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www.PRSGlobalOpen.com 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
operation.1
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.
xxx
xxx
5
Manjula
Plastic & Reconstructive Surgery-Global Open
2016
4
Original Article
10.1097/GOX.0000000000000704
9March2016
14January2016
© 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American
Society of Plastic Surgeons. All rights reserved.
Cosmetic
ORIGINAL ARTICLE
PRS Global Open • 2016
2
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.
METHODS
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.
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
3
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
RESULTS
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-Specic 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
4
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.
DISCUSSION
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
5
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.
CONCLUSION
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
E-mail: kylie@davinciplastic.com
Monica Jackson, PhD
Department of Mathematics and Statistics
American University
4400 Massachusetts Avene NW
WA, D.C. 20016
E-mail: monica@american.edu
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