Antibiotic Prophylaxis for Endocarditis in Dermatological Surgery
A joint statement from the Therapy Guidelines and Audit Sub-Committee (TGASC) of the British Association of Dermatologists and the British Society for Dermatological Surgery (BSDS)
Infective endocarditis has a mortality rate of 20-30% and in the UK there are approximately 200 deaths per year from this disease. Although antibiotic prophylaxis is effective in reducing bacteraemia, there are no prospective data to confirm that it prevents endocarditis. In addition, only 50% of patients with endocarditis have a known predisposing lesion (Bayliss R et al, 1983) and the majority of episodes (about 80%) of endocarditis occur without+ a known specific preceding episode of instrumentation that might have caused bacteraemia (Child J S, 1996). Nevertheless the Endocarditis Working Party of the British Society for Antimicrobial Chemotherapy publish guidelines on the prevention of endocarditis (Simmons N A, 1993) for a number of dental and surgical procedures but give no specific recommendations for dermatological surgery other than to state that antibiotic prohpylaxis is indicated whenever surgery is performed on heavily colonised, infected or contaminated tissue.
There have been only four reported cases of endocarditis associated with skin surgery (Griffin M R et al, 1985, Spelman D W et al, 1993). Five studies have examined the incidence of bacteraemia during skin surgery (Sabetta J B, 1987, Halpern A C, 1988, Zack L, 1989, Maurice P D L, 1991, Carmichael A J, 1996). Cumulatively these studies have documented an incidence of procedure associated bacteraemia of 1.7% (5 of 287 cases, ranging from 0.7 to 7% in the different studies) which is comparable to the 2.1% incidence of random bacteraemia detected in normal volunteers (Wilson W R, 1975). In the largest series by Carmichael et al (1996) coagulase negative staphylococcus (CNS) was the commonest isolate present on 68.5% of pre-operative surgical sites. CNS was isolated from one patient’s postoperative blood culture (0.7%), although the isolate was biochemically distinct from the CNS isolated from the patient’s surgical lesion. The only antibiotic to which all CNS was sensitive in a five month review of their hospital’s CNS isolates was vancomycin which is expensive and must be infused over an hour to minimise the risk of hypotension and rash.
The committee of the British Society for Dermatological Surgery have recently reviewed the literature summarised above and found no significant evidence to support antibiotic prophylaxis for routine dermatological surgery procedures even in the presence of a pre-existing heart lesion. In addition, the Therapy Guidelines and Audit Sub-Committee have recently surveyed members of the BAD and no responders had seen endocarditis as a direct result of dermatological skin surgery. The BSDS and the TGASC, in agreement with the British Society for Antimicrobial Chemotherapy, therefore believe that antibiotic prophylaxis for endocarditis is not required for routine dermatological surgery procedures, even in the presence of a pre-existing heart lesion.
- Antibiotic prophylaxis is effective in reducing bacteraemia, but there are no prospective data to confirm that it prevents endocarditis.
- There have been only four reported cases of endocarditis associated with skin surgery.
- The incidence of bacteraemia during skin surgery is comparable to the 2.1% incidence of random bacteraemia detected in normal volunteers.
- The commonest isolate present on pre-operative surgical sites is coagulase negative staphylococcus, which would require cover by vancomycin given intravenously.
- The TGASC and the BSDS, in agreement with the British Society for Antimicrobial Chemotherapy, believe that antibiotic prophylaxis for endocarditis is not required for routine dermatological surgery procedures even in the presence of a pre-existing heart lesion.
- Bayliss R, Clarke C, Oakley C M, Somerville W, Whitfield A G W. The teeth and infective endocarditis. Br Heart J 1983;50:506-12.
- Carmichael A J, Flanagan P G, Holt P J A, Duerden B I. The occurrence of bacteraemia with skin surgery. Brit J Derm 1996; 134;120-122.
- Child J S. Risks for and prevention of infective endocarditis. Cardiology Clinics 14(3);327-343, 1996.
- Griffin M R, Wilson W R, Edwards W O et al. Infective endocarditis. Olmsted County, Minnesota, 1950 through 1981. JAMA 1985;254:1199-202.
- Halpern A C, Leyden J J, Dzubow L M et al. The incidence of bacteraemia in skin surgery of the head and neck. J Am Acad Dermatol 1988;19:112-6.
- Maurice P D L, Parker S, Azadian B S et al. Minor skin surgery: Are prophylactic antibiotics ever needed for curettage? Acta Derm Venereol (Stockh) 1991;71:267-8.
- Sabetta J B, Zitelli J A. The incidence of bacteraemia during skin surgery. Arch Dermatol 1987;123:213-5.
- Simmons D W, Weinmann A, and Spicer W J. Endocarditis following skin procedures. Journal of Infection 26(2):185-189, 1993.
- Wilson W R, Van Scoy R E, Washington J A. Incidence of bacteraemia in adults without infection. J Clin Microbiol 1975;2:94-5.
- Zack L, Remlinger K, Thompson K et al. The incidence of bacteraemia after skin surgery. J Infect Dis 1989;159:148-50.
Prof Christopher Griffiths
Chairman, Theraphy Guidelines and Audit Sub-Committee
Dr Graham Colver
Former President, British Society for Dermatological Surgery