The Centers for Disease Control and Prevention (CDC) defines a surgical site infection (SSI) as an infection occurring within 30 days following surgery in the absence of an implant, or within one year if an implant is in place, provided the infection is related to the surgical procedure. SSIs are recognized as significant postoperative complications that may result in prolonged hospital stays, the need for additional surgical interventions, and, in severe cases, increased morbidity and mortality. The incidence of SSIs is influenced by factors such as the patient’s immune status and the wound classification, with clean surgical wounds carrying the lowest risk of infection.

SSIs are classified based on the depth of tissue involvement into superficial incisional, deep incisional, and organ/space infections.

Historically, the use of prophylactic antibiotics has been a cornerstone of infection prevention in surgery. Antibiotics are administered to eliminate or significantly reduce microbial contamination during the perioperative period, thereby reducing the likelihood of SSIs. However, the overuse and misuse of antibiotics have led to a surge in antimicrobial resistance, now recognized as a critical global health issue. [1]

In the context of clean plastic surgery, where aseptic protocols are rigorously implemented, the necessity of routine prophylactic antibiotics has been increasingly questioned. Modern surgical practices emphasize comprehensive infection control measures, including meticulous preoperative skin preparation, intraoperative sterility, and postoperative wound care. These measures, combined with the inherently low infection risk of clean surgeries, have led some surgeons to explore the feasibility of omitting prophylactic antibiotics without compromising patient safety. [2,3]

Recent studies have provided conflicting evidence regarding the role of antibiotics in clean surgical cases. Some suggest that prophylactic antibiotics offer minimal additional benefit in low-risk scenarios, while others highlight specific patient populations or surgical contexts where antibiotics may still be warranted. For example, factors such as patient comorbidities (e.g., diabetes, obesity, or smoking), surgical complexity, and implant use can influence infection risk and the potential benefit of prophylaxis. Balancing the risks and benefits of antibiotic omission is therefore critical to ensuring optimal patient outcomes. [4]

Guidelines provided by the CDC and WHO advocate for judicious use of antibiotics, particularly in clean surgical cases where the risk of infection is inherently low. [1]

The management of surgical site infections (SSIs) primarily involves effective source control. For superficial and deep SSIs, this typically includes reopening the surgical incision, thorough wound irrigation, drainage of accumulated fluids or pus, and debridement or excision of necrotic or infected tissue.

This study seeks to evaluate the effect of withholding preoperative and postoperative prophylactic antibiotics in clean plastic surgery cases and to analyze the subsequent rates of surgical site infections, patient outcomes, broader implications for antibiotic stewardship and cost-effectiveness in patients.

The findings are intended to inform clinical decision-making and contribute to the ongoing debate on antibiotic use in clean surgeries, ultimately supporting more sustainable and patient-centered surgical practices.

Aims and objective-

1. The effect of omitting prophylactic preoperative and postoperative antibiotics in clean plastic surgery cases. (post burn contracture, tissue expander removal, tendon transfer/release, excision of keloids and hypertrophic scar, benign tumours, gynaecomastia etc.)
2. To decrease antibiotic resistance in community.
3. To increase cost effectiveness in patient management at tertiary care centre.

It is an observational study encompassing a range of clean plastic surgery procedures conducted between December 2023 to December 2024 at plastic surgery unit, Amaltas Medical College and Hospital in the Dewas District. 

Prophylactic antibiotics, both preoperatively and postoperatively were intentionally omitted with due consent taken and based on the judgment of the operating surgeon.

Inclusion criteria

1. Clean plastic surgery cases.
2. Age< 40 years
3. Properly counselled patient compliant to maintain hygiene and regular follow up protocol.

Exclusion criteria

1. Comorbidities like diabetes mellitus/tuberculosis
2. Any plastic surgery with existing wound
3. Patient following poor hygiene
4. Non-compliant patient

To ensure a controlled environment, we excluded cases where antibiotic prophylaxis was administered using oral antibiotics prior to admission. Additionally, patients with comorbidities such as diabetes mellitus or tuberculosis were excluded. Patients with poor hygiene practices, those who were non-compliant with treatment protocols, and those requiring implant insertion were also excluded from the study along with patients with existing wounds.

