Appropriate Prophylactic Antibiotic Use in Plastic Surgery: The Time Has Come

Surgical site infections are the second most common type of nosocomial infection today. The appropriate use of prophylactic antibiotics has been demonstrated to reduce surgical site infection rates, as well as infection-related morbidity rates and health-care costs, for a number of surgical procedures. Prevention of surgical site infections is a national patient safety goal.1 Unfortunately, as a group, plastic surgeons tend to use prophylactic antibiotics inappropriately. There is no debate about this. It has been repeatedly documented by surgeon practice surveys, literature reviews, and critiques in this Journal and elsewhere.2–6 Although authoritative, widely accepted, evidence-based guidelines for appropriate prophylactic antibiotic agent selection and administration timing and duration exist,7 many plastic surgeons ignore (or are unaware of) them. We generally use prophylactic antibiotics too often and for too long. Over the past several decades, the use of prophylactic antibiotics in plastic surgery, especially for aesthetic procedures, has increased dramatically, yet there is no scientific evidence demonstrating changes in infection rates or antibiotic efficacy.2 The continued anecdotal use of prophylactic antibiotics by plastic surgeons has often been defended by the contention that the necessary scientifically valid data to provide evidence-based guidelines for appropriate prophylactic antibiotic use for most plastic surgery procedures do not exist.2 Although this assertion perhaps can be used to rationalize the dubious administration of a prophylactic antibiotic for a clean procedure such as blepharoplasty, there is absolutely no justification for prolonged and/or poorly timed use and unsuitable agent selection. Despite the rapid proliferation, since 2003, of patient safety and appropriate antibiotic use–dominated surgical quality improvement initiatives (such as the Surgical Care Improvement Project8), which have been embraced by other surgical specialties, plastic surgeons still engage in such practices with unfortunate regularity. Suggestions for the appropriate use of prophylactic antibiotics, relevant for essentially all plastic surgery procedures, are listed in Table 1.7Table 1: Suggestions for Prophylactic Antibiotic Use in Plastic SurgeryA major health-care quality initiative, directed not at hospitals but, for the first time, at all physicians, should ultimately force change in our prophylactic antibiotic use practices. The nascent reengineering of health-care delivery and financing in the United States became “real” for physicians (including plastic surgeons) on July 1, 2007, with implementation of Medicare’s Physician Quality Reporting Initiative. Although voluntary, the Initiative is clearly a first step toward mandatory quality reporting by individual physicians; it is essentially a pay-for-performance program “with training wheels.” The Initiative requires that participating physicians choose three quality measures (from a menu of 74) on which they will report for relevant services or procedures performed on their Medicare patients between July 1 and December 31, 2007. Physicians meeting an 80 percent reporting rate for the chosen measures during the 6-month period will receive a 1.5 percent bonus payment for all allowed Medicare charges during that time period.9 For surgical procedures, the quality measures that have been developed (a collaborative effort in which the Surgical Quality Alliance, of which the American Society of Plastic Surgeons is a member, participated) and approved by the National Quality Forum constitute the Perioperative Care Measure Set. The measure set contains three prophylactic antibiotic use performance measures relevant to plastic surgeons: selection of prophylactic antibiotic agent, timing of antibiotic prophylaxis administration, and discontinuation of prophylactic antibiotics. Compliance requires the use of a first- or second-generation cephalosporin antibiotic (unless the patient has a beta-lactam allergy), antibiotic administration within 1 hour before the incision is made (2 hours for vancomycin), and discontinuation of antibiotics within 24 hours of surgery end time.9,10 So how will the Physician Quality Reporting Initiative change the prophylactic antibiotic utilization patterns of those surgeons who do not participate? The collected data will undoubtedly be used by the Centers for Medicare and Medicaid Services to create performance benchmarks for each quality indicator. The information will be publicly reported; it will be scrutinized by consumers, businesses, insurance carriers, medical societies, hospitals, and regulatory agencies. “Best practices” will be established, and practice guidelines will be promulgated. Individual physicians will receive performance feedback comparing their performance with that of their peer groups. Quality and performance measures are here to stay and will continue to proliferate. They will ultimately affect every one of us, even if we never set foot in a hospital or participate in any insurance plans. In the near future, maintenance of licensure and board certification will, in part, require quality and performance measure reporting and compliance. Physician practice patterns will become much more transparent. Have no misconception, we will be evaluated, and judged! Achieving appropriate prophylactic antibiotic use in surgery represents “low-hanging fruit” for the health-care policy wonks championing surgical quality improvement. Accepting and complying with prophylactic antibiotic-related performance measures is relatively easy; other existing measures (such as appropriate venous thromboembolism prophylaxis, also part of the Perioperative Care Measure Set), and those yet to come our way, will undoubtedly be more difficult for plastic surgeons to widely accept and comply with. It is time to accept the “new realities” of health care. Plastic surgeons can—and must—begin by appropriately using prophylactic antibiotics. DISCLOSURE The author has no financial interests to disclose.