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Compliance of Perioperative Antibiotic Dosing and Surgical Site Infection Rate in Office-Based Elective Surgery



Background: A best practice goal to reduce surgical site infection includes administration of antibiotics in the ideal preoperative window. This article evaluates an office surgical suite antibiotic administration rate and compares it with the timing of a local hospital treating a similar patient population. The hypothesis was that similar or better compliance and surgical site infection rates can be achieved in the office-based suite. Methods: A total of 277 office-based surgeries were analyzed for antibiotic administration time before incision and their corresponding surgical site infection rate. Results: Our facility administered timely prophylactic antibiotics in 96% of cases with a surgical site infection rate of 0.36%. This rate was significantly lower than a reported rate of 3.7%. Conclusion: Low infection rates with high antibiotic administration rate suggest that compliance with best possible practice protocols is possible in the outpatient setting. 1
Prophylactic antibiotic administration is one
of the many recommended guidelines to pre-
vent surgical site infections (SSIs)1–15; how-
ever, data on its effectiveness in outpatient elective
surgery are lacking.9,10,11 There are also conflicting
data on when to administer antibiotics within the
time range.1–10 In general, preventive antibiotic ad-
ministration within 60 minutes of incision has shown
to be an effective means of reducing nosocomial and
wound infections.7
The types of infections that are seen in plastic
surgery are grouped into superficial versus deep in-
cisional, because intracavity is rarely encountered.
Both infections occur within 30 days of the operation.
The superficial infection has purulent drainage from
superficial incision, organisms isolated from a fluid
or tissue culture, and/or 1 of the following—pain/
tenderness, localized swelling redness, or heat. The
deep SSI is indicated by purulent drainage, dehis-
cence or open wound with a fever (>38°C), localized
pain, tenderness, or an abscess.1–3 The placement of
foreign bodies, such as implants, increases the risk of
infection through local contamination and biofilm
formation, which extends monitoring to 1 year after
Although there are varying opinions on the need
for prophylactic antibiotics during simple clean
procedures, there is a general consensus concern-
ing the use of prophylactic antibiotics during clean-
contaminated procedures, as well as elective clean
procedures using a medical implant. In addition,
this protocol is followed to meet standards for facil-
Received for publication January 14, 2016; accepted March
9, 2016.
Copyright © 2016 The Authors. Published by Wolters
Kluwer Health, Inc. on behalf of The American Society of
Plastic Surgeons. All rights reserved. This is an open-access
article distributed under the terms of the Creative Commons
Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and
share the work provided it is properly cited. The work cannot
be changed in any way or used commercially.
DOI: 10.1097/GOX.0000000000000704
From the *DAVinci Plastic Surgery, Wash.; †DAVinci Plastic
Surgery, Georgetown University School of Medicine, Wash.;
and ‡Department of Mathematics and Statistics, American
University, Wash.
Background: A best practice goal to reduce surgical site infection includes
administration of antibiotics in the ideal preoperative window. This article
evaluates an office surgical suite antibiotic administration rate and com-
pares it with the timing of a local hospital treating a similar patient popula-
tion. The hypothesis was that similar or better compliance and surgical site
infection rates can be achieved in the office-based suite.
Methods: A total of 277 office-based surgeries were analyzed for antibiotic
administration time before incision and their corresponding surgical site
infection rate.
Results: Our facility administered timely prophylactic antibiotics in 96% of
cases with a surgical site infection rate of 0.36%. This rate was significantly
lower than a reported rate of 3.7%.
Conclusion: Low infection rates with high antibiotic administration rate
suggest that compliance with best possible practice protocols is possible
in the outpatient setting. (Plast Reconstr Surg Glob Open 2016;4:e710;
doi: 10.1097/GOX.0000000000000704; Published online 19 May 2016.)
Gabrielle LaBove, BS*
Steven P. Davison, DDS, MD†
Monica Jackson, PhD‡
Compliance of Perioperative Antibiotic Dosing
and Surgical Site Infection Rate in Office-Based
Elective Surgery
Disclosure: Steven P. Davison is affiliated with
Georgetown University school of Medicine and Monica
Jackson is a professor at American University. The au-
thors have no financial interest to declare in relation
to the content of this article. The Article Processing
Charge was paid for by the authors.
Office-Based Elective Surgery
LaBove et al.
Plastic & Reconstructive Surgery-Global Open
Original Article
© 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American
Society of Plastic Surgeons. All rights reserved.
PRS Global Open 2016
ity accreditation. The Surgical Care Improvement
Project established a core measure set for infection
prevention, which includes administration of antibi-
otic within 1 hour before incision, careful selection
of the antibiotic for the patient, and discontinuation
of prophylactic antibiotics within 24 hours after sur-
gery.4,7,8,16 Antibiotic dosage and selection reflects
the protocol from the American Society of Health-
System Pharmacists.17
A 2011 analysis of readmissions to hospitals after
outpatient cosmetic surgery from the National Surgi-
cal Quality Improvement Program database showed
a 0.90% readmission rate, of which 19.23% of pa-
tients had superficial SSI and 15.38% had deep SSI.15
Although these data summarize elective plastic sur-
gery infection rates in hospitals, it fails to isolate in-
dividual infection rates by procedure and to address
the infection rates of office-based surgical suites. On
the other spectrum, a retrospective study on SSI in
the ambulatory setting failed to include plastic sur-
gery as one of its analyzed specialties.11 Comprehen-
sive studies merging compliance in the ambulatory
setting for elective surgery are lacking.
Although Centers for Medicare and Medicaid Ser-
vices ask for antibiotic times from participatory am-
bulatory surgical centers, adherence is infrequent,
and reporting SSI rates is not obligatory18; further-
more, Medicare-eligible cases, then, by definition,
exclude outcomes of elective aesthetic surgery cases.
