International comparison of guidelines for management of impetigo: a systematic review.

BACKGROUND: Impetigo is a common superficial skin infection that affects people worldwide and is usually treated with antibiotics; therefore, its management has implications for global antibiotic stewardship. OBJECTIVE: This systematic review and narrative synthesis compares and contrasts international impetigo management guidelines. METHODS: Guidelines for treatment of impetigo that were produced by a national authority; available to primary care physicians; and published since 2008 were included. Following a comprehensive search strategy, data extraction from eligible studies was performed independently in duplicate. Details of antiseptic and antibiotic treatment; methicillin-resistant Staphylococcus aureus treatment; and conservative management and preventative measures were tabulated and analysed descriptively. RESULTS: Fifty-one guidelines were included from 42 different countries. All guidelines recommended systemic antibiotics, 78% of these only for widespread lesions or failure of topical antibiotic treatment. The first-line systemic antibiotic treatment was restricted to narrow-spectrum options in 21 (41%) whilst 7 (14%) recommended only broad-spectrum antibiotics first-line. Thirty-four (67%) guidelines included recommendations for topical antibiotic use. Twenty guidelines (39%) did not mention antiseptic treatment for impetigo. Guidelines did not always provide clear indications for different treatment options. CONCLUSIONS: Despite potentially equal efficacy to systemic antibiotics, only two-thirds of guidelines include topical antibiotic options. Many fail to include recommendations for non-antibiotic treatments such as antiseptics, preventative measures and conservative management, despite potential for antibiotic-sparing. Provision of clear definitions of disease severity and indications for treatment would enhance the ability of clinicians to adhere to recommendations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018117770.

Effect of a Single Preoperative Dose of Oral Antibiotic to Reduce the Incidence of Surgical Site Infection Following Below-Knee Dermatological Flap and Graft Repair.

BACKGROUND: Surgical site infection (SSI) rates for below-knee dermatological surgery are unacceptably high, particularly following complex flap and graft closures. The role of antibiotic prophylaxis for these surgical cases is uncertain. OBJECTIVE: To determine whether SSI following complex dermatological closures on the leg could be reduced by antibiotic prophylaxis administered as a single oral preoperative dose. METHODS: A total of 115 participants were randomized to 2 g of oral cephalexin or placebo 40-60 minutes prior to surgical incision in a prospective, randomized, double-blind, placebo-controlled trial at a primary care skin cancer clinic in North Queensland, Australia. RESULTS: Overall 17/55 (30.9%) controls and 14/55 (25.5%) intervention participants developed infection (P = 0.525). There was no difference between the study groups in adverse symptoms that could be attributed to high-dose antibiotic administration (P = 1). CONCLUSION: A single oral 2-g dose of cephalexin given before complex below-knee dermatological closure did not reduce SSI.

Effect of a single prophylactic preoperative oral antibiotic dose on surgical site infection following complex dermatological procedures on the nose and ear: a prospective, randomised, controlled, double-blinded trial.

OBJECTIVES: There is limited published research studying the effect of antibiotic prophylaxis on surgical site infection (SSI) in dermatological surgery, and there is no consensus for its use in higher-risk cases. The objective of this study was to determine the effectiveness of a single oral preoperative 2 g dose of cephalexin in preventing SSI following flap and graft dermatological closures on the nose and ear. DESIGN: Prospective double-blinded, randomised, placebo-controlled trial testing for difference in infection rates. SETTING: Primary care skin cancer clinics in North Queensland, Australia, were randomised to 2 g oral cephalexin or placebo 40-60 min prior to skin incision. PARTICIPANTS: 154 consecutive eligible patients booked for flap or graft closure following skin cancer excision on the ear and nose. INTERVENTION: 2 g dose of cephalexin administered 40-60 min prior to surgery. RESULTS: Overall 8/69 (11.6%) controls and 1/73 (1.4%) in the intervention group developed SSI (p=0.015; absolute SSI reduction 10.2%; number needed to treat (NNT) for benefit 9.8, 95% CI 5.5 to 45.5). In males, 7/44 controls and 0/33 in the intervention group developed SSI (p=0.018; absolute SSI reduction 15.9%; NNT for benefit 6.3, 95% CI 3.8 to 19.2). SSI was much lower in female controls (1/25) and antibiotic prophylaxis did not further reduce this (p=1.0). There was no difference between the study groups in adverse symptoms attributable to high-dose antibiotic administration (p=0.871). CONCLUSION: A single oral 2 g dose of cephalexin given before complex skin closure on the nose and ear reduced SSI. TRIAL REGISTRATION NUMBER: ANZCTR 365115; Post-results.

Alcoholic versus aqueous chlorhexidine for skin antisepsis: the AVALANCHE trial.

