Key Points
Question
How frequently are antibiotics prescribed after nasal and oculoplastic procedures, and is antibiotic use associated with reduced postoperative infection rates?
Findings
Of 294 039 adult patients in this population-based cohort study, 45.2% of patients filled antibiotic prescriptions after nasal and oculoplastic procedures; these patients were at significantly decreased risk of postoperative infections compared with those who did not fill antibiotic prescriptions. Increased duration of postoperative antibiotics was not associated with reduced infection rates.
Meaning
Antibiotic use after facial plastic and reconstructive procedures is associated with decreased rates of postoperative infections.
Abstract
Importance
Best practices for antibiotic use after facial plastic and reconstructive procedures have been the subject of much debate, and there is a need for large-scale data to guide further development of evidence-based guidelines for antibiotic use in this setting.
Objective
To assess patterns of postoperative antibiotic prescriptions and infection rates after nasal and oculoplastic procedures.
Design, Setting, and Participants
A retrospective population-based cohort study was conducted using IBM MarketScan Commercial and Medicare Supplemental research databases of 294 039 patients who underwent facial plastic surgery procedures between January 1, 2007, and December 31, 2015. Patients were excluded if they were younger than 18 years, lacked continuous insurance coverage for 1 year before and after the procedure, or underwent additional procedures on the surgery date of interest. Statistical analysis was performed from January 1, 2007, to December 31, 2016.
Main Outcomes and Measures
Primary outcomes were antibiotic prescription patterns in the immediate postoperative period and rates of postoperative infectious complications. Explanatory variables included patient demographics, procedure type, and relevant comorbidities, which were used in multivariable logistic regression analysis.
Results
Of the 294 039 patients who met inclusion criteria (55.9% women and 44.1% men; mean [SD] age, 54.0 [18.6 years]), 45.2% filled prescriptions for postoperative antibiotics, including 55.3% of patients undergoing nasal procedures and 14.7% of patients undergoing oculoplastic procedures. Superficial surgical site infections occurred in 1.6% of patients, while deep surgical site infections occurred in 0.3% of patients. On multivariable logistic regression, patients receiving postoperative antibiotics were at significantly decreased risk of postoperative infections (nasal procedures: adjusted odds ratio [aOR], 0.144 [95% CI, 0.102-0.203]; oculoplastic procedures: aOR, 0.254 [95% CI, 0.104-0.622]) compared with those who did not receive postoperative antibiotics. Increased duration of postoperative antibiotics was not associated with reduced rates of infectious complications (nasal procedures: aOR, 1.000 [95% CI, 0.978-1.022]; oculoplastic procedures: aOR, 1.024 [95% CI, 0.959-01.092]). Despite being more likely to experience postoperative infections, patients with a history of tobacco use (aOR, 0.806 [95% CI, 0.747-0.870]), immunodeficiency (aOR, 0.774 [95% CI, 0.737-0.813]), or type 1 or 2 diabetes (aOR, 0.810 [95% CI, 0.772-0.850]) were less likely to be prescribed antibiotics than those without these conditions.
Conclusions and Relevance
Postoperative antibiotic prescriptions were associated with reduced rates of infections after facial plastic surgery. This study highlights the role of population-level data in the development of best practices for postoperative antibiotic use and identifies the need for additional examination of antibiotic use patterns and recommendations for populations at increased risk for postoperative wound infection.
This population-based cohort study assesses patterns of postoperative antibiotic prescriptions and infection rates after nasal and oculoplastic procedures.
Introduction
Surgical site infections (SSIs) can be a major source of morbidity and even mortality for surgical patients; it is estimated that SSIs occur at a rate of 2% to 5% in the inpatient surgical population and that up to 60% of SSIs are considered preventable with the use of evidence-based guidelines.1 Although this rate is even lower in facial plastic surgery procedures, owing to the elective and often cosmetic nature of these procedures, SSIs are considered to be an unacceptable complication of surgery.2,3 Because of this concern, despite the generally low incidence of SSIs in facial plastic surgery procedures, many surveyed clinicians prescribe postoperative antibiotics for SSI prophylaxis.2,4,5 However, the risk of infection must be balanced with the risks of antibiotic use such as antibiotic resistance and superinfection.6 Therefore, it is essential to understand the current literature regarding evidence-based infection prevention, as well as areas where more research is needed.
