Antibiotic Practices in Mohs Micrographic Surgery

May 2020 | Volume 19 | Issue 5 | Original Article | 493 | Copyright © May 2020

Published online April 17, 2020

Matthew J. Lin MD, Danielle P. Dubin BA, Cerrene N. Giordano MD, David A. Kriegel MD, Hooman Khorasani MD

Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY

Background: Mohs micrographic surgery is a safe procedure with low rates of infection.
Objective: To establish current antibiotic prescribing practices amongst Mohs surgeons.
Methods and Materials: 16-question survey sent to American College of Mohs Surgery members.
Results: 305 respondents with collectively 7,634+ years of experience. The majority performed outpatient surgery (95.0%) and avoided oral or topical antibiotics for routine cases (67.7% and 62.8%, respectively). Prophylactic antibiotics were routinely prescribed for artificial cardiac valves (69.4%), anogenital surgery (53.0%), wedge excision (42.2%), artificial joints (41.0%), extensive inflammatory skin disease (40.1%), immunosuppression (38.9%), skin grafts (36.4%), leg surgery (34.2%), and nasal flaps (30.1%). A minority consistently swabbed the nares to check for staphylococcus aureus carriage (26.7%) and decolonized carriers prior to surgery (28.0%).
Conclusion: Disparity exists in antibiotic prescribing practices amongst Mohs surgeons. There may be under-prescription of antibiotics for high risk factors like nasal flaps, wedge excisions, skin grafts, anogenital/lower extremity site, and extensive inflammatory disease. Conversely, there may be over-prescription for prosthetic joints or cardiac valves. Increased guideline awareness may reduce post-operative infections and costs/side effects from antibiotic over-prescription.

J Drugs Dermatol. 2020;19(5): doi:10.36849/JDD.2020.4695


Mohs micrographic surgery in general is associated with low rates of infection. As such, routine prophylactic antibiotics are not recommended. There are, however, several established risk factors for surgical site infection, including: lower leg site, skin grafts, skin flaps on the nose, wedge excisions of the lip or ear, and severe inflammatory skin disease.1 Nasal staphylococcus aureus carriage is also associated with higher rates of postoperative infection. Decolonization with intranasal mupirocin ointment and chlorhexidine body wash prior to Mohs micrographic surgery has been shown to reduce the infection rate for these carriers.2

In 2008, a working group from the Mayo Clinic reviewed prospective trials and obtained expert consensus to create an advisory statement on antibiotic prophylaxis in dermatologic surgery.1

To establish current antibiotic prescribing practices among Mohs micrographic surgeons in the United States, a 16-question online survey sent to all members of the American College of Mohs Surgery (ACMS) in October 2018 via email. The survey was approved by the Mount Sinai Health System Institutional Review Board. Data was collected for 1 month following distribution of the survey. Results were collated and analyzed in a confidential, anonymous fashion. The survey instrument characterized Mohs surgical experience, caseload and surgical setting. The prescription of prophylactic antibiotics was queried for both routine use and in the following surgical situations: nasal flaps, skin grafts, wedge excisions (lip and ear), leg surgery, and anogenital surgery. Prophylactic antibiotic use was also assessed for patients with specific comorbidities: artificial joint replacements, artificial cardiac valves, extensive inflammatory skin disease, and immunosuppression. Finally, respondents were asked if they routinely swabbed the nose for staphylococcus aureus carriage and decolonized carriers with topical antiseptic.

Descriptive statistics, including data distributions and cross-tabulation of the variables of interest were calculated. Pairwise analysis of polytomous variables was conducted using the Pearson chi-square test and an α level of 0.05.


There were 305 respondents (response rate of 18%) with collectively more than 7,634 years of Mohs experience. The surgical experience of the Mohs surgeons is illustrated in Figure 1 and Figure 2. The vast majority of surgeons performed Mohs surgery primarily in an outpatient setting or ambulatory surgical setting (95.0%).

Table 1 summarizes antibiotic usage and decolonization practices in Mohs micrographic surgery among respondents. Most