Surgical prophylaxis for skin and soft tissue surgery

Consider the principles for appropriate prescribing of surgical antibiotic prophylaxis (see Principles for appropriate prescribing of surgical antibiotic prophylaxis). See Skin and soft tissue procedures and their requirement for surgical antibiotic prophylaxis for the recommendations for surgical prophylaxis for skin and soft tissue surgery.

For prophylaxis for patients treated with medicinal leech therapy, see Prophylaxis for medicinal leech therapy. For prophylaxis for traumatic wounds requiring surgical management, see Prophylaxis for traumatic wounds requiring surgical management. Pre-emptive antibiotic therapy is sometimes required for wounds caused by bites and clenched fists (see Bite wound infections, including clenched-fist injury infections).

Although there is a risk of bacterial infection following procedures of the skin or subcutaneous tissue, surgical antibiotic prophylaxis (including oral or topical application) is not routinely indicated for clean or clean–contaminated procedures (see Centers for Disease Control and Prevention stratification of surgical wounds) of the skin or subcutaneous tissue (including procedures that breach the oral mucosa).

Prophylaxis against staphylococcal and streptococcal endocarditis may be reasonable for patients with specific cardiac conditions (see here) who are undergoing a skin and soft tissue procedure through infected skin, skin structures or musculoskeletal tissues, even if surgical antibiotic prophylaxis is not required—see Endocarditis prophylaxis for dermatological or musculoskeletal procedures.

There is no role for antibiotic prophylaxis to prevent prosthetic joint infection for patients undergoing procedures of the skin or subcutaneous tissue (including procedures that breach the oral mucosa).

Herpes simplex virus (HSV) infection (either primary, or more commonly, reactivation) may follow ablative laser resurfacing procedures, leading to delayed healing, bacterial superinfection and scarring. Antiviral prophylaxis is often recommended, particularly for patients who have had previous orofacial HSV infection.

For a printable summary table of the indications and regimens for surgical antibiotic prophylaxis, see here.

Table 1. Skin and soft tissue procedures and their requirement for surgical antibiotic prophylaxis
Procedures	Is surgical antimicrobial prophylaxis indicated?
blepharoplasty rhytidectomy other clean or clean–contaminated procedures (see Centers for Disease Control and Prevention stratification of surgical wounds), including those that breach the oral mucosa	NO
ablative laser facial resurfacing procedures	CONSIDER perioperative antiviral prophylaxis, particularly for patients who have had previous orofacial HSV infection (see discussion above)
breast surgery oral maxillofacial surgery head and neck surgery	see the relevant sections

For HSV prophylaxis for patients undergoing ablative laser facial resurfacing procedures, use:

1 aciclovir 400 mg orally, 12-hourly for 10 days. Start prophylaxis the morning of the procedure. For adults with a GFR less than 10 mL/min, use 200 mg orally, 12-hourly for 10 days surgical prophylaxis, skin and soft tissue aciclovir

1 famciclovir 250 mg orally, 12-hourly for 10 days. Start prophylaxis the morning of the procedure. For dosage adjustment in adults with kidney impairment, see the product information surgical prophylaxis, skin and soft tissue famciclovir

1 valaciclovir 500 mg orally, daily for 10 days. Start prophylaxis the morning of the procedure. For dosage adjustment in adults with kidney impairment, see the product information. surgical prophylaxis, skin and soft tissue valaciclovir