On “Perioperative Antibiotics in the Setting of Microvascular Free Tissue Transfer: Current Practices” (J Reconstr Microsurg 2010;26(6):401–407)

We read with great interest the original article by Reiffel and coworkers entitled “Perioperative Antibiotics in the Setting of Microvascular Free Tissue Transfer: Current Practices.”[1] The authors describe the results of their survey among 90 members of the American Society for Reconstructive Microsurgery about their attitudes and current practice regarding perioperative antibiotics in free flap surgery. We would like to comment on the reported findings of the aforementioned survey.

From a clinical point of view, the first-choice antibiotic is a first-generation cephalosporin. Previously, we have analyzed the course of C-reactive protein (CRP) after free flap transfer in 101 free flap procedures for lower-extremity reconstruction in our clinic. The CRP levels were in the normal range preoperatively in only 47% of the patients we operated on. There was a rapid increase of the mean CRP serum levels with a peak on day 6 at 129 ± 79 mg L⁻¹ and a consecutive decline the following days after free flap surgery.[2] CRP is referred to not only as an indicator for infection but also an acute-phase protein. We concluded that during the first postoperative week following free flap surgery, the diagnostic value of serum CRP is somewhat limited in terms of detecting infections, as an elevation during this time has to be considered an unavoidable reaction to the surgical trauma. We furthermore found that myocutaneous flap surgery, accompanied with greater surgical trauma, led to higher CRP elevations than fasciocutaneous free flap surgery. We also analyzed the effect of various bacteria found at preoperative microbiological analyses in a group of 150 patients who were operated with free flap surgery between July 2001 und March 2007 in our clinic. In 105 patients, there was a positive microbacterial probe before free flap transfer. However, we did not identify any species predictive of free flap failure afterward (Table [1]).

Table 1 Bacterial Colonization of the Wound Bed Prior to Free Flap Transfer n Flap Loss (%) with Positive Antibiogram Flap Loss (%) with Negative Antibiogram p Value Staphylococcus aureus 18 6 7 0.864 Staphylococcus (coagulase negative) 14 14 6 0.215 Enterococcus faecalis 14 7 6 0.981 Pseudomonas aeruginosa 14 7 6 0.918 Methicillin-resistant S aureus 14 0 7 0.301 Enterobacter cloacae 7 14 6 0.392 Peptostreptococcus spp. 4 0 7 0.595 Klebsiella 3 0 7 0.645 Acinetobacter baumanii 3 0 7 0.645 Proteus mirabilis 2 0 7 0.708 Escherichia coli 2 0 7 0.708

Currently, we do not have level I evidence-based recommendations whether to use or to postpone antibiotic prophylaxis in free flap surgery. Findings of retrospective studies suggest that a restriction of use of antibiotics has to be discussed[3] [4] and that antibiotic therapy should be calculated rather than prophylactic. However, we consider antibiotic therapy based on a clinical scenario involving the patients' status in combination with laboratory findings regarding white cell blood count, CRP, procalcitonin, and potentially interleukin-6 under certain circumstances.

REFERENCES

• 1 Reiffel A J, Kamdar M R, Kadouch D J, Rohde C H, Spector J A. Perioperative antibiotics in the setting of microvascular free tissue transfer: current practices.  J Reconstr Microsurg. 2010;  26 (6) 401-407
• 2 Herold C, Jokuszies A, Steiert A et al.. C-reactive protein is not a reliable marker of infection in flap reconstructive procedures of lower extremities.  J Plast Reconstr Aesthet Surg. 2009;  62 (12) e670-e671
• 3 Avery C M, Ameerally P, Castling B, Swann R A. Infection of surgical wounds in the maxillofacial region and free flap donor sites with methicillin-resistant Staphylococcus aureus.  Br J Oral Maxillofac Surg. 2006;  44 (3) 217-221
• 4 Carroll W R, Rosenstiel D, Fix J R et al.. Three-dose vs extended-course clindamycin prophylaxis for free-flap reconstruction of the head and neck.  Arch Otolaryngol Head Neck Surg. 2003;  129 (7) 771-774