General surgical guidelines for SSI prevention are available both through the Centers for Disease Control and Prevention and the World Health Organization.7,8 According to these guidelines, the use of postoperative antibiotic prophylaxis for clean or clean-contaminated procedures in not indicated. For rhinoplasty surgery specifically, the current clinical practice guidelines also recommend against the use of postoperative antibiotics.9 However, much of these data are based on several small studies, many with conflicting results.10 Although infection rates after septoplasty and rhinoplasty tend to be quite low, on the order of 2% to 4%, postoperative infections can be of significant consequence for patients who have undergone placement of cartilage grafts or implants.11 In a recent systematic review and meta-analysis of studies investigating postoperative antibiotic use and infection after rhinoplasty, postoperative antibiotic use was not associated with significantly reduced rates of postoperative infection.10 However, only 5 randomized clinical studies were included in this analysis with a pooled study sample of 589 participants, which is still small given the relatively low incidence of SSIs in this patient population. For eyelid procedures, infection rates tend to be even lower, at less than 1%, but when they do occur, they can lead to vision-threatening complications.5,12,13,14,15 Several studies have shown that systemic prophylactic antibiotics do not provide additional SSI prevention for blepharoplasty and often clinicians tend to provide topical antibiotics at increasing rates.4,5,12,13,16,17 This trend extends to facial plastic surgery in general, as a survey of 114 facial plastic surgeons found that approximately half endorsed routine prescription of postoperative antibiotic regimens of more than 24 hours.5
Because of the variability within the current facial plastic surgery literature regarding SSI prevention with postoperative antibiotic use, the objective of this study was to assess patterns of postoperative antibiotic prescriptions and infection rates after facial plastic and reconstructive procedures using a population-based cohort study model. Because the incidence of SSIs is so low after facial plastic and reconstructive procedures, this study design allows assessment of SSIs in a very large sample size of patients to more adequately assess if antibiotics have an association with decreased rates of SSIs. In addition, the contribution of patient factors, comorbidities, and different procedures were also assessed.
Methods
The IBM MarketScan Commercial and Medicare Supplemental Databases is a national data set that captures administrative employer-based insurance claims. Claims were examined from patients older than 18 years who underwent oculoplastic procedures (including upper blepharoplasty, lower blepharoplasty, and ectropion/entropion repair) or nasal procedures (including septoplasty, primary and secondary rhinoplasty, cleft rhinoplasty, total nasal reconstruction, and repair of nasal stenosis) as determined by Current Procedural Terminology for nasal and eye facial plastic surgery codes (eTable 1 in the Supplement) between January 1, 2007, and December 31, 2015 (the date range for which IBM MarketScan data are available at our institution). Comorbid diagnoses were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes (eTable 2 in the Supplement). Patients were excluded if they were younger than 18 years, lacked continuous insurance coverage for 1 year before and after the procedure, or underwent additional procedures on the surgery date of interest (including more extensive procedures, unrelated procedures, and procedures from both oculoplastic and nasal procedure classes). This study was approved by the Stanford University Institutional Review Board, and was determined to be exempt from human studies review as all data collected from the database were deidentified.
Perioperative antibiotic prescription fills were defined as prescription fills occurring from 14 days before the procedure through 7 days after the procedure; drug classes included cephalosporins, macrolides, penicillins, tetracyclines, and miscellaneous antibiotics (including clindamycin), with collected data including National Drug Codes, dosages, and number of tablets prescribed. The primary outcome was the rate of 30-day postoperative superficial and deep SSIs, with a superficial SSI defined as a diagnosis of cellulitis and a deep SSI defined as an abscess requiring incision and drainage (eTable 2 in the Supplement). Secondary outcomes included 30-day postoperative rates of noninfectious wound healing complications (including wound dehiscence, fistula formation, and tissue necrosis) and hospital admissions (eTable 2 in the Supplement). Postoperative soft-tissue infection rates in the 30 days after the procedure were contrasted among patients who received antibiotics in the immediate postoperative period vs those who did not.
