|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
|Our antibiotic use and wound closure strategies have changed as we have acquired greater experience with replantation and free tissue coverage of contaminated and chronically infected wounds.
Promptly replanted parts do not appear to be especially susceptible to infection, despite ischemia and gross contamination.l,2 Our current guidelines for antibiotic use in replantation are almost entirely empiric, but are similar to the antibiotic treatment of open fractures.3 We now administer a short (2- to 5-day) course of perioperative antibiotics in uncomplicated cases.
The use of microvascular tissue transfers for the reconstruction of chronically infected wounds is leading to new clinical strategies for such problems as osteomyelitis,4 and may result in consistently faster, safer, and more durable reconstructions with fewer complications and shorter hospitalizations.
Antibiotic Use in Routine Microsurgical Procedures (Table 41-1)
Perioperative antibiotic use in digital replantation cases is based in part on the published reports of the bacteriology and antibiotic management of open long bone fractures.3,5 Of these fractures, 65% to 70% can be shown to be contaminated, but with adequate debridement, irrigation, closure, and antibiotic use, actual infection rates are as low as 2%. Skin flora, including Staphylococcus aureus, are the most common contaminants.3 Staphylococcus aureus is the most common infectious agent,5 with a lesser incidence of streptococcal and gram-negative cultures reported. First-generation cephalosporins adequately treat over 90% of these isolates. Antibiotics with broader spectra of activity are rarely indicated except in special circumstances. For example, traumatic wounds contaminated by lake water or sea water might warrant expanded antibiotic coverage for Aeromonas hydrophila6,7 or Vibrio species,8 respectively.
Our perioperative digital replant antibiotic therapy consists of preoperative intravenous administration of a first-generation cephalosporin that is continued for 2 to 5 days postoperatively.2,9 We give cephalosporins to patients with histories of penicillin allergies (except for true anaphylaxis) because true cross-sensitivity to cephalosporin in penicillin-allergic patients is either extremely rare or nonexistent.10 In cases in which we do not use a cephalosporin, we administer a drug effective against Staphylococcus aureus (such as erythromycin, vancomycin or clindamycin). The replanted parts and recipient sites are thoroughly debrided and irrigated at the time of surgery. With this routine, infectious complications of digital replants are rare, not only in our series but in other reports. 1,2,11 Replantation of other body parts 12,13 is successfully managed with similar strategies.
Our patients undergoing toe-to-hand transfers receive the same antibiotic treatment as our replantation patients. We have had no occurrence of hand infections and a 7.3% incidence of donor site infections in our series of toe-to-hand transfers.14 Other surgeons15 report successful, uncomplicated toe-to-hand transfers without using perioperative antibiotics.
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