Effect of a single prophylactic preoperative oral antibiotic dose on surgical site infection following complex dermatological procedures on the nose and ear: a prospective, randomised, controlled, double-blinded trial

Objectives: There is limited published research studying the effect of antibiotic prophylaxis on surgical site infection (SSI) in dermatological surgery, and there is no consensus for its use in higher-risk cases. The objective of this study was to determine the effectiveness of a single oral preoperative 2g dose of cephalexin in preventing SSI following flap and graft dermatological closures on the nose and ear. Design: Prospective double-blinded, randomised, placebo controlled trial testing for difference in infection rates. Setting: Primary care skin cancer clinics in North Queensland, Australia, were randomised to 2 g oral cephalexin or placebo 40–60min prior to skin incision. Participants: 154 consecutive eligible patients booked for flap or graft closure following skin cancer excision on the ear and nose. Intervention: 2 g dose of cephalexin administered 40–60min prior to surgery. Results: Overall 8/69 (11.6%) controls and 1/73 (1.4%) in the intervention group developed SSI (p=0.015; absolute SSI reduction 10.2%; number needed to treat (NNT) for benefit 9.8, 95%CI 5.5 to 45.5). In males, 7/44 controls and 0/33 in the intervention group developed SSI (p=0.018; absolute SSI reduction 15.9%; NNT for benefit 6.3, 95%CI 3.8 to 19.2). SSI was much lower in female controls (1/25) and antibiotic prophylaxis did not further reduce this (p=1.0). There was no difference between the study groups in adverse symptoms attributable to highdose antibiotic administration (p=0.871). Conclusion: A single oral 2 g dose of cephalexin given before complex skin closure on the nose and ear reduced SSI

Effect of a single preoperative dose of oral antibiotic to reduce the incidence of surgical site infection following below-knee dermatological flap and graft repair

Background: Surgical site infection (SSI) rates for below-knee dermatological surgery are unacceptably high, particularly following complex flap and graft closures. The role of antibiotic prophylaxis for these surgical cases is uncertain. Objective: To determine whether SSI following complex dermatological closures on the leg could be reduced by antibiotic prophylaxis administered as a single oral preoperative dose. Methods: A total of 115 participants were randomized to 2 g of oral cephalexin or placebo 40–60 minutes prior to surgical incision in a prospective, randomized, double-blind, placebo-controlled trial at a primary care skin cancer clinic in North Queensland, Australia. Results: Overall 17/55 (30.9%) controls and 14/55 (25.5%) intervention participants developed infection (P = 0.525). There was no difference between the study groups in adverse symptoms that could be attributed to high-dose antibiotic administration (P = 1). Conclusion: A single oral 2-g dose of cephalexin given before complex below-knee dermatological closure did not reduce SSI

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

Objective To determine the effectiveness of a single application of topical chloramphenicol ointment in preventing wound infection after minor dermatological surgery

Practice based research: lessons from the field

Background: the authors sought to describe the process of conducting a successful randomised controlled trial in a primary care setting and identify enabling factors and barriers.\ud \ud Methods: descriptive report of methods used to conduct a randomised controlled trial investigating the effect of allowing sutures to be wet and uncovered in the first 48 hours following minor excisions.\ud \ud Results: the trial identified several enabling factors and barriers to conducting research in a primary care setting. The project described in this article was successful because a group of general practitioners sought to answer an interesting question which was relevant to their clinical practice and which had not been answered by current evidence.\ud \ud Discussion: the findings are likely to assist groups seeking to conduct practice based research in the primary care setting

Adherence to Canadian C-Spine Rule in a regional hospital: a retrospective study of 406 cases

Introduction: Cervical spine radiography may be over-utilised in an emergency department setting. The Canadian C-Spine Rule has been developed to reduce unnecessary radiography. Our aim was to retrospectively determine the proportion of cervical spine radiographs requested through the emergency department for trauma patients that were clinically indicated, according to the Canadian C-Spine Rule.\ud \ud Methods: This was a cross-sectional survey conducted at a regional centre in Northern Queensland, Australia. All cervical spine radiographs for trauma, performed at the Mackay Base Hospital from 1 January 2009 to the 31 December 2009, were reviewed. The relevant patient charts were audited for evidence of indications for radiography.\ud \ud Results: Of 406 patients in the study, 155 patients (38%) (95% confidence interval 33.3%, 42.7%) had cervical spine imaging performed that was not indicated according to the Canadian C-Spine Rule. None of these patients had a significant cervical spine injury on radiography.\ud \ud Conclusion: Applying the Canadian C-Spine Rule would have safely reduced the incidence of cervical spine radiography by 38%. This would also reduce costs, patient morbidity and radiation exposure

Risk factors for surgical site infection after dermatological surgery

Objectives: Surgical site infection (SSI) following minor surgery contributes to patient morbidity and compromises cosmetic outcomes. The purpose of this study was to determine the incidence of and risk factors for SSI after dermatological surgery in general practice.\ud \ud Methods: A prospective, observational study which assessed infection among 972 patients was conducted in regional north Queensland, Australia. Consecutive patients presenting for minor skin excisions were invited to participate. Wounds were assessed for SSI at the time of removal of sutures.\ud \ud Results: Infection occurred in 85 of the 972 excisions; thus, the overall incidence of infection was 8.7% (95% confidence interval 6.5–11.0). Excisions in the upper (P < 0.001) or lower (P < 0.001) extremities, excisions of basal cell carcinoma (BCC) (P = 0.001) or squamous cell carcinoma (SCC) (P = 0.001), and re-excision of skin cancer were found to be independent risk factors for wound infection. The length of the excision (P < 0.001) and the patient’s status as an ex-smoker (P = 0.019) were additional independent risk factors for infection. Diabetes was not found to be an independent risk factor for infection (P = 0.891).\ud \ud Conclusions: Prophylactic antibiotics are probably prescribed excessively or inappropriately for dermatological surgery, and overall we wish to discourage their use. The results of this study may encourage the more judicial use of prophylactic antibiotics by defining high-risk procedures, such as excisions from the extremities, excision of BCC or SCC, and larger excisions, and patients who are at high risk for infection, such as ex-smokers

