Invited Commentary 

May 24, 2023

Local Delivery of Antibiotics—Applications in Cutaneous Surgery and Beyond

Amanda R. Sergesketter, Scott T. Hollenbeck

JAMA Surg. 2023;158(7):727. doi:10.1001/jamasurg.2023.1215

Across surgical subspecialties, surgical site infections (SSIs) represent a prevalent and costly problem to patients and health care systems, affecting 0.5% to 3.0% of surgical patients and resulting in costs ranging from $3.5 billion to $10 billion in the US annually.¹ Accordingly, SSI reduction remains a target of quality improvement initiatives and ongoing research spanning surgical subspecialties. While level 1 evidence has defined the optimal duration and route of antibiotic prophylaxis in some surgical subspecialties, such as colorectal surgery,² the role of antibiotic prophylaxis in clean elective surgery, including skin cancer, extremity, and breast surgery, remains controversial.

Targeted local administration of antibiotics is an emerging concept in surgical fields. Local antibiotic delivery modalities, such as antibiotic beads, polymethylmethacrylate implant coatings, and vancomycin in spine and orthopedic surgery, have been found to reduce SSIs, achieve higher local tissue concentrations, and lower risk of systemic complications compared with systemic prophylaxis.³ Invoking a similar concept through targeted local antibiotic administration in skin cancer surgery, the PICASSo double-blind randomized clinical trial⁴ examined the efficacy of peri-incisional clindamycin or flucloxacillin administered cutaneously with local anesthetic on SSI rates in 681 patients who underwent skin cancer excision. Paralleling prior findings in Mohs surgery,⁵ the authors⁴found that microdosed cutaneous antibiotics, particularly clindamycin, led to reduced SSI rates and prescriptions of oral antibiotics compared with controls, with no reported adverse events within the study period.

The findings of the PICASSo trial supporting local administration of antibiotics to reduce SSIs have applications that extend beyond skin cancer surgery. For example, elective hand surgery, alloplastic and autologous breast surgery, and other flap-based reconstructions are high-volume procedures where local anesthesia is commonly used, the optimal antibiotic prophylaxis remains undefined, and where the use of targeted local antibiotic delivery has not been examined. One advantage of cutaneous antibiotic administration is improved drug delivery to poorly perfused tissue, which would have limited reach by the systemic circulation.^4,6 While not evaluated in this study,⁴ local antibiotic delivery may be especially relevant to larger and more complex wounds. Moreover, this concept may also be particularly beneficial in patients with innately impaired cutaneous vascular delivery of systemic antibiotics, such as those with diabetes, obesity, or tobacco use, who have been shown to have poor tissue penetration of prophylactic systemic antibiotics,⁷ and who represent a substantial portion of the overall surgical population with SSI.¹ Future studies evaluating more complex situations would be the logical next step and represent the most significant potential clinical gains. Such studies should be considered enthusiastically, given the clearly favorable impact on SSI demonstrated in the PICASSo trial.⁴