These SSIs not only extend hospital stay but also lead
to higher costs with readmission.18–23
Historically, the National Surgical Infection
Prevention Project reported a 55.7% compliance
rate of prophylactic antibiotics within the recom-
mended 1 hour before incision.24 As a focus of best
practices, this has improved—a new Surgical Care
Improvement Project national average of 98% has
been established.25 The national average for SSI is
1.9%.26 The purpose of this project was to analyze
whether compliance with guidelines is possible at
an office-based surgery suite and to compare na-
tional compliance rates to those of the office-based
surgery suite. Comparisons with similar population
groups at a hospital setting were also made. The
demographics of the office-based surgical suite and
hospital are identical—same geographic location,
socioeconomics, all adults, and equal male:female
population. These national rates are for general
surgery types. Beyond the lack of literature for
the outpatient office-based setting, there is also a
dearth of research analyzing plastic surgery-specific
infection rates.
Our project focuses on the role of antibiotic pro-
phylaxis guidelines in reducing SSI to show that,
regardless of surgical setting, the same infection pre-
vention measures can be implemented with similar
high compliance and low infection rates.
Our facility is an outpatient surgical suite accred-
ited by the Accreditation Association for Ambulatory
Health Care (AAAHC) and used solely for elective
surgery in an urban, high-rent city. This project was
approved by the Institutional Review Board at Amer-
ican University. Proper presurgical, sterile prepara-
tion protocol per AAAHC and the Association of
Perioperative Registered Nurses guidelines was fol-
lowed for each surgery. There is 1 operating room
that averages 200 surgical procedures per year. We
used data from a neighbor hospital with whom our
facility has a transfer agreement, as well as a simi-
lar surgical patient population to compare with our
Data analysis was both qualitative and quantitative
in nature. The intraoperative reports and longitudi-
nal electronic records over 24 months of the most
recent 277 consecutive patients from 2011 to 2013
were analyzed from an AAAHC-certified single oper-
ating room office-based surgery suite by the research
assistant. In cases in which implantable devices were
used, this was extended to 1 year.
Basic statistical methods were used to deter-
mine the sample size for a proportions test27 based
on a 95% confidence interval with a margin of er-
ror of 3%. Times of OR entry, antibiotic adminis-
tration, and incision were recorded and compared
with any new signs of infection. Data analysis
was retrospective. Data collected were as follows:
(1) antibiotic administration time, (2) cut time,
(3) difference between antibiotic to cut time,
(4) SSI, and (5) SSI rate.
We calculated a 95% confidence interval for the
sample population of 277 patients who received an-
tibiotics within 1 hour before incision. Those with-
out recorded times were removed from the sample.
The 95% confidence interval for the patients who
received antibiotics after incision was calculated as
above 1 hour.
We hypothesized that our antibiotic administra-
tion rate was higher than the historical 55.7% na-
tional average and equal to that of the best practices
98%. We also hypothesized that our infection rate
was less than the 1.9% national average at a 0.05
significance level. We compared the local hospital’s
data28,29 for administration compliance and SSI rate
(Table 1) with that of our facility’s by using the large-
sample method.27 As the reconstructive or overnight
cosmetic patients from the practice are also oper-
ated at this hospital, it was used as a control. Further-
more, the same anesthesiologists and perioperative
LaBove et al. Office-Based Elective Surgery
antibiotics are used at both the hospital and the of-
fice facility.
A 1-sided significance test was used to compare
our specific surgery infection rates versus the corre-
sponding national infection rates by the respective
categories at the 0.05 level. The categories consid-
ered were breast augmentation, breast reduction,
abdominoplasty, and rhinoplasty. Rates are outlined
by Hsu et al26 and were assigned in Table 2 to their
corresponding surgery types—clean versus clean-
contaminated in elective surgery. A national plastic
surgery infection rate was extrapolated based on the
surgery types listed in Table 2 to give us the 3.675
rate used.
All analysis was performed using SPSS (IBM Corp.,
Armonk, N.Y.). Patients were identified and analyzed
by their already assigned and randomly generated ID
number using NexTech Medical Practice Software
(Nextech Systems LLC, Tampa, Fla.) and remained
anonymous during data analysis. All data were gath-
ered electronically and stored in the patient’s medi-
cal file, which is encrypted for all patients. Health
Insurance Portability and Accountability Act guide-
lines were followed. This office-based suite is accred-
ited by the AAAHC, a nonprofit organization that
sets standards for quality patient care based on edu-
cation, research, and peer review. The Association of
Perioperative Registered Nurses guidelines for surgi-
cal site preparation were followed.30
The average time between antibiotic prophylaxis
administration and incision was 15.095 minutes. Re-
cords show that 7 patients received prophylaxis af-
ter incision time. Four of the 277 operative reports
analyzed showed no documentation of prophylaxis
(Table 3); however, these 4 patients had no noted in-
fections postoperatively. The SSI rate was calculated
to be 0.36% for 1 case; of note is that this patient
was at a high risk for infection because it was the pa-
tient’s sixth revisionary clean-contaminated rhino-
plasty surgery.
The resulting 95% confidence interval compar-
ing the national average of antibiotic administra-
tion within an hour of surgery was 92.6% to 97.5%.
Results show a statistically significant difference
and indicate a P value <0.0001. Our facility’s com-
pliance of administering antibiotics within 1 hour
is higher than the national Medicare average. We
compared our administration of antibiotics and
SSI rate (0.36%) with that of the local hospital
(0.26%), resulting in large P values (0.961 and
Table 1. 2013 Comparison of Our Facility’s Surgical
Site Infection with Those of a Local Hospital
Measure of
Success Hospital Year
to Date Office Year
to Date
Total number of surgeries 11,373 277
SSI (includes all surgical
procedures) 27 1
SSI rate 0.24 0.36
This table shows the surgical site infection rates contributed from
a local regional hospital compared with the rates from our office.
The information contained in this document is based on the results
of peer review activities. Therefore, this document and any of the
attachments are subject to certain privilege(s) and protected by state
peer review and internal risk management program laws and federal
protections afforded by the Health Care Quality Improvement Act of
1986, Public Law 99–660. Not for use in litigation.
