Antibiotic Prophylaxis in Outpatient Elective Hand Surgery: A Retrospective Chart Review of 8,850 Cases
Michael R. Bykowski, MS1, Wesley Sivak, MD, PhD1, James Cray, PhD1, Glenn Buterbaugh, MD2, William Hagberg, MD2, Joseph Imbriglia, MD2, W.P. Andrew Lee, MD1.
1University of Pittsburgh, Pittsburgh, PA, USA, 2Hand & UpperEx Center, Wexford, PA, USA.
Background: Prophylactic antibiotic use has been demonstrated to reduce surgical site infection (SSI) following general surgical procedures, but the efficacy remains unclear in clean, elective hand surgery. Strikingly, despite the potential for substantial patient morbidity, there is no clear consensus regarding routine administration of prophylactic antibiotics. Low patient number and low statistical power have limited prior attempts to define their use. The aims of this study are: 1) to assess the efficacy with which prophylactic antibiotics prevent SSI following clean, elective hand surgery, and 2) to identify potential predictors for the development of SSI in this same patient population.
Methods: The database from an outpatient surgical center was queried by CPT code to identify patients who underwent elective hand surgery (see Table). For each of 8850 patient records that met our criteria, the following were collected: demographics, co-morbidities, prophylactic antibiotic administration, and development of SSI. Postoperative SSI surveillance methods involved telephone survey at approximately 10 days after surgery, as well as direct examination of surgical site wounds by a hand surgeon at the surgical center. The presence of SSI was evaluated by reviewing all follow-up clinical notes; CDC/NNIS criteria for SSI were used.
Results: SSI rate was 0.35% with a mean in-office patient follow-up of 79 days. SSI rates did not significantly differ between patients receiving antibiotics (0.54%; 2,755 patients) and those who did not (0.26%; 6,095 patients). Males were more likely to develop a SSI compared to females (χ ²; p=0.017; relative risk=2.3). SSI was associated with smoking status (p=0.001; relative risk=3.5) and longer procedure length (p=0.003; 43.25 vs. 27.32 minutes = mean length of procedure for infection and non-infection group, respectively). Multivariate analysis indicates that smoking status, procedure length, and diabetes mellitus status are significant predictors (p=0.003, 0.0001, and 0.019, respectively).
Conclusions: Prophylactic antibiotics do not effectively reduce SSI following clean, elective hand surgery. Our study identified male sex, diabetes mellitus status, prolonged procedure length, and smoking status as potential predictors of SSI. Moreover, sub-group analysis revealed that antibiotics did not reduce the frequency of SSI among patients with positive predictors of SSI. Failure to see a protective effect of prophylactic antibiotics in these sub-groups may be due to very low SSI rate and relatively small number of subjects per each sub-group analyzed. Given the harmful complications associated with antibiotic use and the lack of evidence that prophylactic antibiotics prevent SSI, we propose that antibiotics should not be routinely administered to patients who undergo clean, elective hand surgery in an outpatient center. However, given that patients with diabetes mellitus have more severe outcomes once SSI is established compared to their non-diabetic counterparts, prophylactic antibiotics may be prudent in this population, but definitive recommendations cannot be made. To our knowledge, this case series represents the largest of its kind.
|CPT Code||CPT Code Description||%age of Total Cases|
|64721||Carpal Tunnel Release||42.76|
|64719||Ulnar nerve neuroplasty at wrist||4.43|
|64718||Ulnar nerve transposition at elbow||4.04|
|26116||Excision tumor/malformation hand, superficial||4.76|
|26055||Tendon sheath incision (trigger finger)||22.51|
|25111||Wrist ganglion excision||7.06|
|25075||Exc. forearm/wrist tumor, subcutaneous||0.36|
|25000||De Quervain's release||11.81|
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