BACKGROUND: Preoperative skin antisepsis is routine practice. We compared alcoholic chlorhexidine with aqueous chlorhexidine for skin antisepsis to prevent surgical site infection after minor skin excisions in general practice. METHODS: We conducted this prospective, multicentre, randomized controlled trial in 4 private general practices in North Queensland, Australia, from October 2015 to August 2016. Consecutive adult patients presenting for minor skin excisions were randomly assigned to undergo preoperative skin antisepsis with 0.5% chlorhexidine in 70% ethanol (intervention) or 0.5% chlorhexidine aqueous solution (control). Our primary outcome was surgical site infection within 30 days of excision. We also measured the incidence of adverse reactions. RESULTS: A total of 916 patients were included in the study: 454 underwent antisepsis with alcoholic chlorhexidine and 462 with aqueous chlorhexidine. Of these, 909 completed follow-up. In the intention-to-treat analysis of cases available at follow-up, there was no significant difference in the incidence of surgical site infection between the alcoholic chlorhexidine arm (5.8%, 95% confidence interval [CI] 3.6% to 7.9%) and the aqueous chlorhexidine arm (6.8%, 95% CI 4.5% to 9.1%). The attributable risk reduction was 0.010 (95% CI -0.021 to 0.042), the relative risk was 0.85 (95% CI 0.51 to 1.41), and the number needed to treat to benefit was 100. Per protocol and sensitivity analyses produced similar results. The incidence of adverse reactions was low, with no difference between groups (p = 0.6). INTERPRETATION: There was no significant difference in efficacy between alcoholic and aqueous chlorhexidine for the prevention of surgical site infection after minor skin excisions in general practice. Trial registration: https://www.anzctr.org.au, no. ACTRN12615001045505.

Topical antibiotics for preventing surgical site infection in wounds healing by primary intention.

BACKGROUND: Surgical site infections (SSI) can delay wound healing, impair cosmetic outcome and increase healthcare costs. Topical antibiotics are sometimes used to reduce microbial contaminant exposure following surgical procedures, with the aim of reducing SSIs. OBJECTIVES: The primary objective of this review was to determine whether the application of topical antibiotics to surgical wounds that are healing by primary intention reduces the incidence of SSI and whether it increases the incidence of adverse outcomes (allergic contact dermatitis, infections with patterns of antibiotic resistance and anaphylaxis). SEARCH METHODS: In May 2015 we searched: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL. We also searched clinical trial registries for ongoing studies, and bibliographies of relevant publications to identify further eligible trials. There was no restriction of language, date of study or setting. The search was repeated in May 2016 to ensure currency of included studies. SELECTION CRITERIA: All randomized controlled trials (RCTs) and quasi-randomised trials that assessed the effects of topical antibiotics (any formulation, including impregnated dressings) in people with surgical wounds healing by primary intention were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies and independently extracted data. Two authors then assessed the studies for risk of bias. Risk ratios were calculated for dichotomous variables, and when a sufficient number of comparable trials were available, trials were pooled in a meta-analysis. MAIN RESULTS: A total of 10 RCTs and four quasi-randomised trials with 6466 participants met the inclusion criteria. Six studies involved minor procedures conducted in an outpatient or emergency department setting; eight studies involved major surgery conducted in theatre. Nine different topical antibiotics were included. We included two three-arm trials, two four-arm trials and 10 two-arm trials. The control groups comprised; an alternative topical antibiotic (two studies), topical antiseptic (six studies) and no topical antibiotic (10 studies), which comprised inert ointment (five studies) no treatment (four studies) and one study with one arm of each.The risk of bias of the 14 studies varied. Seven studies were at high risk of bias, five at unclear risk of bias and two at low risk of bias. Most risk of bias concerned risk of selection bias.Twelve of the studies (6259 participants) reported infection rates, although we could not extract the data for this outcome from one study. Four studies (3334 participants) measured allergic contact dermatitis as an outcome. Four studies measured positive wound swabs for patterns of antimicrobial resistance, for which there were no outcomes reported. No episodes of anaphylaxis were reported. Topical antibiotic versus no topical antibioticWe pooled the results of eight trials (5427 participants) for the outcome of SSI. Topical antibiotics probably reduce the risk of SSI in people with surgical wounds healing by primary intention compared with no topical antibiotic (RR 0.61, 95% CI 0.42 to 0.87; moderate-quality evidence downgraded once for risk of bias). This equates to 20 fewer SSIs per 1000 patients treated with topical antibiotics (95% CI 7 to 29) and a number needed to treat for one additional beneficial outcome (NNTB) (i.e. prevention of one SSI) of 50.We pooled the results of three trials (3012 participants) for the outcome of allergic contact dermatitis, however this comparison was underpowered, and it is unclear whether topical antibiotics affect the risk of allergic contact dermatitis (RR 3.94, 95% CI 0.46 to 34.00; very low-quality evidence, downgraded twice for risk of bias, once for imprecision). Topical antibiotic versus antiseptic We pooled the results of five trials (1299 participants) for the outcome of SSI. Topical antibiotics probably reduce the risk of SSI in people with surgical wounds healing by primary intention compared with using topical antiseptics (RR 0.49, 95% CI 0.30 to 0.80; moderate-quality evidence downgraded once for risk of bias). This equates to 43 fewer SSIs per 1000 patients treated with topical antibiotics instead of antiseptics (95% CI 17 to 59) and an NNTB of 24.We pooled the results of two trials (541 participants) for the outcome of allergic contact dermatitis; there was no clear difference in the risk of dermatitis between topical antibiotics and antiseptics, however this comparison was underpowered and a difference cannot be ruled out (RR 0.97, 95% CI 0.52 to 1.82; very low-quality evidence, downgraded twice for risk of bias and once for imprecision). Topical antibiotic versus topical antibioticOne study (99 participants) compared mupirocin ointment with a combination ointment of neomycin/polymyxin B/bacitracin zinc for the outcome of SSI. There was no clear difference in the risk of SSI, however this comparison was underpowered (very low-quality evidence downgraded twice for risk of bias, once for imprecision).A four-arm trial involved two antibiotic arms (neomycin sulfate/bacitracin zinc/polymyxin B sulphate combination ointment versus bacitracin zinc, 219 participants). There was no clear difference in risk of SSI between the combination ointment and the bacitracin zinc ointment. The quality of evidence for this outcome was low, downgraded once for risk of bias, and once for imprecision. AUTHORS' CONCLUSIONS: Topical antibiotics applied to surgical wounds healing by primary intention probably reduce the risk of SSI relative to no antibiotic, and relative to topical antiseptics (moderate quality evidence). We are unable to draw conclusions regarding the effects of topical antibiotics on adverse outcomes such as allergic contact dermatitis due to lack of statistical power (small sample sizes). We are also unable to draw conclusions regarding the impact of increasing topical antibiotic use on antibiotic resistance. The relative effects of different topical antibiotics are unclear.

