Antibiotic Prophylaxis Has Benefits, Risks in Ear Surgery

PALM DESERT, CALIF.—Is routine antibiotic prophylaxis necessary for patients who are having a surgical procedure on the ear?

Even though almost half of dermatologists surveyed have not adopted this practice, they probably should consider it, according to three experts who spoke at the annual meeting of the American Society for Dermatologic Surgery.

"We should use an antibiotic because we don't know how extensive the surgery is going to be, and we do need to potentially protect against infection and chondritis, which is not successfully done with topical antibiotics," said Dr. Murad Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago.

There are no controlled studies to inform the practice of whether to use antibiotics for ear procedures, nor are any likely to be done in the future, in part because the rate of infection is so low that the study would have to be prohibitively large, Dr. Alam said.

Given this lack of evidence, it's important to weigh the consequences of overusing antibiotics against the welfare of the patient, since an infection could be devastating. In that case, the welfare of the individual patient needs to come first, which often means prescribing an oral antibiotic.

Dr. Alam said he surveyed some dermatologic surgeons about their practice and found that about 60% said they used an antibiotic, mostly ciprofloxacin, to address the possibility of a Pseudomonas infection. The rest did not commonly prescribe an antibiotic. An informal poll taken of the audience members attending Dr. Alam's talk had similar results; about 45% said that they did not usually use an antibiotic.

One study did look at the records of 530 Mohs surgery patients and 517 excisional surgery patients to investigate their infection rates, though the study was retrospective and not controlled, said Dr. Donald J. Grande, a dermatologist who practices in Stoneham, Mass., who was involved in the study while at the Tufts-New England Medical Center, Boston.

The overall infection rate was 2%, but in ears the rate was greater, as 6 of 48 patients developed an infection for a rate of 12.5% (Dermatol. Surg. 1995;21:509–14).

The analysis of those cases indicated that larger defects had been created or more Mohs stages performed, which suggested, in part, that the procedures had taken longer, Dr. Grande said.

The 12.5% rate suggests that patients should receive an antibiotic afterward, particularly those patients with risky features like drainage and crusting of their lesions, a cardiac condition, a prothesis, or a history of immunosuppression or a resistant infection after a previous procedure, Dr. Grande said. He noted that caution also was necessary because of the rising incidence of methicillin-resistant Staphylococcus aureus infections.

He recommends ciprofloxacin, rather than a cephalosporin, because of its efficacy against gram-negative bacteria.

Also making a plea for antibiotic use was Dr. Perry Robins, the moderator of the meeting session at which Dr. Alam and Dr. Grande spoke.

"I do it because the nurses like it, the patients like it, I like it, and my lawyer likes it," said Dr. Robins, chief of the Mohs micrographic surgery unit at New York University Medical Center, New York.

Dr. Perry said he probably has treated 40,000 surgical cases, about 5% of which involved the ear. Only two of those cases developed a Pseudomonas infection, one of which occurred in a patient who did not fill his antibiotic prescription. But that is two cases too many.

"When you are doing an ear case, definitely do Cipro [ciprofloxacin] for your protection," he said. "You don't want to have a case of Pseudomonas. And I have found no allergies or difficulties with the patients taking the medication."

It's important to weigh the consequences of antibiotic overuse against the welfare of the patient. DR. ALAM

PALM DESERT, CALIF.—Is routine antibiotic prophylaxis necessary for patients who are having a surgical procedure on the ear?

Even though almost half of dermatologists surveyed have not adopted this practice, they probably should consider it, according to three experts who spoke at the annual meeting of the American Society for Dermatologic Surgery.

"We should use an antibiotic because we don't know how extensive the surgery is going to be, and we do need to potentially protect against infection and chondritis, which is not successfully done with topical antibiotics," said Dr. Murad Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago.

There are no controlled studies to inform the practice of whether to use antibiotics for ear procedures, nor are any likely to be done in the future, in part because the rate of infection is so low that the study would have to be prohibitively large, Dr. Alam said.

Given this lack of evidence, it's important to weigh the consequences of overusing antibiotics against the welfare of the patient, since an infection could be devastating. In that case, the welfare of the individual patient needs to come first, which often means prescribing an oral antibiotic.

Dr. Alam said he surveyed some dermatologic surgeons about their practice and found that about 60% said they used an antibiotic, mostly ciprofloxacin, to address the possibility of a Pseudomonas infection. The rest did not commonly prescribe an antibiotic. An informal poll taken of the audience members attending Dr. Alam's talk had similar results; about 45% said that they did not usually use an antibiotic.

One study did look at the records of 530 Mohs surgery patients and 517 excisional surgery patients to investigate their infection rates, though the study was retrospective and not controlled, said Dr. Donald J. Grande, a dermatologist who practices in Stoneham, Mass., who was involved in the study while at the Tufts-New England Medical Center, Boston.

