Should a patient with a history of liver transplant receive antibiotic prophylaxis before surgery for removal of a cancer skin lesion?

Antibiotic Prophylaxis for Skin Cancer Surgery in Liver Transplant Recipients

A single dose of intravenous antibiotics should be administered within 60 minutes before skin incision for removal of a cancer skin lesion in a patient with history of liver transplant. 1

Rationale for Antibiotic Prophylaxis

Liver transplant recipients are at increased risk of surgical site infections (SSIs) due to their immunosuppressed state. The most recent guidelines provide clear direction on this matter:

• The 2023 ERAS Society recommendations for perioperative care in liver surgery state that antibiotic prophylaxis should be administered within 60 minutes before surgical incision 1
• Extending antibiotics beyond a single preoperative dose into the postoperative period provides no additional benefit for most liver surgeries without biliary reconstruction 1

Recommended Antibiotic Regimen

For a patient with history of liver transplant undergoing skin cancer surgery:

• First-line option: Cefazolin 1-2g IV administered 30-60 minutes before skin incision 2
• The dose should be adjusted based on renal function and patient weight 2
• For patients with beta-lactam allergies, alternative agents should be considered based on local antimicrobial stewardship guidelines

Special Considerations for Transplant Recipients

Transplant recipients require special attention due to their immunosuppressed status:

• Screening for multidrug-resistant organism (MDRO) colonization may be warranted in high-risk patients 1
• For patients colonized with extended-spectrum beta-lactamase-producing Enterobacterales (ESCR-E), targeted prophylaxis may be considered 1
• The 2023 ESCMID/EUCIC guidelines conditionally recommend targeted prophylaxis for liver transplant recipients colonized with ESCR-E 1

Skin Preparation

In addition to antibiotic prophylaxis, proper skin preparation is crucial:

• Chlorhexidine-alcohol solution (2%) is superior to povidone-iodine for preoperative skin preparation 1, 3
• The antiseptic should be applied thoroughly to the surgical site and allowed sufficient time to dry according to manufacturer's instructions 3

Important Caveats

• Extending antibiotic prophylaxis beyond the perioperative period has not been shown to reduce infection rates and may contribute to antimicrobial resistance 1
• A randomized controlled pilot trial comparing intraoperative antibiotics alone versus extended (72-hour) prophylaxis in liver transplant recipients found no significant difference in SSI rates 4
• Surgical site infections in transplant recipients can be associated with significant morbidity, mortality, and longer hospital stays 5
• The risk of SSIs with multidrug-resistant organisms is higher in transplant recipients, emphasizing the importance of appropriate initial prophylaxis 5

Algorithm for Decision-Making

1. Assess patient's risk factors:

   • Time since transplantation
   • Current immunosuppression regimen
   • History of previous infections
   • Complexity of the planned procedure

2. Administer appropriate prophylaxis:

   • Standard risk: Single dose of cefazolin 1-2g IV within 60 minutes before incision
   • High risk (complex procedure or known colonization with MDROs): Consider targeted prophylaxis based on colonization status

3. Ensure proper skin preparation with chlorhexidine-alcohol solution

4. Do not extend antibiotics into the postoperative period unless specifically indicated by intraoperative findings or patient-specific factors

This evidence-based approach balances the need for infection prevention with antimicrobial stewardship principles in this vulnerable patient population.