Additional sociodemographic and clinical covariates included in the analysis were age, sex, tobacco use, and diagnoses of immunodeficiency, autoimmune disorders, and type 1 or 2 diabetes within the year prior to surgery (eTable 3 in the Supplement). Comorbid conditions were reflected by use of the van Walraven modification of the Elixhauser index, which includes 30 common comorbidities into a numeric score that is closely associated with mortality in the acute setting.18,19
Statistical analysis was performed from January 1, 2007, to December 31, 2016. Univariate descriptive statistics were calculated for demographic variables and comorbidities for each surgical class. A multivariate logistic regression model was estimated to examine differences in postoperative infectious complications and rates of antibiotic prescription, while controlling for patient age, sex, van Walraven index, and prior year diagnoses of tobacco use and other comorbidities associated with immune compromise. A stepwise logistic regression (P < .20 for inclusion) was used to identify relevant patient characteristics for inclusion in the final model. Calculated P values were 2-tailed, with significance defined as P < .05. With the exception of calculation of the van Walraven index using R, version 3.4.2 (R Foundation for Statistical Computing), data extraction and statistical analyses were performed using SAS, version 9.4 (SAS Institute).
Results
A total of 294 039 patients met the inclusion criteria for this study, with most patients (75.0%) undergoing nasal procedures; study population characteristics are displayed in Table 1. A minority of patients undergoing nasal surgery underwent revision rhinoplasty with (6345 of 220 433 [2.9%]) or without (466 of 220 433 [0.2%]) cartilage grafting or primary rhinoplasty with cartilage grafting (7572 of 220 433 [3.4%]) (eTable 4 in the Supplement). The mean (SD) age of patients in the cohort was 54.0 (18.6) years, and most patients were women (65.9%). The most common comorbid condition among patients was diabetes (12.7%), followed by immunodeficiency (11.4%).
Table 1. Study Population Characteristics.
| Characteristic | Patients, No. (%) (N = 294 039) |
|---|---|
| Male sex | 129 671 (44.1) |
| Age, mean (SD), y | 54.0 (18.6) |
| US Region | |
| Northeast | 51 162 (17.4) |
| North Central | 69 393 (23.6) |
| South | 112 486 (38.3) |
| West | 56 202 (19.1) |
| Unknown | 4796 (1.6) |
| van Walraven index, median (IQR) | 0.0 (0.0-3.0) |
| Comorbidities | |
| Immunodeficiency | 33 520 (11.4) |
| Autoimmune disease | 1764 (0.6) |
| Type 1 or 2 diabetes | 37 342 (12.7) |
| Tobacco use | 12 055 (4.1) |
| Procedure class | |
| Nasal | 220 433 (75.0) |
| Oculoplastic | 73 606 (25.0) |
Abbreviation: IQR, interquartile range.
A total of 45.2% of patients filled antibiotic prescriptions. For nasal procedures, 55.3% of patients filled antibiotic prescriptions for a mean (SD) course of 8.7 (5.7) days; for oculoplastic procedures, 14.7% of patients filled antibiotic prescriptions for a mean (SD) course of 8.0 (2.5) days (Table 2). Cephalosporins were the most commonly prescribed antibiotic class for both procedure classes (nasal procedures, 54.8%; oculoplastic procedures, 55.7%).
Table 2. Postoperative Antibiotic Prescription Patterns.
| Characteristic | Patients, No. (%) | |
|---|---|---|
| Nasal Procedures | Oculoplastic Procedures | |
| Any antibiotic prescribeda | 122 017 (55.3) | 10 799 (14.7) |
| No. of days of antibiotics, mean (SD) | 8.7 (5.7) | 8.0 (2.5) |
| Medication classb | ||
| Cephalosporins | 66 874 (54.8) | 6013 (55.7) |
| Erythromycins or macrolides | 13 407 (11.0) | 1808 (16.7) |
| Penicillins | 34 172 (28.0) | 1676 (15.5) |
| Tetracyclines | 2447 (2.0) | 765 (7.1) |
| Miscellaneous (includes clindamycin) | 5117 (4.2) | 536 (4.9) |
The denominator is the number of total procedures in a given procedure class (nasal, 220 433; oculoplastic, 73 606).
The denominator is the number of patients receiving antibiotic prescriptions in a given procedure class.
