Algorithm for the management of antibiotic prophylaxis in onychocryptosis surgery
Introduction
Onychopathies, and in particular onychocryptosis, are frequent reasons for consultation in the podiatric clinic day by day. The patient usually seeks treatment when the pathology is accompanied by considerable localized infection, drainage, erythema, and pain. However, the use of antibiotics associated to the nail surgical treatment is not clearly established, and the scientific evidence for or against its use associated to surgical ingrown-toenails treatment, aimed of improving the clinical course of the pathology, is poor. Currently, the use of antibiotics as an essential component of treatment is controversial. Some authors hold that the use of oral antibiotics prior to surgical procedures associated to matricectomy reduces the risk of developing an infection [1], [2]. On the other hand, the role of antibiotic prophylaxis in dermatologic surgery remains equally controversial [3]. The adverse effects of prophylactic antibiotic use include increased cost, drug reactions, the development of antibiotic resistance, and medication interaction. Some authors support that if partial nail avulsion is performed in the earlier stages of the onychocryptosis, the localized infection can be resolved spontaneously without the need for antibiotics [4]. Some clinical trials carried out on patients with ingrown nails in the presence of infection question the use even of perioperative antibioticotherapy [5], [6]. The scarcity of data and the insufficiency of clinical trials mean that today there is no consensus on the use of antibiotics in nail surgery. Because of this controversy, the present study is aimed at establishing a clinico-therapeutic algorithm based on the existing evidence, and on accepted guidelines in accord with the authority of the main scientific societies specializing in the topic (the British Society for Dermatological Surgery in agreement with the British Society for Antimicrobial Chemotherapy and the American Heart Association, American Dental Association with the American Academy of Orthopedic Surgeons.
Section snippets
Surgical-site infection in nail surgery
Most bacteria resident in the skin are found at a depth of 0.3 mm. The nail folds, because of their morphology, provide an excellent habitat for these bacteria. Rayan and Flournoy found that S. epidermidis is the main microorganism resident on the fingernails, this area of skin being where the highest number of these microorganisms are located, in spite of adequate preoperative hand scrubbing, the fingernails were heavily contaminated [7]. Edwin et al. found that, after the toenail furrows are
Infection in onychocryptosis: considerations
Systems of classification and algorithms of treatment depending on the severity of the signs and symptoms accompanying an ingrown nail (localized infection, drainage, erythema, and pain) have been proposed [12]. Some authors have proposed classification systems based not only on the clinical severity but also on the depth of the nail folds [13]. Recently, Kline proposed a new classification and algorithm of treatment based not only on the signs and symptoms but also on the existence of earlier
Considerations for administration of antibiotic prophylaxis in nail surgery
The morbidity of local surgical infection depends largely on the site of infection and on the characteristics of the patient. These are determinant factors when proposing the need for antibiotic prophylaxis for the surgery. Local surgical infection is associated to various pathologies, depending on the location and the clinical context. The use of antibiotics is justified on one hand by an increased potential risk of infection associated to the surgical site and, on the other, to the increase
Prevention of infective endocarditis and hematogenous total joint infection in onychocryptosis surgery
The risk of local spreading of the infection is also associated to the potential risk of articular infection by hematogenous dissemination, or even the risk of bacterial endocarditis. Most of the clinical trials carried out coincide in indicating a low risk (around 2%) of bacteremia secondary to procedures of dermatological surgery on non-infected healthy skin [21], [22], [23]. Bobrow et al. reported that the incision and drainage of localized cutaneous abscesses in afebrile adults was unlikely
Recommendations for administration of antibiotic prophylaxis in onychocryptosis
On the basis of the existing evidence and the recommendations given in the guides of clinical practice, and using an up-to-date system of classification of onychocryptosis in its various degrees of infection depending on the stage of development, we have constructed an algorithm for the use of antibiotic prophylaxis in nail surgery (Fig. 3). We consider the use of antibiotic prophylaxis in certain cases to be fully justified, and protocols of antibiotic management must be established depending
Conclusions
Current evidence does not support the use of preoperative antibiotic prophylaxis in onychocrytosis surgery except in special patients with infective stage. Antibiotics should be reserved for contaminated or infected onychocryptosis when their application is therapeutic. The adverse effects of prophylactic antibiotics without justification, such as increased cost, adverse drug reactions, development of antibiotic resistance, and medication interactions, should preclude routine use of
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