Cutaneous CO2 Laser Resurfacing Infection Rate With and Without Prophylactic Anti biotics

Transcription

1 Cutaneous CO2 Laser Resurfacing Infection Rate With and Without Prophylactic Anti biotics SUNILA WALIA AND TINA S. ALSTER Washington Institute of Dermatologic Laser Surgery Washington D.C. BACKGROUND. Cutaneous laser resurfacing is a well-accepted modality with excellent clinical outcomes and low morbidity rates for the treatment of a variety of epidermal and dermal lesions. The use of antibiotic prophylaxis continues to be an area of controversy with laser practitioners divided in their approach. OBJECTIVE. To identify the rate of postoperative bacterial infection following full-face carbon dioxide (C02) laser resurfacing with and without antibiotic prophylaxis. METHODS. A retrospective chart review of 133 consecutive patients following full-face CO2 laser resurfacing was performed. The rate severity duration and subsequent treatment of bacterial infections observed in four treatment categories were re- corded: (1) no antibiotic prophylaxis; (2) intraoperative singledose intravenous cephalexin (1 g); (3) postoperative oral azithromycin (1.5 g over 5 days); (4) intraoperative IV cephalexin (1 g) and postoperative oral azithromycin (1.5 g). RESULTS. A significantly higher rate of infection occurred in patients receiving combination intraoperative andlor postoperative antibiotic prophylaxis. The most frequently cultured organisms included Enterobacter and Pseudomonas species. CONCLUSION. The rate of postoperative bacterial infections after full-face CO2 laser resurfacing in this retrospective study was not significantly reduced with the use of prophylactic antibiotics. CUTANEOUS LASER resurfacing is currently a wellaccepted treatment for rhytides acne scars and other skin imperfections. Although excellent postoperative clinical outcomes are common various side effects and complications including but not limited to cutaneous bacterial infections have occurred. Because laser skin resurfacing produces integumental injury proper wound healing remains essential to obtai optimal results. The development of wound infection in dermatologic surgery is influenced by a number of factors including wound location concomitant skin infection intraoperative aseptic technique and the patient's overall nutritional and immunologic status." Infection after cutaneous laser resurfacing has been associated with prolonged postoperative erythema and a higher.- risk of scarring.e> Infected wounds do not heal properly due to the innate limitations of tissue repair. The ". degree to which the administration of antibiotic prophylaxis mitigates the development of wound infection remains inconclusive and controversial. At the center of the controversy is the absence of a definitive study demonstrating its efficacy." Antibiotic prophylaxis in surgery refers to the administration of antimicrobial agents to surgical patients who do not have an established infection with the ultimate goal being a reduction in postoperative wound infection or other infectious sequelae.> The choice of antibiotic depends on its activity against likely endogenous flora its inherent toxicity and its cost. The incidence of infection in clean surgery (surgery with no major contamination of the operative site) is less than 2 %.6 Despite such a low rate of infection the overwhelming opinion expressed in the medical literature (which parallels discussions in the lay press) is that the medical community continues to over administer antibiotics? While it remains difficult to establish general management policies when analyzing retrospective studies (as opposed to controlled prospective studies) retrospective reports are often the only ones available on which to base patient management decisions. Accepted indications for administering prophylactic antibiotics include "clean-contaminated" procedures but new indications that take into consideration wound contamination together with the anesthetic risk and the relative duration of the operation are being determined. The purpose of this study was to help elucidate the role of antibiotic prophylaxis in extensive (fullface) cutaneous laser resurfacing procedures. Address correspondence and reprint requests to: Tina S. Alster 2311 M St. NW Suite 200 Washington D.C Materials and Methods All records of patients undergoing full-face carbon dioxide (C02) laser resurfacing for the treatment of facial rhytides atrophic scars and photoaged skin from January to June were reviewed for postoperative bacterial infections. A retrospective analysis of 133 consecutive full-face 1999 by the American Society for Dermatologic Surgery Inc. Published by Blackwell Science Inc. ISSN: /99/$ Dermatol Surg 1999;25:

2 858 WALIA AND ALSTER: CO 2 LASER RESURFACING DermatolSurg 25: 11:November 1999 '01 Table 1. Proportion of Patients with Postoperative Bacterial Infections Category 7 Control Category 2 IV Only Category 3 Oral Only Category 4 Oral + IV Total N Number of infections p value (versus control) 14 0(0%) N/A 7 1 (14.3%) (0%) (20.7%) (15%).0404 CO 2 laser resurfacing patients (14 men 119 women average age 41 years) was performed by a single investigator (SW). An infection was defined as the presence of a positive bacterial culture with clinical signs and symptoms of infection. All CO 2 laser procedures were performed using identical laser parameters and techniques. No particular preoperative skin preparation was prescribed prior to laser irradiation; however 20% of the patients were using a topical glycolic or retinoic acid maintenance regimen on a daily basis. No patients had a prior history of immunologic disease or problems with wound healing. Immediately prior to the laser resurfacing procedure the entire face was cleansed with a nonalcoholic facial cleanser and thoroughly rinsed with water. Betadine was used to prepare the skin using standard techniques. Intraoperatively partially desiccated tissue was manually removed after each laser pass using sterile salinesoaked gauze. An "open" postoperative wound care regimen involving round-the-clock application of ice water compresses and Catrix-10 or Aquaphor ointments in order to maintain a moist wound environment was used by each patient. Residual serous exudate and crusting was removed with gentle in-office steaming and dilute hydrogen peroxide and acetic acid compresses on a daily basis beginning on the third or fourth postoperative day. Four different antibiotic prophylaxis categories were identified: (1) no antibiotic prophylaxis; (2) intraoperative singledose intravenous cephalexin (1 g); (3) postoperative oral azithromycin (1.5 g over 5 days); (4) intraoperative IV cephalexin (1 g) and postoperative oral azithromycin (1.5 g over 5 days). All patients also received antiherpetic prophylaxis with either acyclovir 400 mg by mouth three times a day or valacyclovir mg twice a day. The rate of bacterial infection was determined for each category (Table 1). Initiation dates and duration of infection with subsequent treatment regimens were recorded and analyzed (Table 2). Results Over the 3-year period 133 full-face CO 2 laser resurfacing procedures were performed. Category 1 (no Table 2. Infections Complicating CO 2 Laser Resurfacing Onset Infection Skin Medrol Day Cultured Organism Treatment Group Duration Type Age Medical History Use 7 Pseudomonas S. aureus Cipro IV 8 days I-II 50 N/A (+) 12 Coagulase (-) Staphylococcus Cipro IV 4 days II 50 IDDM HSV (+) 8 Enterobacter Cipro IV 5 days II 45 N/A (+) 4 Pseudomonas Cipro IV 10 days II 52 Thyroid disease (+) 4 Coagulase (-) Staphylococcus Cipro IV 4 days II 39 N/A (-) 5 Enterobacter Cipro IV 7 days II 53 N/A (+) 5 Pseudomonas Cipro IV 7 days II 55 N/A (+) 4 Enterobacter Pseudomonas Cipro IV 13 days II 41 N/A (+) 5 S. aureus Pseudomonas Cipro IV 7 days II 58 Arthritis HSV (+) 8 S. aureus Pseudomonas IV antibiotics IV 14 days II-III 29 Ulcerative colitis (+) 7 Pseudomonas Cipro IV 8 days II 75 HSV (+) 5 Klebsiella Cipro IV 5 days II 47 HSV (+) 5 Enterobacter Cipro IV v7 days II 23 N/A (+) 4 Serratia Cipro IV 5 days II 50 N/A (+) 6 S. aureus Cipro IV 6 days N/A (+) 5 Enterobacter Cipro IV 7 days II 36 HSV (+) 7 Enterobacter Coagulase (-) Cipro IV 7 days I-II 33 N/A (+) Staphylococcus 7 Enterobacter S. aureus Cipro IV 7 days 64 HTN HSV (+) Staphylococcus sepsis 7 Enterobacter Cipro IV 5 days 46 N/A (+) 5 TSS Oxacillin II 10 days 45 N/A (+) Clindamycin Ceftazidime

3 Dermatol Surg 25:11:November " I prophylaxis) included a total of 14 patients in whom no infections occurred (0%). Seven patients were treated with intraoperative cephalexin (category 2) one of whom developed apparent toxic shock syndrome on the sixth postoperative day without evidence of cutaneous infection. No other cutaneous infections were noted in this group. Twenty patients were treated with oral postoperative azithromycin (category 3) without infection (0%). Ninety-two patients received intraoperative cephalexin and postoperative azithromycin (category 4) with 19 patients (21 %) developing a bacterial infection. Infections were observed 4-12 days postoperatively (mean 6 days). The most commonly cultured pathogens were Enterobacter (n = 8) Pseudomonas aeruginosa (n = 7) and Staphylococcus aureus (n = 5). Two individuals in category 4 also had mucocutaneous herpes simplex reactivation and another category 4 patient had concomitant cutaneous candidiasis in the laser-irradiated skin. Infection with multiple bacterial pathogens were seen in four patients-a combination of gram-negative and gram-positive organisms being most common. Two patients were infected with two different gram-negative organisms. A significantly higher rate of infection (24 %) occurred in patients receiving combination intraoperative and postoperative antibiotic prophylaxis compared to that seen in the nonantibiotic-treated group. Two-sided statistical analysis of data revealed that the infection rates differed between antibiotic-treated patients and control untreated patients (p <.06). Discussion A major area of concern for dermatologic surgeons is determining the circumstances under which antibiotics should