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The rates of cutaneous infection in Mohs micrographic surgery are generally low. However, there are specific indications for the use of antibiotics in certain cases. Preoperative or perioperative antibiotics are commonly prescribed for patients who are susceptible to endocarditis and prosthetic joint infection. In some situations, postoperative antibiotics may be given to patients with specific risk factors for surgical site infection. In 2008, an advisory committee established recommendations on the use of antibiotics for cutaneous surgery, which remain the most current guidelines to date. This activity aims to review these guidelines and emphasize the crucial role of the interprofessional team in preventing adverse outcomes associated with antibiotic administration in the context of cutaneous surgery. Objectives: Identify the conditions that increase the susceptibility of patients to acquire infective endocarditis or prosthetic joint infection during or after Mohs micrographic surgery. Evaluate patients who are at a high risk of developing surgical site infections and may require antibiotic prophylaxis during Mohs micrographic surgery. Implement the antibiotic regimens recommended by the advisory committee for patients at high risk of acquiring infective endocarditis and prosthetic joint infections in the setting of Mohs micrographic surgery. Differentiate patients that require post-operative antibiotics and the appropriate agent in the setting of Mohs micrographic surgery. Access free multiple choice questions on this topic.

Antibiotic use during cutaneous surgery, including Mohs micrographic surgery (MMS), should be used judiciously in the appropriate patient populations. Skin surgery has a low risk of surgical site infection (SSI); therefore, antibiotics are not routinely prescribed. A systematic review and meta-analysis of SSI following MMS without prophylactic antibiotics of various anatomic locations and closure methods found a mean infection range between 1.4% and 2.7%.[1] Special consideration for antibiotic prophylaxis is given to patients with specific risk factors for infection or bacterial dissemination from the surgical site. A recent survey found that most American College of Mohs surgery surgeons queried did not use topical (62.8%) or oral (67.7%) antibiotics in routine cases.[2] Prophylactic antibiotics were given for the following circumstances in decreasing order: artificial cardiac valves (69.4%), anogenital surgery (53.0%), wedge excision (42.2%), artificial joints (41.0%), inflammatory skin disease (40.1%), immunosuppression (38.9%), skin grafts (36.4%), leg surgery (34.2%), and nasal flaps (30.1%).[2] Although specific guidelines for antibiotic administration in the setting of Mohs micrographic surgery are lacking, there is a recognized role for antibiotics in certain situations. Guidelines for antibiotic usage in cutaneous surgery exist primarily for the prevention of endocarditis and prosthetic joint infection. The most current practices rely on guidelines established by The American Heart Association (AHA) in 2007 and The American Academy of Orthopedic Surgeons (AAOS) in conjunction with The American Dental Association (ADA) in 2003. These guidelines identify patients with an increased risk of endocarditis or prosthetic joint infection following dental procedures.[3][4][5] Subsequently, a 2008 advisory statement published in the Journal of the American Academy of Dermatology (JAAD) presented updated indications for antibiotic prophylaxis in cutaneous surgery, considering endocarditis, joint infection, and surgical site infection (SSI). These updated indications were formulated based on a comprehensive analysis of the existing literature, expert opinions, and the aforementioned guidelines.[6]

Subsequently, a 2008 advisory statement published in the Journal of the American Academy of Dermatology (JAAD) presented updated indications for antibiotic prophylaxis in cutaneous surgery, considering endocarditis, joint infection, and surgical site infection (SSI). These updated indications were formulated based on a comprehensive analysis of the existing literature, expert opinions, and the aforementioned guidelines.[6] The advisory statement can be used as a guideline for the Mohs surgeon, but one must carefully consider the risk-to-benefit ratio when selecting patients for antibiotic prophylaxis. The low risk of the patient acquiring an infection from a Mohs surgical site or bacterial dissemination to a heart valve or prosthetic joint must be weighed against the risks of the antibiotic, such as drug reactions, allergies, and increasing antimicrobial resistance. In addition, selecting the appropriate antibiotic regimen is imperative for effectiveness and is determined by the patient’s risk factors, surgical site, and most likely organism to cause infection. The following discussion includes a review of the function and selection of antibiotic prophylaxis, issues of concern, clinical significance, and other issues for MMS.

In the context of Mohs micrographic surgery, the responsibility for implementing appropriate antibiotics lies with the Mohs surgeon, but the support of an interprofessional team is crucial for optimal patient care. Nurses and medical assistants play a critical role by ensuring updated allergy information, making recommendations to clinicians based on their observations, and educating patients on medication administration. Pharmacists, on the other hand, contribute by preventing adverse drug interactions, suggesting alternative medications, counseling patients on proper administration, and providing antibiotic coverage information to the surgeon, thereby improving antibiotic effectiveness and helping to prevent antibiotic resistance. While randomized controlled trials evaluating community pharmacist services in preventing adverse drug effects have shown mixed results, it is important to acknowledge that all members of the interprofessional healthcare team have a vital role in ensuring the appropriate and safe use of antibiotics in the context of Mohs micrographic surgery. Collaborative efforts among team members contribute to optimal patient outcomes.[28] [Level 1]