What Are the Most Common Uses of Antimicrobials in Cutaneous Surgery?

Physicians may prescribe antibiotics prior to skin (cutaneous) surgery if the patient has an underlying health condition, or if the wound gets infected post-procedure.

Cutaneous or dermatologic surgery refers to any surgical procedure performed on the skin. These include biopsies to test for cancer, removal of skin tumors, moles, or skin tags, plastic surgery and other procedures.

As with any surgery, the incision site must be sterilized to prevent infection. In people with a history of health problems, doctors sometimes prescribe antibiotics prohyllactically, that is, preventatively before surgery to head off potential infection at the surgery site or of the blood.

The use of prophylactic antimicrobials (antibiotics) in cutaneous surgery is controversial. Dermatologic operations are generally considered to be clean procedures or clean-contaminated procedures, they only last a short duration, and there is a low risk of infection. 

Antibiotic treatment of surgical site infections on the skin post-operatively, however, is common.

The most common uses for antimicrobials in cutaneous surgery include:

• Preventing infection of the inner lining of the heart (endocarditis)
  • Endocarditis is uncommon, but can be potentially life threatening.
  • Patients at high risk of developing infectious endocarditis are those who have a prosthetic cardiac valve or prosthetic material used for a cardiac repair, a previous history of infective endocarditis, congenital heart disease, or a history of cardiac transplantation with the development of valvulopathy. 
  • For cutaneous procedures on infected skin, prophylactic antimicrobials may be indicated for use in patients with high risk conditions.
• Prevention of blood-based total joint infection
  • High-risk patients who should receive antimicrobial prophylaxis prior to extensive dental procedures include those with a history of inflammatory joint disease, immunosuppression as a result of disease (e.g., cancer, HIV infection) or treatment of a disease, type 1 diabetes, a prior history of prosthetic joint infection, malnourishment, or hemophilia. 
• Prevention of surgical site wound infections
  • There is a low risk of surgical site wound infection in cutaneous procedures. 
  • Risk factors for infection include:
    • Skin condition and location of procedure
    • Bacterial colonization
    • Obesity
    • Advanced age
    • Diabetes 
    • Kidney disease
    • Immunosuppression
    • Corticosteroid use
    • Smoking
    • Alcohol use
    • Concurrent remote infection
    • Malnutrition
    • Perioperative transfusion of blood products
    • Preoperative antiseptic showering and hair removal
    • Length of procedure
    • Design of reconstruction
    • Surgical technique
    • History of hospitalization prior to surgery 
• Treatment of surgical site wound infections
  • Inadequate postoperative wound care can introduce bacteria into a wound, which can lead to infection. 
  • Wound infection symptoms usually appear within 4 to 8 days following a procedure and include swelling, redness, warmth, and discharge of pus.
  • Methicillin-resistant Staphylococcus aureus (MRSA) is a possibility.

When antimicrobial drugs are prescribed for cutaneous surgery, they should be targeted toward the most likely infecting organism, which is usually Staphylococcus and Streptococcus species.

Antimicrobials (antibiotics) used as prophylactic agents in skin surgery and skin infections include:

• Cephalosporins
  • Cephalexin
• Penicillinase-resistant penicillins
  • Dicloxacillin 
• Macrolide antibiotics
  • Clindamycin 
  • Erythromycin 
  • Azithromycin
• Trimethoprim-sulfamethoxazole
• Fluoroquinolones
  • Ciprofloxacin
• Glycopeptide antibiotics
  • Vancomycin