Superficial SSIs occurred in 1.6% of patients (nasal procedures, 1.7%; and oculoplastic procedures, 1.4%), while deep SSIs occurred in 0.3% of patients (nasal procedures, 0.3%; and oculoplastic procedures, 0.3%). Patients who filled postoperative antibiotic prescriptions in the perioperative period had significantly decreased rates of 30-day postoperative superficial infections (nasal procedures: odds ratio [OR], 0.289 [95% CI, 0.237-0.355]; oculoplastic procedures: OR, 0.304 [95% CI, 0.108-0.620]) and deep infections (nasal procedures: OR, 0.631 [95% CI, 0.480-0.842]; oculoplastic procedures: OR, 0.401 [95% CI, 0.250-0.612]) (Table 3). Rates of 30-day wound healing complications were decreased in patients receiving postoperative antibiotics after nasal surgery (OR, 0.301 [95% CI, 0.217-0.416]) and 30-day hospital readmission rates were significantly decreased in patients receiving postoperative antibiotics (nasal procedures: OR, 0.305 [95% CI, 0.288-0.323]; oculoplastic procedures: OR, 0.790 [95% CI, 0.677-0.922]). Pooled 30-day complication rates were lower in patients receiving antibiotics after nasal surgery (OR, 0.314 [95% CI, 0.297-0.332]).
Table 3. Postoperative Antibiotics and 30-Day Complications.
| Characteristic | Patients, No./Total No. (%) | |
|---|---|---|
| Nasal Procedures | Oculoplastic Procedures | |
| Perioperative antibiotics | 122 017/220 433 (55.3) | 10 799/73 606 (14.7) |
| Superficial wound infection | ||
| No perioperative antibioticsa | 2752/98 416 (2.8) | 942/62 807 (1.5) |
| Perioperative antibioticsb | 945/122 017 (0.8) | 57/10 799 (0.5) |
| Odds ratio (95% CI)c | 0.289 (0.237-0.355)d | 0.304 (0.108-0.620)d |
| Deep wound infection | ||
| No perioperative antibioticsa | 456/98 416 (0.5) | 201/62 807 (0.3) |
| Perioperative antibioticsb | 290/122 017 (0.2) | 20/10 799 (0.2) |
| Odds ratio (95% CI)c | 0.631 (0.480-0.842)d | 0.401 (0.250-0.612)d |
| Wound healing complication | ||
| No perioperative antibioticsa | 556/98 416 (0.6) | 276/62 807 (0.4) |
| Perioperative antibioticsb | 196/122 017 (0.2) | 51/10 799 (0.5) |
| Odds ratio (95% CI)c | 0.301 (0.217-0.416)d | 1.127 (0.835-1.520) |
| Hospital admission | ||
| No perioperative antibioticsa | 4287/98 416 (4.4) | 1421/62 807 (2.23) |
| Perioperative antibioticsb | 1579122 017 (1.3) | 185/10 799 (1.7) |
| Odds ratio (95% CI)c | 0.305 (0.288-0.323)d | 0.790 (0.677-0.922)d |
| Any complication | ||
| No perioperative antibioticsa | 5629/98 416 (5.7) | 1773/62 807 (2.8) |
| Perioperative antibioticsb | 2408/122 017 (2.0) | 262/10 799 (2.4) |
| Odds ratio (95% CI)c | 0.314 (0.297-0.332)d | 0.898 (0.787-1.024) |
The denominator is the number of patients in each procedure class who did not receive postoperative antibiotics.
The denominator is the number of patients in each procedure class who received postoperative antibiotics.
Representing the odds of developing a complication in patients receiving postoperative antibiotics vs those who did not.
P < .05.
