Take-home message: Patients using a topical antibiotic ointment after blepharoplasty had a significantly lower rate of surgical site infections than controls using an ocular lubricant ointment in an observational cohort study.
By Cheryl Guttman Krader; Reviewed by Mark A. Alford, MD
Fort Worth, TX
—Surgical site infections after blepharoplasty surgery are uncommon whether or not patients receive antibiotic prophylaxis.
However, postoperative use of a topical antibiotic ointment significantly reduces the risk, according to a prospective, observational, cohort study undertaken by Mark A. Alford, MD.
The findings of the study should also alert surgeons to suspect methicillin-resistant Staphylococcus aureus
(MRSA) as the causative pathogen if infection occurs, said Dr. Alford, the oculoplastic surgeon in private practice, Fort Worth, TX, who conducted the single-surgeon study.
“Although this study has limitations relating to its small size, performance by a single investigator, and potential bias from its cohort design, I hope it starts a further discussion about the need for antibiotic ointment after blepharoplasty,” Dr. Alford said. “In addition, it should inform surgeons that in this day and age, they should think about community-acquired MRSA and get a culture if they see an infection after blepharoplasty.”
Dr. Alford was motivated to conduct the study recognizing that while antibiotic ointment is widely used by oculoplastic surgeons to reduce the risk of infection after blepharoplasty, there is very little scientific evidence to support the practice.
Moreover, there are potential concerns as antibiotic use may lead to contact sensitivity reactions, promote bacterial resistance, and increased cost.
To evaluate its benefits and risks, Dr. Alford conducted an IRB-approved study comparing two similar consecutive groups of patients undergoing upper lid blepharoplasty.
The first cohort included 384 patients operated on from November 2011 to April 2013 who were instructed to use bacitracin ointment twice daily for 7 days, beginning immediately after the surgery.
The second cohort comprised 158 patients operated on from April to December 2013, who used a sterile ocular lubricant ointment (Refresh P.M., Allergan) with the same application regimen.
Patients were excluded if they had a history of allergy to bacitracin or had used any antibiotic within the week before surgery. They were all operated on with the same technique, which involved a full sterile prep, running suture closure with 6-0 silk, and follow-up at 1 to 2 weeks after surgery.
One patient using antibiotic ointment developed a surgical site infection (0.26%), which did not culture positive for MRSA. In the control group, there were 10 patients with a surgical site infection (6.3%). Nine of the patients had a bilateral event and all were positive for community-acquired MRSA (CA-MRSA).
All of the infections were managed by suture removal and treatment with an oral antibiotic chosen based on culture and sensitivity testing. All of the infections cleared, but all patients with a CA-MRSA infection were left with hypertrophic scars.
“I stopped enrolling patients in the second cohort earlier than planned because the between-group difference in infection rate was statistically significant,” said Dr. Alford.
“The hypertrophic scarring that developed in patients with the CA-MRSA is improving, but they are all finding the scarring is cosmetically significant.”
Among the patients who used bacitracin, 14 (3.6%) developed an allergic reaction characterized by bilateral erythema, edema, and itching. Cultures were done in all cases and were negative, and the reactions resolved after discontinuation of the antibiotic.
“The rate of allergic reactions to bacitracin ointment in this study is lower than what has been previously reported,” Dr. Alford said.
Consistent clinical appearance
Dr. Alford noted that the CA-MRSA infections were characterized by the presence of significant erythema, purulent material, and elevation along the suture line along with areas of tissue necrosis at the site of the sutures and only minimal edema.
Concerning the possible source of the pathogens, Dr. Alford noted the cultured organisms represented various strains and subtypes of MRSA. He said that the infection rates were low (<0.2%) over the past 2 years at both surgery centers where the procedures were performed.
In addition, all personnel who came into contact with the patients in the operating room were negative for MRSA colonization. Only 1 patient who developed an MRSA infection was a health-care worker. None had a previous Staphylococcal infection or smoked.
“The finding that all of the infections were caused by CA-MRSA is really not unexpected, considering it is a virulent pathogen that has become epidemic in the United States,” Dr. Alford said.
“We believe the surgical wounds became contaminated by exposure to a community source or self-inoculation from a colonized nasal cavity,” he said.
Dr. Alford also emphasized that he was not promoting the use of bacitracin ointment to prevent infection after blepharoplasty.
“Any antibiotic ointment that provides good coverage against Gram-positive organisms might have similar effects,” he said.
Mark A. Alford, MD
E: [email protected]
This article was adapted from Dr. Alford’s presentation at the 2014 meeting of the American Academy of Ophthalmology. Dr. Alford has no relevant financial interests to disclose.