The overall infection rate was 2%, but in ears the rate was greater, as 6 of 48 patients developed an infection for a rate of 12.5% (Dermatol. Surg. 1995;21:509–14).

The analysis of those cases indicated that larger defects had been created or more Mohs stages performed, which suggested, in part, that the procedures had taken longer, Dr. Grande said.

The 12.5% rate suggests that patients should receive an antibiotic afterward, particularly those patients with risky features like drainage and crusting of their lesions, a cardiac condition, a prothesis, or a history of immunosuppression or a resistant infection after a previous procedure, Dr. Grande said. He noted that caution also was necessary because of the rising incidence of methicillin-resistant Staphylococcus aureus infections.

He recommends ciprofloxacin, rather than a cephalosporin, because of its efficacy against gram-negative bacteria.

Also making a plea for antibiotic use was Dr. Perry Robins, the moderator of the meeting session at which Dr. Alam and Dr. Grande spoke.

"I do it because the nurses like it, the patients like it, I like it, and my lawyer likes it," said Dr. Robins, chief of the Mohs micrographic surgery unit at New York University Medical Center, New York.

Dr. Perry said he probably has treated 40,000 surgical cases, about 5% of which involved the ear. Only two of those cases developed a Pseudomonas infection, one of which occurred in a patient who did not fill his antibiotic prescription. But that is two cases too many.

"When you are doing an ear case, definitely do Cipro [ciprofloxacin] for your protection," he said. "You don't want to have a case of Pseudomonas. And I have found no allergies or difficulties with the patients taking the medication."

It's important to weigh the consequences of antibiotic overuse against the welfare of the patient. DR. ALAM

PALM DESERT, CALIF.—Is routine antibiotic prophylaxis necessary for patients who are having a surgical procedure on the ear?

Even though almost half of dermatologists surveyed have not adopted this practice, they probably should consider it, according to three experts who spoke at the annual meeting of the American Society for Dermatologic Surgery.

"We should use an antibiotic because we don't know how extensive the surgery is going to be, and we do need to potentially protect against infection and chondritis, which is not successfully done with topical antibiotics," said Dr. Murad Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago.

There are no controlled studies to inform the practice of whether to use antibiotics for ear procedures, nor are any likely to be done in the future, in part because the rate of infection is so low that the study would have to be prohibitively large, Dr. Alam said.

Given this lack of evidence, it's important to weigh the consequences of overusing antibiotics against the welfare of the patient, since an infection could be devastating. In that case, the welfare of the individual patient needs to come first, which often means prescribing an oral antibiotic.

Dr. Alam said he surveyed some dermatologic surgeons about their practice and found that about 60% said they used an antibiotic, mostly ciprofloxacin, to address the possibility of a Pseudomonas infection. The rest did not commonly prescribe an antibiotic. An informal poll taken of the audience members attending Dr. Alam's talk had similar results; about 45% said that they did not usually use an antibiotic.

One study did look at the records of 530 Mohs surgery patients and 517 excisional surgery patients to investigate their infection rates, though the study was retrospective and not controlled, said Dr. Donald J. Grande, a dermatologist who practices in Stoneham, Mass., who was involved in the study while at the Tufts-New England Medical Center, Boston.

The overall infection rate was 2%, but in ears the rate was greater, as 6 of 48 patients developed an infection for a rate of 12.5% (Dermatol. Surg. 1995;21:509–14).

The analysis of those cases indicated that larger defects had been created or more Mohs stages performed, which suggested, in part, that the procedures had taken longer, Dr. Grande said.

The 12.5% rate suggests that patients should receive an antibiotic afterward, particularly those patients with risky features like drainage and crusting of their lesions, a cardiac condition, a prothesis, or a history of immunosuppression or a resistant infection after a previous procedure, Dr. Grande said. He noted that caution also was necessary because of the rising incidence of methicillin-resistant Staphylococcus aureus infections.

He recommends ciprofloxacin, rather than a cephalosporin, because of its efficacy against gram-negative bacteria.

Also making a plea for antibiotic use was Dr. Perry Robins, the moderator of the meeting session at which Dr. Alam and Dr. Grande spoke.

"I do it because the nurses like it, the patients like it, I like it, and my lawyer likes it," said Dr. Robins, chief of the Mohs micrographic surgery unit at New York University Medical Center, New York.

Dr. Perry said he probably has treated 40,000 surgical cases, about 5% of which involved the ear. Only two of those cases developed a Pseudomonas infection, one of which occurred in a patient who did not fill his antibiotic prescription. But that is two cases too many.

"When you are doing an ear case, definitely do Cipro [ciprofloxacin] for your protection," he said. "You don't want to have a case of Pseudomonas. And I have found no allergies or difficulties with the patients taking the medication."

It's important to weigh the consequences of antibiotic overuse against the welfare of the patient. DR. ALAM