Table 4 shows the sociodemographic and procedural factors associated with rates of 30-day postoperative SSIs (both superficial and deep SSIs) for patients in the nasal and oculoplastic surgery cohorts after multivariable logistic regression analysis. Patients receiving postoperative antibiotics were at significantly decreased risk of postoperative infectious complications compared with those who did not (nasal procedures: adjusted OR [aOR], 0.144 [95% CI, 0.102-0.203]; oculoplastic procedures: aOR, 0.254 [95% CI, 0.104-0.622]). Increased duration of postoperative antibiotics did not lead to reduced infection rates (nasal procedures: aOR, 1.000 [95% CI, 0.978-1.022]; oculoplastic procedures: aOR, 1.024 [95% CI, 0.959-01.092]). Independent risk factors for increased postoperative infectious complications included immunodeficiency (nasal procedures: aOR, 2.081 [95% CI, 1.401-3.091]; oculoplastic procedures: aOR, 2.433 [95% CI, 1.034-5.725]), diabetes (nasal procedures: aOR, 1.915 [95% CI, 1.252-2.929]), and tobacco use (nasal procedures: aOR, 2.614 [95% CI, 1.642-4.162] for nasal procedures).
Table 4. Multivariable Logistic Regression Models for 30-Day Postoperative Superficial and Deep Wound Infections.
| Characteristic | Adjusted Odds Ratio (95% CI) | |
|---|---|---|
| Nasal Procedures | Oculoplastic Procedures | |
| Age | 0.996 (0.986-1.006) | 0.988 (0.949-1.029) |
| Male sex | 1.129 (0.835-1.527) | 0.730 (0.315-1.693) |
| Postoperative antibiotics | 0.144 (0.102-0.203)a | 0.254 (0.104-0.622)a |
| Days of postoperative antibiotics | 1.000 (0.978-1.022) | 1.024 (0.959-1.092) |
| Past-year comorbidities | ||
| Immunodeficiency | 2.081 (1.401-3.091)a | 2.433 (1.034-5.725)a |
| Autoimmune disease | 0.800 (0.111-5.789) | 0.001 (0.001-999.9) |
| Type 1 or 2 diabetes | 1.915 (1.252-2.929)a | 0.895 (0.330-2.423) |
| Tobacco use | 2.614 (1.642-4.162)a | 2.327 (0.537-10.082) |
| van Walraven index | 1.423 (1.245-1.601)a | 1.001 (0.999-1.003) |
P < .05.
Table 5 shows the sociodemographic and procedural factors associated with antibiotic prescriptions in the entire cohort after multivariable logistic regression analysis. Factors associated with greater prescription rates were male sex (aOR, 1.182 [95% CI, 1.139-1.227]), later procedure year (aOR, 1.013 [95% CI, 1.005-1.022]), and nasal procedures (aOR, 1.304 [95% CI, 1.249-1.363]). Factors associated with decreased antibiotic prescription rates included increased age (aOR, 0.995 [95% CI, 0.994-0.996]), immunodeficiency (aOR, 0.774 [95% CI, 0.737-0.813]), autoimmune disease (aOR, 0.737 [95% CI, 0.613-0.885]), diabetes (aOR, 0.810 [95% CI, 0.772-0.850]), tobacco use (aOR, 0.806 [95% CI, 0.747-0.870]), and oculoplastic procedures (aOR, 0.876 [95% CI, 0.813-0.943]).
Table 5. Multivariable Logistic Regression Model for Postoperative Antibiotic Prescription.
| Model Variable | Adjusted Odds Ratio (95% CI) |
|---|---|
| Age | 0.995 (0.994-0.996)a |
| Male sex | 1.182 (1.139-1.227)a |
| Year | 1.013 (1.005-1.022)a |
| Past-year comorbidities | |
| Immunodeficiency | 0.774 (0.737-0.813)a |
| Autoimmune disease | 0.737 (0.613-0.885)a |
| Type 1 or 2 diabetes | 0.810 (0.772-0.850)a |
| Tobacco use | 0.806 (0.747-0.870)a |
| Van Walraven index | 1.066 (0.912-1.246) |
| Procedure type | |
| Nasal | 1.304 (1.249-1.363)a |
| Oculoplastic | 0.876 (0.813-0.943)a |
P < .05.
