Local Delivery of Antibiotics—Applications in Cutaneous Surgery and Beyond

Abstract

Across surgical subspecialties, surgical site infections (SSIs) represent a prevalent and costly problem to patients and health care systems, affecting 0.5% to 3.0% of surgical patients and resulting in costs ranging from $3.5 billion to $10 billion in the US annually. 1 Accordingly, SSI reduction remains a target of quality improvement initiatives and ongoing research spanning surgical subspecialties. While level 1 evidence has defined the optimal duration and route of antibiotic prophylaxis in some surgical subspecialties, such as colorectal surgery, 2 the role of antibiotic prophylaxis in clean elective surgery, including skin cancer, extremity, and breast surgery, remains controversial.Targeted local administration of antibiotics is an emerging concept in surgical fields. Local antibiotic delivery modalities, such as antibiotic beads, polymethylmethacrylate implant coatings, and vancomycin in spine and orthopedic surgery, have been found to reduce SSIs, achieve higher local tissue concentrations, and lower risk of systemic complications compared with systemic prophylaxis. 3 Invoking a similar concept through targeted local antibiotic administration in skin cancer surgery, the PICASSo double-blind randomized clinical trial 4 examined the efficacy of peri-incisional clindamycin or flucloxacillin administered cutaneously with local anesthetic on SSI rates in 681 patients who underwent skin cancer excision. Paralleling prior findings in Mohs surgery, 5 the