Table 2. Comparison of Plastic Surgery-Specic Infection Rates between Our Facility and Hsu et al26
Surgery OBSS Cases OBSS Infections OBSS Rates (%) Hsu Et al.’s Rates (%)
Breast augmentation 69 0 0 0
Breast reduction 41 0 0 8.5
Abdominoplasty 30 0 0 7.3
Rhinoplasty 30 1 3.3 8.9
This table compares the rates of infection in the office-based surgical suite with those summarized by Hsu et al26 for the same types of surgeries.
These are elective surgery-specific rates, illustrating our facility’s infection rate.
Table 3. Perioperative Antibiotic Type and Dose Used by Caseload with Postoperative Surgical Site Infection
Occurrence Explained
Perioperative Antibiotic Cases Receiving
Antibiotic Postoperative
Infection Procedure
with Infection Result
1 g Ancef 266 1 rhinoplasty with rib graft 20-day Bactroban*
2 g Ancef 4 0 n/a N/A
400 g Cipro 1 0 n/a N/A
600 mg clindamycin 6 0 n/a N/A
This table outlines the only (superficial) infection that resulted from surgery in the last 277 cases in the office-based surgical suite. It is catego-
rized by antibiotic used and, in the sole infection case, explains the procedure and follow-up care. This summary is significant in that the only
infection in our project analysis was in a high-risk case. In addition, the infection resolved with proper postoperative care.
*Original postoperative doxycycline was discontinued after cultures showed Serratia marcescens.
PRS Global Open 2016
0.681) This indicates that there is no difference
between our administration times or our infection
rate and those of the hospital’s at the 0.05 signifi-
cance level.
Statistically significant differences were found
when comparing our infection rate (0.36%) with the
national infection rate of 1.9% [P = 0.030, standard
error (SE) = 0.008) and the national plastic surgery
infection rate of 3.675% (P = 0.0017, SE = 0.011).
At the 0.05 significance level, our infection rates for
breast augmentation, breast reduction, abdomino-
plasty, and rhinoplasty were compared with those
discussed by Hsu et al.26 The clinical suite infection
rate for mammoplasty reduction was found to be sig-
nificantly less than the 8.5% discussed by Hsu et al
(P = 0.025, SE = 0.043). Breast augmentation rates
could not be compared mathematically because
the infection rates were both 0. Abdominoplasty
(P = 0.0654, SE = 0.049) and rhinoplasty (P = 0.141,
SE = 0.052) did not result in significance because of
the large SEs based on sample size.
Although extensive Centers for Disease Control
and Prevention and Association of Perioperative
Registered Nurses recommendations for aseptic
technique are implemented in our office-based sur-
gical center, our project focused on the compliance
of prophylaxis in the facility. Antibiotic dosing guide-
lines can be met through repetitive teaching of pro-
tocol but may be difficult to achieve in a complex
environment such as a teaching hospital. Factors
such as staff/shift changes, differing teaching meth-
ods, and high volume can inhibit proper protocol.
This project is comparative because surgeon, anes-
thesiologist, physician assistant, nurses, resident, and
patient populations were at both facilities.
This failure to comply in hospitals is reflected in
the historical National Surgical Infection Prevention
Project audit—with only 55.7% of patients receiving
prophylaxis within an hour.24 Nemeth et al31 exam-
ined whether including a prophylaxis reminder in
the time-out would improve timeliness compliance.
This seems to have indeed worked with compliance
increasing to 98%. The University of Washington
implemented a software system giving real-time an-
tibiotic reminders to anesthesiologists, increasing
timely compliance by 9.3%, and maintaining a >99%
compliance rate long term.32
A study at an Italian teaching hospital found a re-
duction in SSI rates over 6 years by implementing
appropriate antibiotic administration.33 However, a
noted flaw in the study was inconsistency in objec-
tive data recording. This is a real risk if there are no
protocol reminders or checklists.
Our project analysis showed 96% compliance
with prophylaxis guidelines. The other 4% is more
informative in identifying areas of improvement, in
that 4 patients lacked documentation of prophylaxis
in their operative reports. We interpret this as either
complete lack of prophylaxis administration by the
anesthesiologist or, more likely, a failure to record
the time by the circulator. Seven patients in our
analysis also received antibiotics after incision time.
A check is now included in the time-out.
Although we can show compliance of prophy-
laxis is possible, if not better, in an outpatient facil-
ity than a hospital, we cannot definitively state that
prophylaxis decreases SSI incidence. Besides proper
draping30 and the extensive no-touch technique and
Keller funnels used with implant surgery,34,35 our
low infection rate could also possibly be attributable
to low sample size. The 0.24% SSI rate at the local
hospital is incredibly low compared with the 1.9%
national average, setting a high bar to which we com-
pare our infection rates.
Anigian et al9 show that difference in timing of
prophylaxis did not affect their complication rate,
and they debate the effectiveness for prophylaxis
in clean cases. Hsu et al analyzed the studies look-
ing at breast and other elective surgery—despite
the use of implants and nipple contamination risk,
there was a minimal difference in SSI in breast aug-
mentations when antibiotic prophylaxis was used
(0%–0.7%); however, in clean-contaminated cases
such as rhinoplasty, there was a significant difference
between prophylactic and nonprophylactic group
(0%–8.9%).26 A study by Landes et al36 showed that
despite widespread use of prophylaxis by plastic sur-
geons, SSI rates were still present and considered sig-
nificant—9.3% of 335 procedures.
