The Use of Preoperative Antibiotics in Elective Soft-Tissue Procedures in the Hand

Abstract

» The use of preoperative antibiotic prophylaxis is not supported for elective cases of patients undergoing soft-tissue hand procedures that are ≤2 hours in length. » The use of preoperative antibiotic prophylaxis is not supported for patients with diabetes undergoing elective, soft-tissue hand surgical procedures. » There is a paucity of literature evaluating the use of preoperative antibiotic prophylaxis in patients with rheumatoid arthritis, those with cardiac valves, and those taking corticosteroids; because of this, there is no evidence to vary from our general recommendations. Surgical site infections are a major source of morbidity and impose a large economic burden in orthopaedic surgery 1-3. Preoperative antibiotic prophylaxis is commonly used to prevent surgical site infection. Although there is evidentiary support for the use of preoperative antibiotic prophylaxis for many orthopaedic procedures (e.g., open fractures 4-6 , lowerextremity fractures 7-9 , and total joint replacement 10-12), the use of preoperative antibiotic prophylaxis for elective soft-tissue hand surgical procedures is controversial 13,14. For example, current recommendations from the American Association of Plastic Surgeons are to not utilize preoperative antibiotic prophylaxis for clean hand surgical procedures, and current recommendations from the American Academy of Orthopaedic Surgeons are to not utilize preoperative antibiotic prophylaxis for carpal tunnel release 15,16. Despite these recommendations, 2 surveys of hand surgeons reported rates of antibiotic use for carpal tunnel syndrome between 31% and 49% 17,18. Although millions of soft-tissue hand procedures are performed each year 19,20 , the rate of infection is reported to be low, with studies showing infection rates between 0.3% and 1.5% 13,21-25 for elective cases (e.g., carpal tunnel release and trigger finger release). Although the rate of infection for urgent soft-tissue cases is reported to be higher (e.g., 1.1% to 9.8% for lacerations, open fractures, or bite injuries 26-28), this review will focus on elective soft-tissue surgical procedures (e.g., carpal tunnel release, trigger finger release, Dupuytren contracture release). Despite the low rate of infections, complications can be devastating, leading to soft-tissue loss, stiffness, scarring, and amputation 29. Preoperative antibiotic prophylaxis, given to prevent infection, is associated with its own complications,

The Impact of Clinical Practice Guidelines on Preoperative Antibiotic Administration for Carpal Tunnel Release

“…Multiple studies have found that diabetes is not associated with increased risk for infection following outpatient hand surgery. 6,10 This is an area for improvement and continued discussion at our institution, and may be relevant at other institutions as well.…”

“…5 A 2019 review article concluded that the use of preoperative antibiotic prophylaxis (AP) is not supported for elective cases of patients undergoing soft tissue hand procedures less than 2 hours in length, even in patients with diabetes. 6…”

“…5 A 2019 review article concluded that the use of preoperative antibiotic prophylaxis (AP) is not supported for elective cases of patients undergoing soft tissue hand procedures less than 2 hours in length, even in patients with diabetes. 6 Despite this, preoperative AP in clean hand surgery remains common. In a survey of 716 hand surgeons in 2015, roughly half of the respondents routinely administered preoperative antibiotics before open CTR.…”

The Use of Preoperative Antibiotics in Hardware-Based Hand Procedures Is Not Necessary

“…More recent data support foregoing the use of preoperative antibiotics for routine, outpatient, soft-tissue procedures, including carpal tunnel, cubital tunnel, and trigger finger releases. [2][3][4][5][6] Antibiotics are not benign and have complications of their own, even when given as one dose, including allergic reactions, resistance, and Clostridium difficile infections. 7 There is a paucity of data for the need for preoperative antibiotics for hardware-based hand procedures.…”

Periprosthetic Joint Infection Following Clean Hand Surgery: A Systematic Review

“… 10 Although current consensus guidelines recommend against the use of prophylaxis prior to clean, soft-tissue procedures, the perceived advantages of antibiotics have led to their widespread use. 10 , 11 , 12 , 13 , 14 Demonstrated benefits of prophylactic antibiotics have been reported in cases of dog and human bites, elbow arthroplasty, and emergency hand operations. 15 , 16 , 17 , 18 In contrast, evidence against prophylaxis suggests that surgical factors, such as poor sterile techniques and operating room setups, or patient-related factors, such as tobacco use and diabetes mellitus, may play greater roles in infection risk.…”