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Methods. A prospective study of 573 consecutive patients with 670 tumors undergoing Mohs surgery with
same-day reconstruction or second-intention healing
evaluated whether a low rate of surgical site infection (SSI)
could be maintained with a low-cost infection-control protocol. Surgical site infections were tracked from January
through September 2010 in a single-surgeon academic
Mohs practice (termed low-cost group), and these were
compared with those from a previously published group
of 585 cases in which the infection rate had dropped from
2.5% (the practices initial infection rate) to 0.9% with
initiation of a more stringent but expensive infectioncontrol protocol (high-cost group). 1 The infectioncontrol protocols investigated are summarized in Table 1.
The study was approved by the Partners Human Research Office.
Erythema
Edema
OR
No other signs/symptoms
No infection
Patient instructed to return if
signs or symptoms of
infection developed, if wound
looked worse to them, or if it
failed to heal
Characteristic
Jewelry restrictions
Surgical caps
Mohs excision
Staff hand wash
Gloves
Drape
Reconstruction
Staff hand wash
Gloves
Drape
Gowns
Total Cost per Case
High-Cost Protocol1
(0.9% Infection Rate)
Low-Cost Protocol
(0.7% Infection Rate)
None
None
CG-EA, $0.84
Sterile, $2.92
Sterile paper drape, $1.59
CG-EA, $0.84
Clean, negligible cost
Sterile paper drape, $1.59
CG-EA, $0.84
Sterile, $2.92
Sterile towels, a negligible cost
CG-EA, $0.84
Sterile, $2.92
Sterile half sheet, $1.06, and sterile
towels, a negligible cost
Sterile knee length, $4.42
$14.62 ($10.86 increase over initial
protocol)
CG-EA, $0.84
Sterile, $2.92
Sterile towels, a negligible cost
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Table 2. Characteristics of Patients in the High- and Low-Cost Infection-Control Protocol Groups a
Infection-Control Protocol
Characteristic
Age, mean, y
Female
Tumor type
BCC
SCC
Other
Location
Head and neck
Trunk
Upper limbs
Lower limbs
Mohs stages, mean No.
Post-Mohs area, mean, cm2
Closure type
Primary
Flaps
Grafts
Secondary intention
Referral
Other
Prophylactic antibiotics
Before surgery
After surgery
Unknown
Current tobacco use
Diabetes
Immunosuppression
High Cost
(n = 585)
Low Cost
(n = 670)
P Value
67.3
260 (45)
67.4
324 (48)
NA
NA
NA
NA
347 (60)
184 (32)
54 (8)
433 (65)
215 (32)
22 (3)
NA
NA
NA
NA
NA
NA
525 (90)
15 (3)
21 (4)
24 (4)
1.3
2.26
549 (82)
35 (5)
32 (5)
54 (8)
1.3
2.94
.001
.01
NA
.004
NA
NA
15.41
6.06
NA
8.39
NA
NA
374 (64.5)
86 (15)
38 (7)
18 (3)
42 (7)
26 (4)
446 (67)
90 (13)
38 (6)
62 (9)
30 (4)
3 (0.5)
NA
NA
NA
.001
NA
NA
NA
NA
NA
19.97
NA
NA
43 (7)
0
1 (1)
22 (4)
47 (8)
59 (10)
29 (4)
0
0
48 (7)
56 (8)
34 (5)
.02
NA
NA
.01
NA
.001
5.27
NA
NA
6.87
NA
11.43
preparations are reportedly equivalent.2 There were no personnel changes, and resident participation was consistent
(approximately 20% of cases) between the groups.
Potential confounders that differed significantly on 2
test results between infection control protocol groups were
tested for association with the primary study outcome
(presence or absence of infection) via the Fisher exact
test. Statistical significance was set at P .05 (STATA 9;
StataCorp LP).
The cost of infection control per case was calculated
by tabulating the costs of infection-control protocols for
a 1-stage Mohs procedure and reconstruction performed by 1 surgeon and 1 assistant (Table 1). The cost
per infection prevented was calculated by dividing the
cost of infection control per case by the reduction in infection risk from the baseline risk of 2.5%.
Results. Patients in the low-cost group were statistically different from those in the high-cost group with regard to several variables (Table 2). However, none of
these variables was significantly associated with infection on Fisher exact testing (data not shown), indicating that there was no confounding of infection risk due
to these between-group differences.
Infection risk was the same between high-cost (n=5,
0.9%) and low-cost groups (n = 5, 0.7%). The cost of infection control per case was lowered from $14.62 in the
high-cost group to $6.22 in the low-cost group. Compared with the baseline cost of $3.76 and infection risk
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ers. In addition, since the 3 changes in the low-cost protocol were made simultaneously, the impact of each individual change cannot be evaluated. However, infectioncontrol measures are frequently implemented and studied
as regimens involving several elements. A randomized, multicenter trial comparing infection regimens would eliminate the possibility of bias from use of historical controls
and enhance generalizability of results. Such studies are
needed to define optimally cost-effective infection-control
protocols in the dermatologic surgery patient population.
Evelyn Lilly, MD
Chrysalyne D. Schmults, MD, MSCE
Accepted for Publication: February 3, 2012.
Author Affiliations: Mohs and Dermatologic Surgery Center, Department of Dermatology, Brigham and Womens Hospital, Harvard Medical School, Boston, MA.
Correspondence: Dr Schmults, Mohs and Dermatologic Surgery Center, Department of Dermatology,
Brigham and Womens Hospital, 1153 Centre St, Ste 4349,
Jamaica Plain, MA 02130 (cschmults@partners.org).
Author Contributions: Both authors had full access to
all of the data in the study and take responsibility for the
integrity and the accuracy of the data analysis. Study concept and design: Schmults. Acquisition of data: Lilly. Analysis and interpretation of data: Lilly and Schmults. Drafting
of the manuscript: Lilly. Critical revision of the manuscript
for important intellectual content: Lilly and Schmults.
Statistical analysis: Schmults. Administrative, technical, and
material support: Lilly. Study supervision: Schmults.
Financial Disclosure: None reported.
1. Martin JE, Speyer LA, Schmults CD. Heightened infection-control practices
are associated with significantly lower infection rates in office-based Mohs
surgery. Dermatol Surg. 2010;36(10):1529-1536.
2. Aly R, Maibach HI. Comparative antibacterial efficacy of a 2-minute surgical
scrub with chlorhexidine gluconate, povidone-iodine, and chloroxylenol
sponge-brushes. Am J Infect Control. 1988;16(4):173-177.
3. Eisen DB. Surgeons garb and infection control: whats the evidence? J Am Acad
Dermatol. 2011;64(5):960.e1-960.e20.
4. Rogers HD, Desciak EB, Marcus RP, Wang S, MacKay-Wiggan J, Eliezri YD.
Prospective study of wound infections in Mohs micrographic surgery using
clean surgical technique in the absence of prophylactic antibiotics. J Am Acad
Dermatol. 2010;63(5):842-851.
5. Dixon AJ, Dixon MP, Askew DA, Wilkinson D. Prospective study of wound
infections in dermatologic surgery in the absence of prophylactic antibiotics.
Dermatol Surg. 2006;32(6):819-827.
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