Our facility continues using the Centers for Dis-
ease Control and Prevention-recommended options
and doses for antibiotic prophylaxis.1 Through re-
cords and codes, Centers for Medicare and Med-
icaid Services quality indicators show that smaller
office-based suites and ambulatory surgical centers
perform better than hospitals9,10; yet do not provide
adequate information or basis to compare elective
aesthetic surgery infection rates. Even national data-
bases that include cosmetic surgery data, such as the
National Surgical Quality Improvement Program or
Tracking Operations and Outcomes for Plastic Sur-
geons, are still difficult to analyze because certain
variables are unsearchable, are unspecific input nar-
rows specificity by procedure, and can include sub-
jective details during input.14,15 The average dose to
incision time was 15 minutes. This is less than hos-
pitals, which normally do 30 minutes to 1 hour. It is
a reflection of operating room efficiency and may
LaBove et al. Office-Based Elective Surgery
require modification if data become available that
identify more ideal timing. Modification may in-
clude administration of prophylaxis in holding, rath-
er than intraoperatively. Patient care is shifting from
inpatient hospital settings to ambulatory outpatient
settings, and accreditation services require evidence
of adherence to safety guidelines. Patients in general
are concerned with infection rates; studies such as
these allow patients to make educated choices.
The average antibiotic administration to cut time
was 15.095 minutes, closer to incision time than some
comparisons and within the recommended range of
1 hour. Perioperative administration times of a sin-
gle-dose antibiotic were recorded in 96% of the cases
examined, although no infections resulted from the
4% of cases in which perioperative antibiotic times
were not recorded or within an hour of incision. This
suggests that a controllable comparison of prophy-
laxis compliance was statistically better than national
rates. It also suggests that our facility’s compliance is
higher, yet statistically equal to a local hospital, with
the same team environment, when protocols are in
place, and that a culture of safety is possible in an
office-based surgical suite. Of the 277 surgeries ana-
lyzed, the SSI rate was 0.36%. This is significantly less
than the national average SSI rate of 1.9% and the
national plastic surgery rate of 3.675%, but not dif-
ferent than the local hospital’s plastic surgery rate
of 0.24%. This shows that an accredited office-based
suite following appropriate guidelines can meet or
exceed expectations for patient safety.
Steven P. Davison, DDS, MD
DAVinci Plastic Surgery
Georgetown University School of Medicine
3301 New Mexico Ave NW
Suite 236
WA, D.C. 20016
Monica Jackson, PhD
Department of Mathematics and Statistics
American University
4400 Massachusetts Avene NW
WA, D.C. 20016
1. Mangram, AJ, Horan TC, Pearson, MD, et al. Guideline for
Prevention of Surgical Site Infection. Atlanta, GA: Centers for
Disease Control and Prevention. 1999: 247–278.
2. Calise F, Capussotti L, Caterino S, et al. Perioperative an-
tibiotic prophylaxis in adults. Outline of the principal rec-
ommendations. National reference guidelines. Minerva
Anestesiol. 2009;75:543–547, 548–552.
3. Edminston CE Jr, Spencer M, Lewis B, et al. Reducing the
risk of surgical site infections: did we really think SCIP
was going to lead us to the promised land? Surg Infect
(Larchmt). 2011;12:169–177.
4. Liau KH, Aung KT, Chua N, et al. Outcome of a strategy
to reduce surgical site infection in a tertiary-care hospital.
Surg Infect (Larchmt). 2010;11:151–159.
5. Bratzler DW, Houck PM; Surgical Infection Prevention
Guidelines Writers Workgroup; American Academy of
Orthopaedic Surgeons; American Association of Critical Care
Nurses; American Association of Nurse Anesthetists; American
College of Surgeons; American College of Osteopathic
Surgeons; American Geriatrics Society; American Society
of Anesthesiologists; American Society of Colon and Rectal
Surgeons; American Society of Health-System Pharmacists;
American Society of PeriAnesthesia Nurses; Ascension Health;
Association of periOperative Registered Nurses; Association
for Professionals in Infection Control and Epidemiology;
Infectious Diseases Society of America; Medical Letter;
Premier; Society for Healthcare Epidemiology of America;
Society of Thoracic Surgeons; Surgical Infection Society.
Antimicrobial prophylaxis for surgery: an advisory statement
from the National Surgical Infection Prevention Project. Clin
Infect Dis. 2004;38:1706–1715.
6. Conley DM, Singer SJ, Edmondson L, et al. Effective
surgical safety checklist implementation. J Am Coll Surg.
7. Hranjec T, Swenson BR, Sawyer RG. Surgical site in-
fection prevention: how we do it. Surg Infect (Larchmt).
8. Dellinger EP. Prophylactic antibiotics: administration and
timing before operation are more important than admin-
istration after operation. Clin Infect Dis. 2007;44:928–930.
9. Anigian KT, Miller T, Constantine RS, et al. Effectiveness
of prophylactic antibiotics in outpatient plastic surgery.
Aesthet Surg J. 2014;34:1252–1258.
10. Physician Quality Reporting System. Baltimore, MD: Centers
for Medicare and Medicaid Services. https://www.cms.
Instruments/PQRS/. Accessed March 24, 2014.
11. Owens PL, Barrett ML, Raetzman S, et al. Surgical site in-
fections following ambulatory surgery procedures. JAMA.
12. Hall BL, Hamilton BH, Richards K, et al. Does surgical
quality improve in the American College of Surgeons
National Surgical Quality Improvement Program:
an evaluation of all participating hospitals. Ann Surg.
13. Alderman AK, Collins ED, Streu R, et al. Benchmarking
outcomes in plastic surgery: national complication rates
for abdominoplasty and breast augmentation. Plast
Reconstr Surg. 2009;124:2127–2133.
14. Hanwright PJ, Hirsch EM, Seth AK, et al. A multi-institu-
tional perspective of complication rates for elective non-
reconstructive breast surgery: an analysis of NSQIP data
from 2006 to 2010. Aesthet Surg J. 2013;33:378–386.
15. Mioton LM, Alghoul MS, Kim JY. A comparative analysis
of readmission rates after outpatient cosmetic surgery.
Aesthet Surg J. 2014;34:317–323.
16. Bratzler DW, Hunt DR. The surgical infection prevention
and surgical care improvement projects: national initia-
tives to improve outcomes for patients having surgery.
Clin Infect Dis. 2006;43:322–330.
17. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical prac-
tice guidelines for antimicrobial prophylaxis in surgery.
Am J Health-Syst Pharm. 2013;70:195–283.
PRS Global Open 2016
18. Smith B. Infection prevention in ambulatory surgery. OR
Nurse J. 2013:11–13.
19. Auerbach AD. Prevention of Surgical site infections.
Available at:
chap20a.htm. Accessed April 2016.
20. Haines K, RN, CNOR. Surgical site infections (ssi) follow-
ing orthopedic surgery. OR Connection 2012;7:29–38.
21. Bagdasarian N, Schmader KE, Kaye KS. The epidemi-
ology and clinical impact of surgical site infections in
the older adult. Burr Transl Geriatr Exp Gerontol Rep.
22. Kusachi S, Kashimura N, Konishi T, et al. Length of stay
and cost for surgical site infection after abdominal and
cardiac surgery in Japanese hospitals: multi-center sur-
veillance. Surg Infect (Larchmt). 2012;13:257–265.
23. de Lissovoy G, Fraeman K, Hutchins V, et al. Surgical site
infection: incidence and impact on hospital utilization
and treatment costs. Am J Infect Control. 2009;37:387–397.
24. Bratzler DW, Houck PM, Richards C, et al. Use of anti-
microbial prophylaxis for major surgery: baseline results
from the National Surgical Infection Prevention Project.
Arch Surg. 2005;140:174–182.
25. Surgical Care Improvement Project. The Joint Commission.
Available at:
care_improvement_project/. Accessed February 2014.
26. Hsu P, Bullocks J, Matthews M. Infection prophylaxis up-
date. Semin Plast Surg. 2006;204:241–248.
27. Moore D, McCabe G, Craig B. Introduction to the Practice of
Statistics. 7th ed. New York, NY: WH. Freeman; 2012.
28. Sibley Infectious Disease Department. Sibley Memorial Hospital
Infection Control Committee Data. 2012. Washington, DC.
29. Sibley Infectious Disease Department. Sibley Memorial
Hospital Surgical Site Infections Report. 2013. Washington, DC.
30. Periooperative Standards and Recommended Practices. Denver,
CO: AORN, Inc; 2014.
31. Nemeth TA, Beilman GJ, Hamlin CL, et al. Preoperative
verification of timely antimicrobial prophylaxis does not
improve compliance with guidelines. Surg Infect (Larchmt).
32. Nair BG, Newman SF, Peterson GN, et al. Feedback mech-
anisms including real-time electronic alerts to achieve
near 100% timely prophylactic antibiotic administration
in surgical cases. Anesth Analg. 2010;111:1293–1300.
33. Prospero E, Barbadoro P, Marigliano A, et al. Perioperative
antibiotic prophylaxis: improved compliance and impact
on infection rates. Epidemiol Infect. 2011;139:1326–1331.
34. Michael SG, Bell MD, Danial McKee. An illuminating
nou-touch device for breast augmentation. Can J Plast
Surg. 2009;17:30–31.
35. Moyer HR, Ghazi B, Saunders N, Losken A. Contamination
in smooth gel breast implant placement: testing a funnel
versus digital insertion technique in a cadaver model.
Aesthet Surg J. 2012;32:194–199.
36. Landes G, Harris PG, Lemaine V, et al. Prevention of
surgical site infection and appropriateness of antibiotic
prescribing habits in plastic surgery. J Plast Reconstr Aesthet
Surg. 2008;61:1347–1356.
... The Surgical Care Improvement Project recommends IV antibiotic prophylaxis between 30 and 59 minutes of incision (2 hours for vancomycin and fluoroquinolones). [101][102][103] Preoperative antibiotics should be tailored to the patient; cefazolin, or clindamycin in those with beta-lactam allergies, is commonly used. If the surgery lasts over 4 hours, repeat dosing is indicated. ...
Full-text available
Outpatient procedures are extremely prevalent in plastic surgery, with an estimated 82% of cosmetic plastic surgery occurring in this setting. Given that patient safety is paramount, this practical review summarizes major contemporary, evidence-based recommendations regarding office-based plastic surgery. These recommendations not only outline clinical aspects of patient safety guidelines, but administrative, as well, which in combination will provide the reader/practice with a structure and culture that is conducive to the commitment to patient safety. Proper protocols to address potential issues and emergencies that can arise in office-based surgery, and staff familiarity with thereof, are also necessary to be best prepared for such situations.
... However, maintaining inhibitory antimicrobial plasma and tissue levels during surgery depends not only on the timing of the first dose but also on antimicrobial redosing. These studies were either retrospective studies with no intervention or only a few interventions or focused on certain patient populations or clinical settings [11,[20][21][22][23][24][25][26]. Very few studies have incorporated multifaceted interventions and showed a sustained improvement in antibiotic redosing [14]. ...
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Background Compliance with perioperative antibiotic prophylaxis is crucial for preventing surgical site infection. Anesthesiologists can play a significant role in reducing surgical site infections by following clinical practice guidelines for antibiotic prophylaxis and redosing during surgery. A quality assurance initiative was implemented at a tertiary hospital with the goal of improving cefazolin perioperative antibiotic compliance. Methods A multifaceted intervention was initiated to address low compliance with cefazolin redosing. Multifaceted interventions included the development of a perioperative antibiotic guide for anesthesia providers, automated reminders in anesthesia electronic medical records, grand rounds education, survey and email communications, and regular feedback reports to the anesthesia department. Results Rates of redose compliance were examined in three time periods: pre-intervention, intervention, and post-intervention. Cefazolin redosing compliance was 58% in the pre-intervention period and 90% in the post-intervention period. There was a significant positive change in the trend of compliance during the intervention period, indicating that the odds of compliance increased by 13% per month in the intervention period compared to the pre-intervention period (odds ratio = 1.13, p<0.001). Redose compliance improvements were sustained a year after the post intervention period (average 91%). Surgical site infection rates for colon, coronary artery bypass graft and hip surgeries did not show any significant trend during these time periods. Conclusion Multifaceted interventions led to significant and sustained improvements in cefazolin redosing compliance in the main operating room of a tertiary hospital.