Prevention of surgical site infection in lower limb skin lesion excisions with single dose oral antibiotic prophylaxis: a prospective randomised placebo-controlled double-blind trial.

OBJECTIVES: To determine the effectiveness of a single perioperative prophylactic 2 g dose of cephalexin in preventing surgical site infection (SSI) following excision of skin lesions from the lower limb. DESIGN: Prospective double-blinded placebo-controlled trial testing for difference in infection rates. SETTING: Primary care in regional North Queensland, Australia. PARTICIPANTS: 52 patients undergoing lower limb skin lesion excision. INTERVENTIONS: 2 g dose of cephalexin 30-60 min before excision. MAIN OUTCOME MEASURES: Incidence of SSI. RESULTS: Incidence of SSI was 12.5% (95% CI 2.7% to 32.4%) in the cephalexin group compared with 35.7% (95% CI 18.6% to 55.9%) in the placebo group (p=0.064). This represented an absolute reduction of 23.21% (95% CI -0.39% to 46.82%), relative reduction of 65.00% (95% CI -12.70% to 89.13%) and number-needed-to-treat of 4.3. CONCLUSIONS: Administration of a single 2 g dose of cephalexin 30-60 min before skin lesion excision from the lower limb may produce a reduction in the incidence of infection; however, this study was underpowered to statistically determine this. TRIAL REGISTRATION NUMBER: ACTRN12611000595910.

Adherence to Canadian C-Spine Rule in a regional hospital: a retrospective study of 406 cases.

INTRODUCTION: Cervical spine radiography may be over-utilised in an emergency department setting. The Canadian C-Spine Rule has been developed to reduce unnecessary radiography. Our aim was to retrospectively determine the proportion of cervical spine radiographs requested through the emergency department for trauma patients that were clinically indicated, according to the Canadian C-Spine Rule. METHODS: This was a cross-sectional survey conducted at a regional centre in Northern Queensland, Australia. All cervical spine radiographs for trauma, performed at the Mackay Base Hospital from 1 January 2009 to the 31 December 2009, were reviewed. The relevant patient charts were audited for evidence of indications for radiography. RESULTS: Of 406 patients in the study, 155 patients (38%) (95% confidence interval 33.3%, 42.7%) had cervical spine imaging performed that was not indicated according to the Canadian C-Spine Rule. None of these patients had a significant cervical spine injury on radiography. CONCLUSION: Applying the Canadian C-Spine Rule would have safely reduced the incidence of cervical spine radiography by 38%. This would also reduce costs, patient morbidity and radiation exposure.

