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INVESTIGATIVE REPORT ActaDV ActaDV Advances in dermatology and venereology Acta Dermato-Venereologica
Risk Factors for Surgical Site Infections in Dermatological Surgery
Xiaomeng LIU 1 – 3, Melissa SPRENGERS 1, Patty J. NELEMANS 4, Klara MOSTERD 1, 2 and Nicole W. J. KELLENERS-SMEETS 1, 2
1
Department of Dermatology, 2 GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht,
3
Department of Dermatology, Flevo Hospital, Almere, 4 Department of Epidemiology, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
Current literature on risk factors for surgical site infection( SSI) in dermatological surgery in the absence of antibiotic prophylaxis is limited. The aim of this study was to retrospectively evaluate patients presenting for dermatological surgery. A total of 1,977 procedures were reviewed. SSI was clinically suspected in 79( 4.0 %) patients and confirmed by culture in 38( 1.9 %). Using the strictest definition of SSI( clinical symptoms with positive culture) significantly higher risk of SSI was found for location on the ear( odds ratio( OR) 6.03, 95 % confidence interval( 95 % CI) 2.12 – 17.15), larger defects( OR 1.08 per cm 2 increase, 95 % CI 1.03 – 1.14), closure with flaps( OR 6.35, 95 % CI 1.33 – 30.28) and secondary intention( OR 3.01, 95 % CI 1.11 – 8.13). These characteristics were also associated with higher risk of clinically suspected SSI regardless of culture results with slightly lower ORs. In conclusion, the risk of acquiring a SSI is increased in surgeries performed on the ear, in larger wounds and in defects closed with flaps or healed by secondary intention.
Key words: surgical site infection; wound healing; antibiotic prophylaxis; dermatological surgery.
Accepted Nov 13, 2017; Epub ahead of print Nov 14, 2017 Acta Derm Venereol 2018; 98: 246 – 250.
Corr: Xiaomeng Liu, Department of Dermatology, Maastricht University Medical Centre, P. Debyelaan 25, NL-6229 HX Maastricht, The Netherlands. E-mail: xmxmliu @ gmail. com
Increasing numbers of patients with skin malignancies requiring surgical treatment are presenting to dermatologists worldwide( 1, 2). These procedures are generally associated with a low risk(< 5 %) of surgical site infection( SSI)( 3 – 10). However, there is ongoing debate that, under certain circumstances, the risk of SSI is significantly increased and could surpass the acceptable threshold.
Different factors could influence the risk of SSI after dermatological surgery. The first group consists of“ patient-related factors”, which include diabetes and immunological status. The impact of these factors on the risk of SSI in dermatological surgery is a matter of debate( 5 – 7, 9). The second group of potential risk factors are“ procedure-related factors”, such as environmental circumstances, type of procedure and method of closure. Several studies have compared the risk of SSI after Mohs micrographic surgery( MMS) and excision and found no significant difference( 6 – 8). Studies have not reached consensus as to whether the method of closure is a significant independent risk factor( 6, 7, 9, 10). The last and most studied group consists of“ lesion-related factors”, such as anatomical site and defect size. Regarding anatomical site, the nose, ears, genital / groin, and location below the knees and on extremities have been identified as risk factors in various studies( 3, 6 – 8, 11). Several studies have also shown that larger defects are associated with an increased risk of SSI( 4, 8, 11).
Many published studies evaluating risk factors in dermatological surgery have included a group of patients who received antibiotic treatment during the perioperative period. To our knowledge, the only large study including patients who did not use antibiotics was published by Dixon et al. in 2006, including 5,091 procedures in 2,424 patients( 6). Although the study presented an in-depth evaluation of different risk factors for SSI, no multivariate analysis was performed to assess the independent effect of risk factors. Routine use of antibiotic prophylaxis should be avoided, as this could lead to adverse reactions and increase bacterial resistance. In 2008, an advisory statement in the USA was published on this topic, suggesting antibiotic prophylaxis be used for certain patients or operations on high-risk locations( 12). The authors, however, emphasized that the available evidence was limited, and encouraged researchers to further identify important risk factors.
The aim of this study was to perform a comprehensive evaluation of the independent effect of multiple risk factors on the risk of SSI, using a multivariate approach in patients not receiving any antibiotics in the perioperative period.
METHODS
An observational cohort study was conducted at the Department of Dermatology, Maastricht University Medical Centre for one year. All patients who received surgery under local anaesthesia were eligible. A waiver to obtain written informed consent was authorized by the local ethics committee as the study protocol did not differ from standard care. Biopsies, curettages, shave-excisions or laser procedures were excluded. Patients who received antibiotics in the perioperative period( 1 month prior to or after the procedure) were also excluded.
Data on patient-related characteristics( age, sex, diabetes and immunosuppression), surgical procedure characteristics( setting, number of separate procedures on one day, type of procedure and type of closure) and lesion-related characteristics( type, location and defect size) were collected retrospectively from the electronic patient charts.
Surgical procedures were performed at 2 locations. At the operation theatre, both the patient and healthcare professionals were doi: 10.2340 / 00015555-2844 Acta Derm Venereol 2018; 98: 246 – 250
This is an open access article under the CC BY-NC license. www. medicaljournals. se / acta Journal Compilation © 2018 Acta Dermato-Venereologica.