRefGoogle Scholar
  47. 47.
    Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2006; (3): CD004122Google Scholar
  48. 48.
    Amici JM, Rogues AM, Lasheras A, et al. A prospective study of the incidence of complications associated with dermatological surgery. Br J Dermatol 2005; 153: 967–71PubMedCrossRefGoogle Scholar
  49. 49.
    Leaper DJ. Silver dressings: their role in wound management. Int Wound J 2006; 3: 282–94PubMedCrossRefGoogle Scholar
  50. 50.
    Vermeulen H, van Hattem JM, Storm-Versloot MN, et al. Topical silver for treating infected wounds. Cochrane Database Syst Rev 2007; (1): CD005486Google Scholar
  51. 51.
    Collier M. Silver dressings: more evidence is needed to support their widespread clinical use. J Wound Care 2009 Feb; 18 (2): 77–8PubMedGoogle Scholar
  52. 52.
    Childress BB, Berceli SA, Nelson PR, et al. Impact of an absorbent silvereluting dressing system on lower extremity revascularization wound complications. Ann Vasc Surg 2007; 21: 598–602PubMedCrossRefGoogle Scholar
  53. 53.
    Lay-Flurrie K. Honey in wound care: effects, clinical application and patient benefit. Br J Nurs 2008; 17: S30, S32-6Google Scholar
  54. 54.
    Visavadia BG, Honeysett J, Danford MH. Manuka honey dressing: an effective treatment for chronic wound infections. Br J Oral Maxillofac Surg 2008; 46: 55–6PubMedCrossRefGoogle Scholar
  55. 55.
    Blaser G, Santos K, Bode U, et al. Effect of medical honey onwounds colonised or infected with MRSA. J Wound Care 2007; 16: 325–8PubMedGoogle Scholar
  56. 56.
    Jull A, Walker N, Parag V, et al. Randomized clinical trial of honeyimpregnated dressings for venous leg ulcers. Br J Surg 2008; 95: 175–82PubMedCrossRefGoogle Scholar
  57. 57.
    Moy RL, Grossfeld JS, Baum M, et al. Reconstruction of the nose utilizing a bilobed flap. Int J Dermatol 1994; 33: 657–60PubMedCrossRefGoogle Scholar
  58. 58.
    Garland R, Frizelle FA, Dobbs BR, et al. A retrospective audit of long-term lower limb complications following leg vein harvesting for coronary artery bypass grafting. Eur J Cardiothorac Surg 2003; 23: 950–5PubMedCrossRefGoogle Scholar
  59. 59.
    Burke JP. Maximizing appropriate antibiotic prophylaxis for surgical patients: an update from LDS Hospital, Salt Lake City. Clin Infect Dis 2001; 33 Suppl. 2: S78–83CrossRefGoogle Scholar
  60. 60.
    Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992; 326: 281–6PubMedCrossRefGoogle Scholar
  61. 61.
    Nichols RL. Antibiotic prophylaxis in surgery. J Chemother 1989; 1: 170–8PubMedGoogle Scholar
  62. 62.
    Eaglstein WH. Moist wound healing with occlusive dressings: a clinical focus. Dermatol Surg 2001; 27: 175–81PubMedCrossRefGoogle Scholar
  63. 63.
    Hutchinson JJ, Lawrence JC. Wound infection under occlusive dressings. J Hosp Infect 1991; 17: 83–94PubMedCrossRefGoogle Scholar
  64. 64.
    Mertz PM, Marshall DA, Eaglstein WH. Occlusive wound dressings to prevent bacterial invasion and wound infection. J Am Acad Dermatol 1985; 12: 662–8PubMedCrossRefGoogle Scholar
  65. 65.
    Merei JM. Pediatric clean surgical wounds: is dressing necessary? J Pediatr Surg 2004; 39: 1871–3PubMedCrossRefGoogle Scholar
  66. 66.
    Eaglstein WH. Effect of occlusive dressings on wound healing. Clin Dermatol 1984; 2: 107–11PubMedCrossRefGoogle Scholar
  67. 67.
    Eaglstein WH. Occlusive dressings. J Dermatol Surg Oncol 1993; 19: 716–20PubMedGoogle Scholar
  68. 68.
    Slater M. Does moist wound healing influence the rate of infection? Br J Nurs 2008 Nov 13-26; 17 (20): S4–15Google Scholar