... As one of the most important medical measures to reduce SSIs, the WHO global guidelines strongly recommend the administration of pre-operative prophylactic antibiotic depending on the type of surgery 2 . Within the literature, the effectiveness of preoperative antibiotics in preventing post-operative infections in plastic surgery operations has been widely demonstrated [3][4][5][6] . One particular study has illustrated that in clean contaminated procedures, prophylactic antibiotics prevents wound dehiscence, bone mal-union, stitch and septal abscesses 7 . ...
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Background: Surgical antibiotic prophylaxis has been widely used for prevention of surgical site infections (SSI's). World Health Organization (WHO) global guidelines strongly recommend the administration of pre-operative prophylactic antibiotic, depending on the type of surgery, to reduce SSI's. However, within Gulf Cooperation Council (GCC) countries, antibiotic resistance has been rising due to unregulated prescribing practice. We aimed to assess adherence to local/international guidelines in the plastic surgery unit of Salmaniya Medical Complex. Methods: This study was a retrospective review of adults' undergoing plastic surgery between the dates of 1st of January 2019 to 30th of April 2019. Recommendations and guidelines were provided by South Australian Guidelines for Surgical Antimicrobial Prophylaxis, NHS Greater-Glasgow Foundation Trust. Salmaniya Medical Complex Guidelines were also taken into consideration. This was followed by an implementation of standardized guidelines and a re-assessment period for another four months. Results: There were 106 patients who met the inclusion/exclusion criteria throughout the primary cohort. With respect to choice and dose of antibiotics, only 21 (19.8%) of the procedures were adherent to global/local guidelines. Similarly, only 11.5% of those cases have met the recommended timing for pre-operative antibiotic administration. After the implementation period, adherence to guidelines regarding choice and time of antibiotic administration has increased to 36.8% and 32.6% respectively. SSI decreased from 1.8% to 0.08%. Conclusion: Practice in SMC in plastic surgery pre-operative antibiotic prophylaxis shows poor compliance to both local and international guidelines in terms of choice, dose, and time of administration. We were able to significantly improve adherence to international/local practice in both areas by implementing an integrated protocol in liaison with the medical staff involved in the plastic surgery unit and operating theatres.
... A meta-analysis by Stijn et al, demonstrated the importance of timing of administration (30-60 minutes prior to incision time), selection of agent for specific microbes (narrow spectrum antibiotics) and duration of prophylaxis (single pre-operative dose or intraoperative re-dosing if indicated) in prevention of SSI [2]. Unfortunately, non-compliance to guidelines is still observed and prolonged use of antibiotics leads to an increase in SSI rates and increased antimicrobial resistance rates [3][4][5]. An antimicrobial resistance situation analysis in 2015 in Tanzania indicated the resistance of Streptococcis pnemoniae to Trimethoprim and Sulphamethoxazole had increased from 25% in 2006 to 80% in 2012. ...
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Background Surgical Site Infections are a major cause of morbidity and mortality among operated patients. In spite of the accessibility of universal and national guidelines for surgical prophylaxis, recent studies surveying the present routine of prophylaxis have demonstrated overutilization of a wide range antibacterial medication for a single patient. Few studies have shown qualitatively factors influencing this and perceptions of surgeons on surgical antibiotic prophylaxis use. Unfortunately, none of these studies have been done in Tanzania. Objective To describe the perceptions of surgeons on surgical antibiotic prophylaxis use at an urban tertiary hospital. Methods A qualitative study involving in-depth interviews with surgeons was conducted in English by the primary investigator. The interviews were audio-recorded and transcribed verbatim. Systematic text condensation by Malterud was used for data analysis. Findings Fourteen surgeons and obstetrics and gynaecologists participated. Their perceptions were summarized into three main categories: Inadequate data to support practice; one who sees the patient decides the antibiotic prophylaxis; prolonged antibiotic use for fear of unknown. The participants perceived that choice of antibiotic should be based on local hospital data for bacterial resistance pattern, however the hospital guidelines and data for surgical site infection rates are unknown. Fear of getting infection and anticipating complications led to prolonged antibiotics use. Conclusion The study provides an understanding of surgical antibiotic prophylaxis use and its implementation challenges. This was partly expressed by unavailability of local data and guidelines to enhance practice. To improve this, there is a need of guidelines that incorporates local resistance surveillance data and enhanced antibiotic stewardship programmes. A strong consideration should be placed into ways to combat the fears of surgeons for complications, as these significantly affect the current practise with use of surgical antibiotic prophylaxis.
... We have already extensively studied and published on infection control in breast tissue. 32,33 Of course, the breast case becomes inherently colonized over the course of the surgical procedure; however, the sources of the infectious agents are the nipple ducts and axilla, not the instruments. We have found no evidence in the literature to suggest that changing instruments leads to a decrease in surgical site infection rates. ...
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As healthcare costs continue to rise at unsustainable rates (at an average rate of 5.5% a year), expenses without measurable outcomes need review.1 In reconstructive surgery, empiric change of instruments between oncologic and reconstructive segments of surgery is one such practice. Breast surgery for ductal carcinoma in situ (DCIS), prophylaxis, and partial extirpation has little possible increase in seeding or implantation risk based on the literature. With undue extrapolation from higher risk cancers (such as ovarian), preventative practices of changing out trays, re-gloving, re-gowning, re-preparing, and re-draping between phases persist in operating rooms across the country. From real case costs, the additional expense of 2 surgical setups in the United States is conservatively estimated at $1232 per case, or over $125 million per year for this theoretical risk. Using implantation risk for core breast biopsies as a denominator, this cost is $1.65-$5.8 million per potential recurrence. This is an unacceptably high cost for hypothetical recurrence risk reduction, especially one that does not impact survival outcomes.