be prescribed in order to prevent or reduce the incidence of postoperative wound infection. Antimicrobial prophylaxis in any surgery is deemed necessary in situations where there is a high risk for postoperative infection and/or when the anticipated postoperative infection is potentially severe.! Clean wounds created in uncontaminated sterile skin generally exhibit infection rates lower than 5% whereas "clean-contaminated" wounds which occur in contaminated areas (eg perineum oral mucosa) or as a result of minor breaks in septic technique are associated with infection rates of 10%. On the basis of standard criteria the wound after laser resurfacing should be considered "clean uncontaminated.t's'? It is not until a wound is "contaminated" that unacceptably high (20-30%) rates of infection are seen. Previous studies have shown that surgical procedures such as laser vaporization on noninfected skin have a very low rate ( %) of postoperative infection.l+'? Sriprachya-Anunt et al.13 first reported postlaser infection rates as high as 4.3% pre- sumably due to the use of a "closed" postoperative dressing technique. Despite the use of prophylactic ciprofloxacin these same investigators showed in a later retrospective study an infection rate of 8.2%.14 Other investigators demonstrated postoperative bacterial infection rates ranging from 0% to 1% using predominantly an "open" wound care regimen.l+'? Only one prospective study assessing postoperative infection rates with laser resurfacing has been reported in which the authors support the use of prophylactic narrowspectrum antibiotics.p However the number of extensive (full-face) laser procedures analyzed in this latter study were few and information regarding predisposing risk factors for infection were not disclosed. In our study the rate of postoperative infection was not significantly reduced with the use of prophylactic oral and/or intravenous antibiotics in the peri- or postoperative period. Additional chi-squared analysis comparing the antibiotic-treated and untreated groups with respect to possible risk factors for infection including patient age and presence of comorbidity (eg diabetes corticosteroid use) failed to demonstrate differences that could account for the variable infection rates seen. All groups were also found to be comparable with respect to the use of topical ointments and oral antiviral treatments. Known adverse effects of antibiotic prophylaxis include drug-associated toxicities supra infection gastrointestinal upset and allergic reactions. The development of antimicrobial resistance to prescribed antibiotics is another realistic concern as cutaneous CO2 laser resurfacing produces a wound bed similar to that of a partial-thickness burn with creation of sparsely vascular residual tissue which may limit the ingress of host defense factors and systemically administered antibiotics. The intense public and medicolegal pressure to use prophylactic antibiotics creates an ideal environment for the development of bacterial resistance. Because antibiotic prophylaxis does not intuitively appear to be necessary to compensate for infection rates of less than 5% emphasis should be placed on strict adherence to aseptic surgical technique rather than on antibiotic prophylaxis. Prophylactic antibiotics will not surpass the importance of surgical skill and if the bacterial challenge is sufficiently high or if the patient's resistance is sufficiently low prophylactic antibiotics will not prevent the development of an infecrion.l= In fact published studies on antibiotic prophylaxis have demonstrated that a single preoperative dose of an appropriate antimicrobial agent provides optimal prophylaxis and postoperative doses yield no further benefit." The Medical Letter on Drugs and Therapeutics states that "a single dose of a parenteral antimicrobial given within 30 minutes of an operation usually provides adequate tissue concentrations throughout the

4 860 Dermato/Surg :November 1999 " Figure 1. Patient with marked erythema oozing and crusting 5 days after full-face CO2 laser resurfacing (Group 4). Patient had exhibited only moderate erythema and serous discharge with decreased swelling and pain for the previous 2 days. Bacterial cultures revealed heavy growth of Pseudomonas. Viral cultures were negative. procedure; postoperative administration of prophylactic drugs is usually unnecessary and may be harmful." 