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MRSA Implicated in Majority of Post-Facelift Infections 3-18-08

NEW YORK, March 18 -- Although surgical-site infections after face-lift procedures are uncommon, those that occur are often caused by methicillin-resistant Staphylococcus aureus, making them difficult to treat.

Surgical-site infections developed in 0.6% of patients who underwent deep-plane rhytidectomy, but 80% tested positive for MRSA according to a retrospective, single-center study reported by Richard A. Zoumalan, M.D., and David B. Rosenberg, M.D., both of the Lennox Hill-Manhattan Eye, Ear, and Throat Hospital here, in the March/April issue of the Archives of Facial Plastic Surgery.

"For surgical site infections, the facial plastic surgeon should have a high suspicion for MRSA as the causative pathogen," the researchers wrote.

MRSA has become the leading causative pathogen in surgical-site, skin, and soft tissue infections. It is also more virulent, costs approximately $3,700 more to treat, and has three times the mortality rate of methicillin-sensitive S. aureus, they noted.

The only study of surgical-site infection rates for face-lift surgery, though, was done more than 10 years ago before the rise of community-acquired MRSA.

The researchers reviewed charts of 780 consecutive patients who underwent deep-plane rhytidectomy from January 2001 to January 2007 by a single surgeon at the same outpatient surgical center.

Cases of revision rhytidectomy were included and patients could also have undergone other procedures, including blepharoplasty, browpexy, rhinoplasty, autologous fat transfer, laser resurfacing, and chemical peel.

To prevent infection, patients showered and washed their hair with chlorhexidine solution on the morning of surgery. After induction of anesthesia but before incision, their faces were scrubbed with chlorhexidine (Peridex, Periogard) and povidone-iodine and they were given 1 g of intravenous cefazolin sodium (Ancef).

After surgery, patients received seven days of prophylactic antibiotics with oral cefadroxil (Duricef).

Even so, five patients overall developed a postoperative wound infection (0.6%). Four of the patients with a postoperative wound infection had cultures tested positive for MRSA (0.5% of the total).

Two of the infected patients required hospitalization for intravenous antibiotic therapy (0.3% of the total). Both had MRSA with potential exposure to MRSA preoperatively.

One of these patients spent about 10 days visiting her spouse in the cardiac intensive care unit four months prior to her operation. The other patient frequently saw her brother-in-law, who is a cardiologist.

This "stresses the importance of hospital and physician-related contacts in history taking," the researchers said. Other factors that should be considered during history taking include recent antimicrobial therapy and previous MRSA colonization, they said.

However, all patients had minimal to no scarring after the infection and wound healed.

These rates of surgical-site infection were similar to those in the only prior study looking at rates after face lift (0.18% versus 0.3% for hospitalization).

Although all four MRSA-infected patients were sensitive to trimethoprim-sulfamethoxazole (Septra or Bactrim) and vancomycin (Vancocin), all were resistant to erythromycin. Only one was sensitive to clindamycin (Cleocin, Clinda-Derm), and one was sensitive to ciprofloxacin (Cipro).

Reason for the high proportion of MRSA infections compared with other pathogens could include the aggressive nature of MRSA and the use of post-operative antibiotics effective against methicillin-sensitive S. aureus, Drs. Zoumalan and Rosenberg said.

"With the rise of MRSA colonization and infections," they said, "facial plastic surgeons performing rhytidectomy and other soft tissue procedures may want to consider introducing screening protocols to identify patients who are at increased risk for infection."