Prevention of surgical site infection in lower limb skin lesion excisions with single dose oral antibiotic prophylaxis: a prospective randomised placebo-controlled double-blind trial

Objectives: To determine the effectiveness of a single perioperative prophylactic 2 g dose of cephalexin in preventing surgical site infection (SSI) following excision of skin lesions from the lower limb.\ud \ud Design: Prospective double-blinded placebo-controlled trial testing for difference in infection rates.\ud \ud Setting: Primary care in regional North Queensland, Australia.\ud \ud Participants: 52 patients undergoing lower limb skin lesion excision.\ud \ud Interventions: 2 g dose of cephalexin 30–60 min before excision.\ud \ud Main outcome measures: Incidence of SSI.\ud \ud Results: Incidence of SSI was 12.5% (95% CI 2.7% to 32.4%) in the cephalexin group compared with 35.7% (95% CI 18.6% to 55.9%) in the placebo group (p=0.064). This represented an absolute reduction of 23.21% (95% CI −0.39% to 46.82%), relative reduction of 65.00% (95% CI −12.70% to 89.13%) and number-needed-to-treat of 4.3.\ud \ud Conclusions: Administration of a single 2 g dose of cephalexin 30–60 min before skin lesion excision from the lower limb may produce a reduction in the incidence of infection; however, this study was underpowered to statistically determine this

Differences in diagnostic accuracy between GPs and specialists in the management of skin cancer

Background: Skin cancer is an increasing problem in fair-skinned populations world-wide. In north Queensland the majority of skin cancer is managed initially by general practitioners (GPs). It is important that doctors are able to diagnose skin lesions accurately.\ud There are limited studies comparing the diagnostic accuracy of GPs and specialists. The objective of this report is to compare diagnostic agreement based on histopathology between GPs and specialists. \ud \ud Methods: All excised and histologically confirmed skin cancers in Townsville/Thuringowa, Australia were recorded between December 1996 and October 1999. Clinical diagnoses were recorded and compared to histological diagnoses. Positive predictive values (PPVs) and sensitivities were calculated for the clinical diagnoses and stratified by histological subtype. The results were then compared between the GPs and specialists. \ud \ud Results: A total of 193 doctors – 174 GPs and 19 specialists - were recorded in the database. Only one of the 19 specialists was a dermatologist. Of the 8,694 first excisions, 1443 lesions (16.6%) were treated by specialists, the rest by GPs. For basal cell carcinoma, positive predictive value was significantly higher for specialists compared to GPs (81.2% versus 70.6%, p<0.001). For squamous cell carcinoma, common naevi and seborrhoeic keratosis sensitivity was significantly higher for GPs than for specialists (42.2% versus 34.6%; p=0.005, 42.9% versus 30.5% p=0.036 and12.9% versus 4.3% p=0.018, respectively). \ud \ud Conclusions: In the present analysis, although specialists had higher accuracy in the diagnosis of basal cell carcinomas, GPs were more accurate in the diagnosis of squamous cell carcinoma, common naevi and seborrhoic keratosis. Overall there was little difference in the diagnostic performance between the two groups of doctors. These findings contrast with previous studies which have found the diagnostic performance of specialists to be superior to that of GPs. It is possible that this improved diagnostic performance may be a reflection\ud of the higher caseload of skin cancer experienced by GPs in North Queenslan

International comparison of guidelines for management of impetigo: a systematic review

BACKGROUND: Impetigo is a common superficial skin infection that affects people worldwide and is usually treated with antibiotics; therefore, its management has implications for global antibiotic stewardship.OBJECTIVE: This systematic review and narrative synthesis compares and contrasts international impetigo management guidelines.METHODS: Guidelines for treatment of impetigo that were produced by a national authority; available to primary care physicians; and published since 2008 were included. Following a comprehensive search strategy, data extraction from eligible studies was performed independently in duplicate. Details of antiseptic and antibiotic treatment; methicillin-resistant Staphylococcus aureus treatment; and conservative management and preventative measures were tabulated and analysed descriptively.RESULTS: Fifty-one guidelines were included from 42 different countries. All guidelines recommended systemic antibiotics, 78% of these only for widespread lesions or failure of topical antibiotic treatment. The first-line systemic antibiotic treatment was restricted to narrow-spectrum options in 21 (41%) whilst 7 (14%) recommended only broad-spectrum antibiotics first-line. Thirty-four (67%) guidelines included recommendations for topical antibiotic use. Twenty guidelines (39%) did not mention antiseptic treatment for impetigo. Guidelines did not always provide clear indications for different treatment options.CONCLUSIONS: Despite potentially equal efficacy to systemic antibiotics, only two-thirds of guidelines include topical antibiotic options. Many fail to include recommendations for non-antibiotic treatments such as antiseptics, preventative measures and conservative management, despite potential for antibiotic-sparing. Provision of clear definitions of disease severity and indications for treatment would enhance the ability of clinicians to adhere to recommendations.SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018117770.</p