17 Most investigators involved in surgical antibiotic research are in general agreement that postoperative antibiotic use beyond 24 hours increases the risk of bacterial resistance and increases the potential for drug toxicity." Along the same line the general consensus among burn specialists is that systemic antibiotic prophylaxis is unwarranted in the management of burn wounds. The fact that bacteria traditionally isolated from burn wounds is virtually identical to those species isolated from the patients in our study confirms categorization of the laser-induced wound as a "burn" wound and gives further strength to the argument against prophylactic antibiotic use. Several comparative studies have been performed on the treatment of extensive burns with and without antibiotics all of which show no objective evidence that antibiotics reduce the incidence of infections complications or the mortality rate Improved survival rates of burn victims has been shown to be most dependent on good wound care rather than on prophylactic antibiotic use.22 In fact only a small percentage of burn patients (2-5%) develop infections even when no systemic prophylaxis is used.2324 In summary the results of this retrospective study demonstrated that the rate of postoperative infections following full-face CO2 laser resurfacing is not significantly reduced with prophylactic antibiotic use. While the number of patients evaluated in each group were not equal (thereby making the result difficult to interpret) the study raises the concern that pre- and/or post-operative antibiotic use may increase the incidence of antibiotic resistance and predispose the patient to infections with organisms of increased pathogenicity. For Figure 2. Patient without signs or symptoms of infection 5 days after full-face CO2 laser resurfacing (Group 4). Erythema and mild serous drainage with early reepithlialization is noted. routine dermatologic laser surgery without complicating host or environmental factors (class 1: clean uncontaminated wounds) prophylactic antibiotics appear to be unnecessary particularly if appropriate postoperative wound care is being followed. While this retrospective study is not intended to establish general management policies its results are consistent with a trend that mitigates against the use of prophylactic antibiotics in class 1 clean uncontaminated wounds. In order to reach a definitive conclusion on this issue however a well-controlled prospective study is necessary. References 1. Kerstein. Wound infection: assessment and management. Wounds 1996;8: Weinstein C Ramirez OM Pozner ]N. Postoperative care following CO2 laser resurfacing: avoiding pitfalls. Plast Reconstr Surg 1997;100: Goldman MP. Pre and post operative care of the laser resurfacing patient. Int] Aesthetic Restor Surg 1997;5: George P. Dermatologists and antibiotic prophylaxis. ] Am Acad DermatoI1995;33: Ludwig KA Carlson MA Condon RE. Prophylactic antibiotics in surgery. Annu Rev Med 1993;44: Mini SN Periti P. Methicillin-resistant staphylococci clean surgery: Is there a role for prophylaxis? Drugs 1997;54(suppl 6): Haas AF. Practical thoughts on antibiotic prophylaxis [correspondence]. Arch DermatoI1998;134: Lycka B. Antibiotic prophylaxis and dermatologic surgery [correspondence]. Arch Dermatol 1987;123: Haas AF Grekin RC. Antibiotic prophylaxis in dermatologic surgery. J Am Acad DermatoI1995;32: Rabb DC Lesher ]L. Antibiotic prophylaxis in cutaneous surgery. Dermatol Surg 1995;21: Bernstein L] Kauvar ANB Grossman MC Geronemus RG. The short- and long-term side effects of carbon dioxide laser resurfacing. Dermatol Surg 1997;23: Nanni CA Alster TS. Complications of carbon dioxide laser resurfacing: an evaluation of 500 patients. Dermatol Surg 1998;24: Sriprachya-Anunt S Fitzpatrick RE Goldman MP Smith SR. In-

5 Dermatol Surg : I1:November I fections complicating pulsed carbon dioxide laser resurfacing for photoaged skin. Derrnatol Surg 1997;23: Manuskiatti W Fitzpatrick RE Goldman MP Krejci-Papa N. Prophylactic antibiotics in patients undergoing laser resurfacing of the skin. J Am Acad DermatoI1999;40: Ross VE Amesbury EC Barile A Proctor-Shipman L Feldman BD. Incidence of postoperative infection or positive culture after facial laser resurfacing: a pilot study a case report and a proposal for a rational approach to antibiotic prophylaxis. J Am Acad DermatoI1998;39: Griego RD Zitelli JA. Intra-incisional prophylactic antibiotics for dermatologic surgery. Arch Dermatol 1998;134: Taylor E. General principles of antibiotic prophylaxis. In: Taylor E ed. Infections in Surgical Practice 6th ed. Oxford: Oxford University Press 1992: Cho CY Lo JS. Dressing the part. Dermatol Clin 1998;16: Monasterio Fa Rebeil AS Barrera G et al. Comparative study on the treatment of extensive burns with and without antibiotics. In: Artz CPo Research in Burns. Philadelphia: FA Davis 1962: Gillet AP. Antibiotic prophylaxis and therapy in burns. J Hosp Infect 1985;6(suppl B}: Dacso CG Luterman A Curreri PW. Systemic antibiotic treatment in burned patients. Surg Clin N Am 1987;67: Boss WK Brand DA Acampora D Barese PA Frazier WHo Effectiveness of prophylactic antibiotics in the outpatient treatment of burns. J Trauma 1985;25: Larkin JM Moylan JA. The role of prophylactic antibiotics in burn care. Am J Surg 1976; Timmons M]. Are systemic prophylactic antibiotics necessary for burns? Ann R Coll Surg 1983;65:80-2. Commentary Antibiotic prophylaxis is generally considered for two indications. One is to prevent sub-acute bacterial endocarditis and infection of various prostheses and transplants. The second indication is to prevent wound infection. Despite the availability of antibiotics for more than fifty years the efficacy of antibacterial