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A look at facial plastic surgeons' perioperative antibiotic use

Philadelphia — Facial plastic surgeons are, for the most part, using perioperative antibiotics according to guidelines, according to a new national survey.

David Reiter, M.D., facial plastic surgeon and professor of otolaryngology/head and neck surgery at Jefferson Medical College, Philadelphia, created a Web-based survey asking facial plastic surgeons about their knowledge of and practice patterns for using antibiotics to lower the risk of surgical site infection.

He sent the survey to American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) members, and 114 facial plastic surgeons responded in December 2004.

"One of the proven ways to minimize infection associated with surgery is to use antibiotics properly at the time of surgery for cases in which they have been shown to reduce infection. There are published guidelines and best practices," Dr. Reiter says. "What we wanted to do was to explore how close to the best practice members of the academy come and identify opportunities for improvement."

Reiter and colleagues found that nearly all members of the academy who responded to the survey did use perioperative antibiotics. Although they varied in choice of antibiotic, dose and duration, the vast majority of respondents used antibiotics in a manner consistent with the criteria of the Centers for Disease Control and Prevention, Joint Commission for Accreditation of Health Care Organizations and other oversight groups.

"Most published guidelines for antibiotic use are similar. I found that the vast majority of our academy members responding did in fact practice within acceptable standards," Dr. Reiter says. "We identified some areas in which a change in the antibiotic might make a minor improvement, but I was quite pleased that most of our members were practicing the way they should be."

Less than 10 percent of those who responded were not within guidelines, most often because they did not have formal policies for administering and documenting the antibiotics they used.

"Documentation is important because we are judged on what is documented, rather than what is actually done," according to Dr. Reiter.

Almost all the facial plastic surgeons who responded used a first-generation cephalosporin, the most common antibiotic recommendation for facial plastic and reconstructive surgery.

"This is strongly supported by the literature," he says.

None of the respondents used perioperative antibiotics recklessly or inappropriately, according to Dr. Reiter.

"In general, the state of practice in this regard in facial plastic surgery, at least among academy members, was extremely high," he says.

The researchers looked at all procedures considered within the spectrum of facial plastic and reconstructive surgery, for example, facelift, otoplasty, rhinoplasty and liposuction of the neck. Not all procedures justify using perioperative antibiotics, according to Dr. Reiter. In fact, there is no "black and white" when it comes to using antibiotics in facial plastic surgery, where infections are so rare even without antibiotic use.

"There is a lot of outcomes research showing that the infection rate after many procedures is not changed at all by use of antibiotics, and that current public demand for them is inappropriate because antibiotics have a risk," he says. "One should only use antibiotics where the benefit is clearly documented. It is not as clearly documented in nasal surgery, for example, unless packing is used."

Although the literature is conflicting on antibiotic use in cosmetic facial procedures, there is strong evidence for their use in head and neck trauma or in cancer surgery, where the wound is often contaminated by mouth contents.

In addition to looking at whether facial plastic surgeons were using antibiotics, Dr. Reiter and colleagues asked the question: Are they using them correctly? For example, staph and strep cause most postoperative wound infections in facial plastic surgery. There are many sophisticated, expensive antibiotics that do not kill staph or strep, according to Dr. Reiter.

The concern, according to Dr. Reiter, is that patient demand might tempt physicians to use more expensive but less effective medications.

"There is no such thing as a 'stronger' antibiotic; rather, it is the spectrum of action that is important. Will it kill the bacteria that you are likely to run into?" he says.

Duration of prescription is also important, Dr. Reiter adds.


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