Discussion
In this cohort of 294 039 patients undergoing nasal and oculoplastic procedures, 45.2% of patients filled prescriptions for postoperative antibiotics, most of which were filled by patients undergoing nasal surgery (55.3%). Although the overall infection rate was low, postoperative antibiotic prescriptions were found to be significantly associated with decreased infection rates in both groups. Duration of antibiotic use was not significantly associated with reduced rates of infectious complications. Most postoperative antibiotic prescriptions were for 5-, 7-, or 10-day antibiotic courses, with a small number of antibiotic prescriptions (particularly after nasal surgery) being for 24 hours or less (eFigure 2 in the Supplement). Of course, understanding whether or not reduced duration of perioperative antibiotics is possible without increasing the risk of infection is of interest. Although patients with immunodeficiency had greater rates of SSIs, they were also less likely to receive a prescription for antibiotics (eTable 5 in the Supplement). The reasons for decreased rates of antibiotic prescription among these patients is unclear, although it is possible that because immunocompetent patients make up most of the cohort, some of these patients may receive antibiotic prescriptions at increased rates for reasons that are not captured by the analysis performed here. It is also possible that some diagnoses of immunocompromise (including sickle cell disease and multiple myeloma, among others) are less likely to be identified as such by surgical clinicians and may not receive special treatment in the perioperative period, given the lack of perceived increased risk of SSIs. Finally, data analyzed in this study are limited to the quality of data input by clinicians, leading to the possibility that available diagnosis codes do not accurately reflect patients’ true prior-year diagnoses.
Among patients undergoing nasal procedures, there has been an overall trend toward stable to increasing frequency of postoperative antibiotic prescriptions from 2008 to 2015, which mirrors patterns of antibiotic use in the general surgical population despite increasing expert consensus, evidence, and guidelines calling for postoperative and intraoperative antibiotic de-escalation (eFigure 1 in the Supplement).16 In contrast, antibiotic prescriptions after oculoplastic surgery have remained relatively stable during the same time period. However, most of this evidence is based on studies that were not adequately powered to assess the association between antibiotic use and SSIs, as the incidence of SSIs in these populations is so low. Thus, to our knowledge, this study is the first population-based cohort study of this issue that provides a sample size large enough to adequately assess this association.
Although SSI rates for rhinoplasty surgery were found to be low, at a rate of 2% to 4%, in a recent review of the literature,11 reported rates vary anywhere from 0% to 18% in the literature.20 Our study found an overall SSI rate of 2.0% for nasal procedures (1.7% superficial SSIs, and 0.3% deep SSIs). Indications for postoperative antibiotic use in nasal surgery includes patients with valvular heart disease or who are immunocompromised, to prevent septicemia, as well as patients with complex revisions with extensive cartilage grafting.21,22 Many additional studies have found mixed results or no added reduction in SSI rates with postoperative antibiotics for nasal surgery.11,23,24 These findings lead to the recommendation in the most recent rhinoplasty clinical practice guidelines against postoperative antibiotic use.25 However, most of these studies were of small cohorts of patients and varied widely in methods. Thus, the strength of our study was the number of patients included (220 433 undergoing nasal surgery) who did find a benefit in a reduced SSI rate with antibiotic prescription, while controlling for other patient factors.
Similar to rhinoplasty surgery, oculoplastic procedures also have very low SSI rates of less than 1%, primarily because of the clean nature of these procedures and the very high vascularity of the orbit.26,27,28,29 Despite this low infection rate, complications of SSIs can be severe and vision threatening, and there has been an overall trend toward increased antibiotic prescribing among surveyed surgeons.4,5,15,16 This study found a low infection rate for oculoplastic procedures (1.7%) as well as a lower antibiotic prescription rate compared with nasal surgery (55.3% for nasal surgeries vs 14.7% for oculoplastic surgeries). However, after multivariable analysis, antibiotic use in the eyelid surgery cohort of patients was also found to be significantly associated with decreased rates of SSIs. In the current oculoplastic literature, given the potential complications of systemic antibiotic use, and the efficacy of topical antibiotic use in this population, topical antibiotics are more commonly prescribed.5,12 Management of postoperative SSIs was a common cause of hospital readmission postoperatively, particularly among patients who underwent oculoplastic procedures (eTable 6 in the Supplement).