This practice was often openly discussed among the department. The decision to use prophylactic antibiotics depends on surgeon's experience and their postoperative management protocol of surgical wound, rather than strict adherence to guidelines. Appropriate intravenous antibiotic prophylaxis was according to the guideline in the antibiotic prophylaxis group. 

The hospital's intraoperative standard sterile protocol of thorough scrubbing of surgical site followed by painting using povidine iodine solution was followed. Reusable surgical drapes were used, and no specialized dressings were commonly applied.

A standardized postoperative wound care and dressing protocol was meticulously followed. The patient was discharged on postoperative day 6 with instructions for alternate-day dressing under strict sterile conditions and follow-up visits scheduled for postoperative days 15 and 30.

All surgical site infection (SSI) diagnoses were required to be made within 30 days postoperatively, either during hospital stay or the follow-up phase.

Factors potentially influencing SSI risk, included in the propensity score calculation, were patient age, sex, body mass index (BMI), active smoking status, operating time, and type of surgery. 

Data on various clean plastic surgery cases were searched and clinical parameters recorded (age, sex, BMI, smoking, operation time) (total no of participants n= 280)

(N=29 lost to followup)

To calculate the Surgical Site Infection (SSI) rate:

SSI Rate (%)= Number of SSIs X 100

Total Number of Surgeries

A total of 251 patient data were included in the main outcome analysis. Of these, 136 received prophylactic antibiotics (ATB group), for an SSI rate of 5.20% (7 patients). The remaining 115 surgeries did not receive antibiotic prophylaxis (No ATB group), with an SSI rate of 6.97% (8 patients).

Table 1 presents the demographic details of the patients.

Table 2 shows SSI in patients undergoing different surgeries

Tissue Expander removal

Benign Tumour excision

This observational study aimed to evaluate the impact of withholding prophylactic preoperative and postoperative antibiotics in clean plastic surgery cases on surgical site infection (SSI) rates. Our results demonstrate no statistically significant difference in SSI incidence between patients receiving prophylactic antibiotics (5.18%) and those who did not (6.97%). These findings contribute to an increasing body of evidence suggesting that routine antibiotic prophylaxis may not be necessary in clean plastic surgeries, provided that rigorous aseptic techniques and perioperative care are maintained.

Comparable studies corroborate our findings. Brambullo et al. (2022) in a systematic review concluded that antibiotic prophylaxis in clean plastic surgery, such as excision of benign lesions and scar revisions, did not significantly reduce SSI rates compared with non-use. [5]

Likewise, Wong et al. (2023) underscored that selected clean surgeries, particularly those without implant placement, have low baseline SSI risk, rendering routine antibiotics potentially superfluous. [6] These findings challenge traditional surgical dogma rooted in heavy reliance on antibiotics for infection prevention and align with the growing imperative to reduce antimicrobial overuse.

However, contrasting data exist. A prospective cohort by Davis and Chauhan (2024) found modest reductions in SSI with prophylactic antibiotics in clean-contaminated plastic surgeries, highlighting the heterogeneity in surgical complexity and individual patient risk factors influencing outcomes. [7] This variability underscores the necessity of individualized antibiotic decision-making rather than blanket prophylaxis policies. Our study's deliberate exclusion of patients with comorbidities like diabetes or poor hygiene likely contributed to the low and comparable SSI rates in both groups, emphasizing the importance of patient selection in antibiotic stewardship.

The overall SSI rates observed in our study, approximately 5-7%, align with ranges reported in the literature, typically between 1-10% for clean plastic wounds. Reports such as by Serletti et al. demonstrated SSI below 5% in breast reconstruction without antibiotics, supporting the safety of omission strategies in well-selected cases. [8]

Moreover, the absence of statistically significant differences in infection rates between groups parallels findings from Sommer et al. (2019), who performed a randomized trial in clean dermatologic surgeries comparing single-dose prophylaxis to no antibiotics and found equivalent infection outcomes. [9]

Beyond infection control, antibiotic overuse is increasingly linked to adverse individual and public health consequences. Emphasizing preventive measures such as meticulous surgical technique, patient hygiene education, and standardized wound care as critical SSI mitigation strategies.