  69. 69.
    Kamath S, Sinha S, Shaari E, et al. Role of topical antibiotics in hip surgery: a prospective randomised study. Injury 2005; 36: 783–7PubMedCrossRefGoogle Scholar
  70. 70.
    Eedy DJ, Breathnach SM, Walker NPJ. Surgical dermatology. Oxford: Blackwell Science, 1996: 13–34Google Scholar
  71. 71.
    Czarnecki DB, Nash CG, Bohl TG. The use of mupirocin before skin surgery. Int J Dermatol 1991; 30: 218–9PubMedCrossRefGoogle Scholar
  72. 72.
    Dixon AJ, Dixon MP, Dixon JB. Randomized clinical trial of the effect of applying ointment to surgical wounds before occlusive dressing. Br J Surg 2006; 93: 937–43PubMedCrossRefGoogle Scholar
  73. 73.
    Gehrig KA, Warshaw EM. Allergic contact dermatitis to topical antibiotics: Epidemiology, responsible allergens, and management. J Am Acad Dermatol 2008; 58 (1): 1–21PubMedCrossRefGoogle Scholar
  74. 74.
    Heal CF, Buettner PG, Cruickshank R, et al. Does single application of topical chloramphenicol to high risk sutured wounds reduce incidence of wound infection after minor surgery? Prospective randomised placebo controlled double blind trial. BMJ 2009; 338: a2812Google Scholar
  75. 75.
    Perl TM. Prevention of Staphylococcus aureus infections among surgical patients: beyond traditional perioperative prophylaxis. Surgery 2003; 134: S10–7CrossRefGoogle Scholar
  76. 76.
    Perl TM, Golub JE. New approaches to reduce Staphylococcus aureus nosocomial infection rates: treating S. aureus nasal carriage. Ann Pharmacother 1998; 32: S7–16Google Scholar
  77. 77.
    Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev 1997; 10: 505–20PubMedGoogle Scholar
  78. 78.
    Wenzel RP, Perl TM. The significance of nasal carriage of Staphylococcus aureus and the incidence of postoperative wound infection. J Hosp Infect 1995; 31: 13–24PubMedCrossRefGoogle Scholar
  79. 79.
    van Rijen M, Bonten M, Wenzel R, et al. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev 2008; (4): CD006216Google Scholar
  80. 80.
    Huether MJ, Griego RD, Brodland DG, et al. Clindamycin for intraincisional antibiotic prophylaxis in dermatologic surgery. Arch Dermatol 2002; 138: 1145–8PubMedCrossRefGoogle Scholar
  81. 81.
    Griego RD, Zitelli JA. Intra-incisional prophylactic antibiotics for dermatologic surgery. Arch Dermatol 1998; 134: 688–92PubMedCrossRefGoogle Scholar
  82. 82.
    Affleck AG, Birnie AJ, Gee TM, et al. Antibiotic prophylaxis in patients with valvular heart defects undergoing dermatological surgery remains a confusing issue despite apparently clear guidelines. Clin Exp Dermatol 2005; 30: 487–9PubMedCrossRefGoogle Scholar
  83. 83.
    Spelman DW, Weinmann A, Spicer WJ. Endocarditis following skin procedures. J Infect 1993; 26: 185–9PubMedCrossRefGoogle Scholar
  84. 84.
    Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997; 277: 1794–801PubMedCrossRefGoogle Scholar
  85. 85.
    Durack DT. Prevention of infective endocarditis. N Engl J Med 1995; 332: 38–44PubMedCrossRefGoogle Scholar
  86. 86.
    American Dental Association; American Academy of Orthopaedic Surgeons. Advisory statement: antibiotic prophylaxis for dental patients with total joint replacements. J Am Dent Assoc 1997; 128: 1004–8Google Scholar

Copyright information

© Adis Data Information BV 2010

Authors and Affiliations

  1. 1.Skin Cancer DepartmentBond UniversityBelmontAustralia
  2. 2.Skin Cancer Research Group, School of Public Health, Tropical Medicine and Rehabilitation SciencesJames Cook UniversityTownsvilleAustralia

Personalised recommendations