The concept of enhanced recovery after surgery (ERAS) was developed in 2001 in order to create a multimodal, scientifically based approach to the development and audit of protocols for improving outcomes after surgical procedures. These protocols undergo constant evolution and evaluation toward the goal of quality of recovery. The BodyLift (BL) is the procedure that most comprehensively addresses the cosmetic needs of patients after massive weight loss (MWL). In the course of performing 136 consecutive outpatient BL surgeries over 7 years, we have developed a management protocol that has provided consistently high patient satisfaction, minimized frequent complications, and has documented 100% safety in all cases performed without deep vein thrombosis (DVT), transfusion and with 1 postoperative hospital admission. Each evidence-based component in the protocol was instituted to reduce risk of complications known to be most commonly associated with circumferential body contouring surgery. ERAS protocols are now widely used in many other surgical subspecialties. These protocols have the common goal of returning the patient to normal function as expeditiously as possible and are associated with decreased complications as well as shorter length-of-stay (LOS) and reduced costs. We have enumerated the many components of our protocol and aligned each with elements of an ERAS paradigm. In our retrospective review of 7 years of BL surgery (n = 136), this protocol has reduced both major and minor complications to previously unpublished levels. Our independently formulated ERAS protocol for outpatient BL surgery aligns closely with the ERAS concept, limiting surgical stress, thus reducing complications and affording a smooth and predictable perioperative experience. This is of importance for elective cosmetic surgery patients, who often have high expectations for an uneventful recovery and are unaccepting of potentially out-of-pocket costs associated with complications.
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Background: The effectiveness of prophylactic antibiotics has not been established for patients who undergo plastic surgery as outpatients, and consensus guidelines for antibiotic administration in clean-contaminated plastic surgery are not available. Objectives: In a retrospective study of outpatients, the authors examined preoperative timing of prophylactic antibiotics, whether postoperative antibiotics were administered, and whether any correlations existed between these practices and surgical complications. Methods: The medical records of 468 plastic surgery outpatients were reviewed. Collected data included preoperative antibiotic timing, postoperative antibiotic use, comorbidities, and complications. Rates of complications were calculated and compared with other data. Results: All 468 patients received antibiotics preoperatively, but only 93 (19.9%) received them ≥1 hour before the initial incision. Antibiotics were administered 15 to 44 minutes before surgery in 217 patients (46.4%). There was no significant difference in complication rates between the 315 patients who received postoperative prophylactic antibiotics (16.2%) and the 153 who did not (20.9%). Comorbidities had no bearing on postoperative complications. Conclusions: Postoperative antibiotic prophylaxis may be unnecessary for outpatient plastic surgery patients. Level of Evidence: 3
In January 2003, leadership of the Medicare National Surgical Infection Prevention Project hosted the Surgical Infection Prevention Guideline Writers Workgroup (SIPGWW) meeting. The objectives were to review areas of agreement among the most-recently published guidelines for surgical antimicrobial prophylaxis, to address inconsistencies, and to discuss issues not currently addressed. The participants included authors from most of the groups that have published North American guidelines for antimicrobial prophylaxis, as well as authors from several specialty colleges. Nominal group process was used to draft a consensus paper that was widely circulated for comment. The consensus positions of SIPGWW include that infusion of the first antimicrobial dose should begin within 60 min before surgical incision and that prophylactic antimicrobials should be discontinued within 24 h after the end of surgery. This advisory statement provides an overview of other issues related to antimicrobial prophylaxis, including specific suggestions regarding antimicrobial selection.
Surgical site infections can result in substantial morbidity following inpatient surgery. Little is known about serious infections following ambulatory surgery. To determine the incidence of clinically significant surgical site infections (CS-SSIs) following low- to moderate-risk ambulatory surgery in patients with low risk for surgical complications. Retrospective analysis of ambulatory surgical procedures complicated by CS-SSIs that require a postsurgical acute care visit (defined as subsequent hospitalization or ambulatory surgical visit for infection) using the 2010 Healthcare Cost and Utilization Project State Ambulatory Surgery and State Inpatient Databases for 8 geographically dispersed states (California, Florida, Georgia, Hawaii, Missouri, Nebraska, New York, and Tennessee) representing one-third of the US population. Index cases included 284 098 ambulatory surgical procedures (general surgery, orthopedic, neurosurgical, gynecologic, and urologic) in adult patients with low surgical risk (defined as not seen in past 30 days in acute care, length of stay less than 2 days, no other surgery on the same day, and discharged home and no infection coded on the same day). Rates of 14- and 30-day postsurgical acute care visits for CS-SSIs following ambulatory surgery. Postsurgical acute care visits for CS-SSIs occurred in 3.09 (95% CI, 2.89-3.30) per 1000 ambulatory surgical procedures at 14 days and 4.84 (95% CI, 4.59-5.10) per 1000 at 30 days. Two-thirds (63.7%) of all visits for CS-SSI occurred within 14 days of the surgery; of those visits, 93.2% (95% CI, 91.3%-94.7%) involved treatment in the inpatient setting. All-cause inpatient or outpatient postsurgical visits, including those for CS-SSIs, following ambulatory surgery occurred in 19.99 (95% CI, 19.48-20.51) per 1000 ambulatory surgical procedures at 14 days and 33.62 (95% CI, 32.96-34.29) per 1000 at 30 days. Among patients in 8 states undergoing ambulatory surgery, rates of postsurgical visits for CS-SSIs were low relative to all causes; however, they may represent a substantial number of adverse outcomes in aggregate. Thus, these serious infections merit quality improvement efforts to minimize their occurrence.