prophylaxis has been controversial for both of these indications. This is especially true in dermatologic surgery. In the area of prevention of wound infection no large-scale studies exist to show that clean or clean-contaminated surgery is benefited in the prevention of wound infection by antibacterial use. Studies have shown that in contaminated wounds or in areas of classic preoperative contamination such as the genital/inguinal region the axilla and mucocutaneous membranes that prophylactic antibiotic use can decrease the rate of wound infection. Accepted use of antibiotic therapy in this setting is to give one preoperative dose of the antibacterial agent. None of these studies specifically addressed cutaneous surgery. Surgery involving only the skin and superficial subcutaneous tissue in noncontaminated areas is associated with a very low rate of infection. In this author's practice the rate is between one and two percent. This is probably due to the rich vascularity of the skin and its very active immune mechanisms. No one would argue that for the routine dermatologic surgical procedures such as skin cancer excision cyst excision nevus excision curettage and electrodesiccation of warts that routine antibiotic prophylaxis is necessary. For some reason physicians performing cosmetic surgery believe it is more important in this setting to utilize prophylactic antibiotics whereas they wouldn't in non-cosmetic procedures. They are most likely "treating themselves" as they fear medico-legal repercussion should an infection occur. Drs. Walia and Alster present their experience in carbon dioxide laser resurfacing of the full-face and post-operative wound infections. They evaluate 133 consecutive cases in their practice in which some were given antibiotic prophylaxis and some were not. While the control group is small (14/133) it is remarkable that there are no infections in this group. The group receiving a preoperative intravenous dose of antibiotic followed by a 5-day course of oral azithromycin exhibited infection in 19 of 92 patients. Interestingly most of the infections were by either pseudomonas and entrobacter (14 out 19). The other infection occurred in a patient who only received intravenous preoperative prophylaxis. While the control group is small and the significance of the study may be questioned it is undeniable that the use of prophylactic antibiotics do not prevent postoperative wound infections in cutaneous laser resurfacing procedures. It appears entirely possible that the antibiotic prophylaxis may in fact promote infection by altering the normal skin flora and allowing for a super infection with typically non-responsive organisms. There are other problems associated with prophylactic antibiotic use. These include side effects of the antibiotics including possible super infections in other parts of the body the cost of the antibiotics and most importantly the increased exposure of bacteria to the antibiotics resulting in accelerated development of resistance. As the authors state and this author agrees strongly the most important aspect of prevention of postoperative wound infection in CO2 laser resurfacing (and in any surgical procedure) is meticulous and expert surgical technique followed by appropriate postoperative care and close follow-up. This author does not and has never used prophylactic antibiotics in resurfacing procedures. Unquestionably an occasional infection occurs. Because we follow our patients closely these are picked up cultured and immediately and appropriately treated. With early diagnosis and treatment these infections do not result in increased long-term complication and only a minimal delay in the overall recovery process. Dr. Walia and Dr. Alster use an open dressing technique postoperatively. This author uses a closed technique. It was reported by Goldman et al. that the use of occlusive dressings increases the rate of infection postoperatively in resurfacing procedures'. In their study the dressing was applied and left in place intact for one week. This resulted in approximately a doubling of the postoperative infection rate. In our practice we change the occlusive dressing at day one and three and discontinue its use at day five. Meticulous cleansing occurs at each dressing change. Employing this technique we have not exhibited an increase rate of infection postoperatively in our resurfacing patients. Drs. Walia and Alster support a long held belief by this author that prophylactic antibiotics are neither necessary nor indicated in laser resurfacing patients and may in fact promote infection along with the other problems associated with widespread antibiotic use. While this is not a popular finding I applaud their forthright reporting of their experience and hope that the readers will respond appropriately. The most effective preventive activities we can take against wound infection is precise surgical technique and close postoperative follow-up and antibiotics are certainly no substitute for either of these actions. Roy C. GREKIN San Francisco California