Risk factors for surgical site infection after dermatological surgery.

OBJECTIVES: Surgical site infection (SSI) following minor surgery contributes to patient morbidity and compromises cosmetic outcomes. The purpose of this study was to determine the incidence of and risk factors for SSI after dermatological surgery in general practice. METHODS: A prospective, observational study which assessed infection among 972 patients was conducted in regional north Queensland, Australia. Consecutive patients presenting for minor skin excisions were invited to participate. Wounds were assessed for SSI at the time of removal of sutures. RESULTS: Infection occurred in 85 of the 972 excisions; thus, the overall incidence of infection was 8.7% (95% confidence interval 6.5-11.0). Excisions in the upper (P<0.001) or lower (P<0.001) extremities, excisions of basal cell carcinoma (BCC) (P=0.001) or squamous cell carcinoma (SCC) (P=0.001), and re-excision of skin cancer were found to be independent risk factors for wound infection. The length of the excision (P<0.001) and the patient's status as an ex-smoker (P=0.019) were additional independent risk factors for infection. Diabetes was not found to be an independent risk factor for infection (P=0.891). CONCLUSIONS: Prophylactic antibiotics are probably prescribed excessively or inappropriately for dermatological surgery, and overall we wish to discourage their use. The results of this study may encourage the more judicial use of prophylactic antibiotics by defining high-risk procedures, such as excisions from the extremities, excision of BCC or SCC, and larger excisions, and patients who are at high risk for infection, such as ex-smokers.

Agreement between histological diagnosis of skin lesions by histopathologists and a dermato-histopathologist.

BACKGROUND: Skin cancer is an increasing problem in fair-skinned populations worldwide. It is important that doctors are able to diagnose skin lesions accurately, and this is supported by accurate histological diagnosis. OBJECTIVE: To compare agreement for histological diagnosis between local histopathologists with a dermato-histopathologist from a stratified random sample of excised skin lesions derived from a set of epidemiological data. METHODS: All excised and histologically confirmed skin cancers in Townsville/Thuringowa, Australia from December 1996 to October 1999 were recorded. A stratified sample of 407 of 8694 skin excisions slides was analyzed. Results Positive predictive values (PPVs) for the primary histological diagnosis were above 90% for basal cell carcinoma, cutaneous melanoma, and common naevus. For squamous cell carcinoma (SCC), the PPV was 72.6% [95% CI = (65.5, 79.0)]. DISCUSSION: Lack of agreement between histopathologists regarding the diagnosis of SCC and actinic keratosis has been previously recognized in the literature and this is again reflected in our study. The result also illustrates the difficulty involved for doctors in accurately clinically diagnosing lesions for which a consensus is hard to reach histologically.

Does single application of topical chloramphenicol to high risk sutured wounds reduce incidence of wound infection after minor surgery? Prospective randomised placebo controlled double blind trial.

OBJECTIVE: To determine the effectiveness of a single application of topical chloramphenicol ointment in preventing wound infection after minor dermatological surgery. DESIGN: Prospective randomised placebo controlled double blind multicentre trial. SETTING: Primary care in a regional centre in Queensland, Australia. PARTICIPANTS: 972 minor surgery patients. INTERVENTIONS: A single topical dose of chloramphenicol (n=488) or paraffin ointment (n=484; placebo). MAIN OUTCOME MEASURE: Incidence of infection. RESULTS: The incidence of infection in the chloramphenicol group (6.6%; 95% confidence interval 4.9 to 8.8) was significantly lower than that in the control group (11.0%; 7.9 to 15.1) (P=0.010). The absolute reduction in infection rate was 4.4%, the relative reduction was 40%, and the relative risk of wound infection in the control group was 1.7 (95% confidence interval 1.1 to 2.5) times higher than in the intervention group. The number needed to treat was 22.8. CONCLUSION: Application of a single dose of topical chloramphenicol to high risk sutured wounds after minor surgery produces a moderate absolute reduction in infection rate that is statistically but not clinically significant. Trial registration Current Controlled Trials ISRCTN73223053.

Practice based research - lessons from the field.

BACKGROUND: The authors sought to describe the process of conducting a successful randomised controlled trial in a primary care setting and identify enabling factors and barriers. METHODS: Descriptive report of methods used to conduct a randomised controlled trial investigating the effect of allowing sutures to be wet and uncovered in the first 48 hours following minor excisions. RESULTS: The trial identified several enabling factors and barriers to conducting research in a primary care setting. The project described in this article was successful because a group of general practitioners sought to answer an interesting question which was relevant to their clinical practice and which had not been answered by current evidence. DISCUSSION: The findings are likely to assist groups seeking to conduct practice based research in the primary care setting.