Background: Despite the increasing scrutiny of surgical procedures, outpatient cosmetic surgery has an established record of safety and efficacy. A key measure in assessing surgical outcomes is the examination of readmission rates. However, there is a paucity of data on unplanned readmission following cosmetic surgery procedures. Objectives: The authors studied readmission rates for outpatient cosmetic surgery and compared the data with readmission rates for other surgical procedures. Methods: The 2011 National Surgical Quality Improvement Program (NSQIP) data set was queried for all outpatient procedures. Readmission rates were calculated for the 5 surgical specialties with the greatest number of outpatient procedures and for the overall outpatient cosmetic surgery population. Subgroup analysis was performed on the 5 most common cosmetic surgery procedures. Multivariate regression models were used to determine predictors of readmission for cosmetic surgery patients. Results: The 2879 isolated outpatient cosmetic surgery cases had an associated 0.90% unplanned readmission rate. The 5 specialties with the highest number of outpatient surgical procedures were general, orthopedic, gynecologic, urologic, and otolaryngologic surgery; their unplanned readmission rates ranged from 1.21% to 3.73%. The 5 most common outpatient cosmetic surgery procedures and their associated readmission rates were as follows: reduction mammaplasty, 1.30%; mastopexy, 0.31%; liposuction, 1.13%; abdominoplasty, 1.78%; and breast augmentation, 1.20%. Multivariate regression analysis demonstrated that operating time (in hours) was an independent predictor of readmission (odds ratio, 1.40; 95% confidence interval, 1.08–1.81; P = .010). Conclusions: Rates of unplanned readmission with outpatient cosmetic surgery are low and compare favorably to those of other outpatient surgeries.
Surgical site infections (SSI) are the second most frequent healthcare-associated infection (HAI), accounting for approximately 20 % of all HAIs in the United States, and an important cause of morbidity and mortality in older adults. With the aging of the population and the expected increase in surgical procedures in the elderly, strategies for prevention and treatment of SSI, will assume increased importance. In this review we describe risk factors for and outcomes associated with SSI, and recommend treatment and prevention strategies for SSI in older adults.
EXECUTIVE SUMMARYThe “Guideline for Prevention of Surgical Site Infection, 1999” presents the Centers for Disease Control and Prevention (CDC)’s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.1 and 2 Part I, “Surgical Site Infection: An Overview,” describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis. Part II, “Recommendations for Prevention of Surgical Site Infection,” represents the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) regarding strategies for the prevention of SSIs.3 Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, there are a limited number of studies that clearly validate risk factors and prevention measures for SSI. By necessity, available studies have often been conducted in narrowly defined patient populations or for specific kinds of operations, making generalization of their findings to all specialties and types of operations potentially problematic. This is especially true regarding the implementation of SSI prevention measures. Finally, some of the infection control practices routinely used by surgical teams cannot be rigorously studied for ethical or logistical reasons (e.g., wearing vs not wearing gloves). Thus, some of the recommendations in Part II are based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific knowledge. It has been estimated that approximately 75% of all operations in the United States will be performed in “ambulatory,” “same-day,” or “outpatient” operating rooms by the turn of the century.4 In recommending various SSI prevention methods, this document makes no distinction between surgical care delivered in such settings and that provided in conventional inpatient operating rooms. This document is primarily intended for use by surgeons, operating room nurses, postoperative inpatient and clinic nurses, infection control professionals, anesthesiologists, healthcare epidemiologists, and other personnel directly responsible for the prevention of nosocomial infections. This document does not:•Specifically address issues unique to burns, trauma, transplant procedures, or transmission of bloodborne pathogens from healthcare worker to patient, nor does it specifically address details of SSI prevention in pediatric surgical practice. It has been recently shown in a multicenter study of pediatric surgical patients that characteristics related to the operations are more important than those related to the physiologic status of the patients.5 In general, all SSI prevention measures effective in adult surgical care are indicated in pediatric surgical care.•Specifically address procedures performed outside of the operating room (e.g., endoscopic procedures), nor does it provide guidance for infection prevention for invasive procedures such as cardiac catheterization or interventional radiology. Nonetheless, it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures.•Specifically recommend SSI prevention methods unique to minimally invasive operations (i.e., laparoscopic surgery). Available SSI surveillance data indicate that laparoscopic operations generally have a lower or comparable SSI risk when contrasted to open operations.6, 7, 8, 9, 10 and 11 SSI prevention measures applicable in open operations (e.g., open cholecystectomy) are indicated for their laparoscopic counterparts (e.g., laparoscopic cholecystectomy).•Recommend specific antiseptic agents for patient preoperative skin preparations or for healthcare worker hand/forearm antisepsis. Hospitals should choose from products recommended for these activities in the latest Food and Drug Administration (FDA) monograph. 12
Background: As elective nonreconstructive breast surgery increases in popularity, there is greater demand for accurate multi-institutional data on minor and major postoperative complications. Objective: The authors utilized a multi-institutional database to compare 30-day morbidities and reoperation rates among the different types of elective nonreconstructive breast surgery. Methods: Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective nonreconstructive breast surgery between 2006 and 2010 were identified. Twenty defined morbidities were compared among mastopexy, reduction mammaplasty, and augmentation mammaplasty patients using analysis of variance and χ2 tests for continuous variables and categorical variables, respectively. Logistic regression modeling was employed to identify preoperative risk factors for complications. Results: Of the 3612 patients identified, 380 underwent mastopexy, 2507 underwent reduction mammaplasty, and 725 underwent augmentation mammaplasty. Complication rates were low in all cohorts, and patients undergoing augmentation mammaplasty had the lowest overall complication rate compared with mastopexy and reduction mammaplasty (1.24%, 2.37%, and 4.47%). Patients undergoing reduction mammaplasty had a modestly elevated incidence of overall morbidity, superficial surgical site infections, and wound disruptions (P < .05). Moreover, 30-day reoperation rates for mastopexy, reduction mammaplasty, and augmentation mammaplasty were low (1.58%, 2.07%, and 0.97%), as were the rates of life-threatening complications (0%, 0.16%, and 0%). One death was observed for all 3612 procedures (0.03%). Conclusions: Elective breast surgery is a safe procedure with an extremely low incidence of life-threatening complications and mortality. Comprehensive data collated from the NSQIP initiative add to the literature, and the findings of this multi-institutional study may help further guide patient education and expectations on potentially deleterious outcomes. Level of Evidence: 3