Patient comorbidities should also be taken into account when determining whether to prescribe antibiotics after facial plastic surgery. In this study, diabetes, tobacco use, and immunodeficiency were all found to be associated with higher infection rates, yet these patients were actually less likely to receive postoperative antibiotics than the remainder of the cohort. Other large multicenter studies of clean surgeries determined that age, body mass index, and tobacco use lead to greater SSI rates.30,31 Although diabetes has shown more varied effects on SSI rates in the literature, the Centers for Disease Control and Prevention and World Health Organization recommend intraoperative glucose control to less than 200 mg/dL (to convert glucose to millimoles per liter, multiply by 0.0555) to help reduce SSI rates.7,8 As expected, increasing wound classification also increases risk of SSIs, which is shown in this study as well, as nasal surgery is general considered clean-contaminated, and has a higher infection rate than generally clean eye surgery.32,33
Limitations
To our knowledge, this is the first study describing population-level patterns of antibiotic use and rates of postoperative SSIs among patients undergoing nasal and oculoplastic procedures. However, this study has several limitations. As in all database studies, the data available for analysis are limited by the quality of data, which is input by medical practitioners at the patient’s point of service, including the inability to determine which patients underwent revision rhinoplasty or cartilage grafting except by Current Procedural Terminology codes that are input at the time of surgery. Likewise, patients who underwent placement of implants (besides cartilage grafts) were not able to be identified by the available data. As this database includes only outpatient prescription data, the results described in this study do not account for rates of perioperative antibiotic use. In addition, these data are unable to reliably exclude patients with a history of facial radiation exposure, as our institution lacks access to IBM MarketScan data predating January 1, 2007. Finally, this study comprises patients who underwent functional or reconstructive procedures that were covered by employer-based insurance; while many of the included procedures are also performed for cosmetic purposes, these patients are not included in this study cohort. Thus, the functional and reconstructive nature of these procedures (and demographic characteristics of this population, including prior-year medical comorbidities) may affect the generalizability of these conclusions for the population of individuals undergoing these procedures for cosmetic purposes (eTable 1 in the Supplement).
Finally, this study highlights the need for further research regarding antibiotic use in facial plastic surgery procedures. Because of the low incidence of SSI rates, the need for large sample sizes is essential to accurately determine whether postoperative antibiotics reduce SSI rates to adequately power these studies. These database studies do not easily capture possible complications of prophylactic antibiotic use such as antibiotic resistance or superinfection. These complications would be better assessed by a large, multicenter randomized clinical trial to both properly power the study and to document nuances of the treatment and adverse effects that insurance claims data cannot capture.
Conclusions
Among a cohort of adults undergoing nasal and oculoplastic procedures, the rate of postoperative 30-day deep and superficial SSIs was significantly decreased among those prescribed postoperative antibiotics; however, increased duration of postoperative antibiotics was not associated with decreased rates of postoperative infection. Although prior-year diagnoses of tobacco use, diabetes, and immunocompromise were associated with a significantly increased risk of postoperative SSIs, these patients were less likely to receive postoperative antibiotics.
eFigure 1. Temporal Trends in Postoperative Antibiotic Prescriptions
eFigure 2. Duration of Postoperative Antibiotic Courses After Nasal and Oculoplastic Surgery
eTable 1. Procedure Classes by Current Procedural Terminology (CPT) Code
eTable 2. 30-Day Postoperative Complications by ICD-9/CPT Code
eTable 3. Past-Year Comorbidities by ICD-9/HCPCS Code
eTable 4. Number of Patients Undergoing Primary and Secondary Rhinoplasty with Cartilage Grafting
eTable 5. Patients With Prior-Year Diagnoses of Immunocompromise are Less Likely to Receive Postoperative Antibiotics Than Immunocompetent Patients
eTable 6. Readmission Rates and Causes Among Patients Undergoing Facial Plastic Surgery
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eFigure 1. Temporal Trends in Postoperative Antibiotic Prescriptions
eFigure 2. Duration of Postoperative Antibiotic Courses After Nasal and Oculoplastic Surgery
eTable 1. Procedure Classes by Current Procedural Terminology (CPT) Code
eTable 2. 30-Day Postoperative Complications by ICD-9/CPT Code
eTable 3. Past-Year Comorbidities by ICD-9/HCPCS Code
eTable 4. Number of Patients Undergoing Primary and Secondary Rhinoplasty with Cartilage Grafting
eTable 5. Patients With Prior-Year Diagnoses of Immunocompromise are Less Likely to Receive Postoperative Antibiotics Than Immunocompetent Patients
eTable 6. Readmission Rates and Causes Among Patients Undergoing Facial Plastic Surgery