DS16 Prosthetic joint infections in dermatological surgery: a survey of British Society for Dermatological Surgery members

Abstract Late-onset prosthetic joint infections (PJIs) are almost always haematogenous in nature, with nearly half of recorded cases noted to occur secondary to skin infections. A recently published systematic review by McKesey et al. found no reported cases of PJI secondary to skin surgery (McKesey J, Mazhar M, Alam M et al. Incidence of bacteremia, infective endocarditis, or prosthetic joint infection in dermatologic surgery: a systematic review. Dermatol Surg 2024; 50: 428–33). This finding prompted us to survey members of the British Society for Dermatological Surgery (BSDS) to assess local practices and identify potential cases. In total, 426 members with active BSDS accounts were surveyed via an anonymized online questionnaire using Microsoft Forms. From these, 68 (16%) responses were obtained. Overall, 58 responders (85%) did not routinely screen for prosthetic implants perioperatively. In the context of skin surgery, 35 responders (51%) believed antibiotic prophylaxis (AP) is not necessary in patients with prosthetic implants, 19 (28%) would consider AP in high-risk patients, two (3%) followed specific AP guidelines and the remaining 12 (18%) stated ‘none’ or ‘other’ to current practices. Only two members (3%) reported a PJI. This was a mutual case of PJI in an 83-year-old patient with undiagnosed chronic lymphocytic leukaemia who underwent two small biopsies on the left leg – a 4-mm punch from an ulcerated basal cell carcinoma on the shin and an incisional ellipse from a livedoid rash on the thigh. The patient’s PJI treatment journey was complex and it ended up requiring a Girdlestone resection arthroplasty. Her implant was 3 years old and the sampled skin was not infected, deeming her low risk for AP. An advisory statement by Wright et al. claims that joint replacements within the first 2 years are at highest risk (Wright TI, Baddour LM, Berbari EF et al. Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008. J Am Acad Dermatol 2008; 59: 464–73). However, emerging literature on haematogenous PJIs highlights that most cases occur > 24 months after implantation. This advisory statement also recommends use of AP to prevent haematogenous PJI in selected cases, including those with infected surgical sites and/or when there is breach of the oral mucosa. However, these recommendations do not appear to have been adopted by most surveyed BSDS members. Special consideration should be given when operating in high-risk sites (e.g. lower extremity) and in the context of certain patient groups like those who are immunocompromised or immunosuppressed. The results of the survey highlight that perioperative risk assessment of surgical-site infection and AP use in patients with prosthetic joints vary greatly among BSDS members. Our patient case reminds us of the substantial morbidity and mortality associated with PJIs, reflecting the need for official guidelines and consideration of a revised AP timeline.