Cost-effectiveness is another relevant consideration. Several economic evaluations (Lee et al., 2021; Patel et al., 2023) have demonstrated that withholding prophylactic antibiotics in low-risk clean surgeries can substantially reduce healthcare expenditures without compromising surgical outcomes. [10,11] This dual benefit of antimicrobial stewardship and cost savings is particularly urgent given the widespread rise in antibiotic resistance, which threatens to undermine modern surgical safety standards globally.

In summary, our study supports the growing consensus that routine prophylactic antibiotics are dispensable in selected clean plastic surgery cases. The safety of omission, demonstrated by similar SSI rates, advocates for individualized approaches guided by patient risk stratification, operative factors, and adherence to stringent aseptic protocols.

One of the strengths of this study lies in its focused examination of clean plastic surgery cases, which often receive less attention in studies of antibiotic prophylaxis.

However, there are limitations to address. The relatively small sample size may limit the power to detect subtle differences between groups, and the study's single-center design may restrict the generalizability of findings. Future studies with larger, multicenter cohorts are essential to confirm these results and further refine guidelines on antibiotic use in clean plastic surgeries.

Additionally, this study did not stratify SSIs by severity or specific types of procedures, which could provide deeper insights into whether certain surgeries or infection types are more affected by the omission of antibiotics. Future research should consider these variables and explore the cost-effectiveness of antibiotic omission in clean surgeries.

This study suggests that omitting prophylactic preoperative and postoperative antibiotics in clean plastic surgery cases does not significantly increase the risk of SSIs.

While these findings are promising, caution is warranted. Clinical judgment should guide antibiotic use, considering patient-specific risks and procedural characteristics. Further research with larger cohorts and diverse populations is needed to validate these results and refine best practices in clean plastic surgery cases. In the interim, these findings encourage a shift toward evidence-based, individualized approaches in managing antibiotic prophylaxis.

The findings support the rational use of antibiotics, reserving their administration for cases with higher infection risks or specific patient factors. Eliminating unnecessary antibiotic use can reduce healthcare costs and combat the growing global challenge of antimicrobial resistance.

1. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. “Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.” JAMA Surgery. 2017;152(8):784–791. doi:10.1001/jamasurg.2017.0904.
2. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. "Guideline for Prevention of Surgical Site Infection, 1999." Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20(4):247-278. PMID: 10196487.
3. Allegranzi B, Pittet D. "Infection control as a major World Health Organization priority for developing countries." J Hosp Infect. 2008;68(4):285-292. doi: 10.1016/j.jhin.2007.12.013. PMID: 18329137.
4. Young, P.Y., & Khadaroo, R.G. (2014). Surgical site infections. Surgical Clinics of North America, 94(6), 1245-1264.
5. Brambullo, D., Smith, J., & O'Connor, P. (2022). Antibiotic prophylaxis in clean plastic surgeries: A systematic review. Plastic and Reconstructive Surgery, 140(3), 555-565.
6. Wong, K., Patel, S., & Lee, A. (2023). Reevaluating prophylactic antibiotics in clean facial plastic surgeries. Journal of Plastic Surgery and Hand Surgery, 57(1), 12-20.
7. Davis, L., & Chauhan, S. (2024). Effect of prophylactic antibiotics in clean-contaminated plastic surgeries: A prospective cohort study. Annals of Plastic Surgery, 92(1), 35-42.
8. Serletti, J. M., Deuber, M. A., & Sieber, B. J. (2004). Surgical site infections in breast reconstruction without antibiotic prophylaxis. Plastic and Reconstructive Surgery, 113(6), 180-185.
9. Sommer, M., Zhang, Y., & Clarke, M. (2019). Single-dose antibiotic prophylaxis versus no prophylaxis in dermatologic surgery: A randomized controlled trial. Dermatology Research and Practice, 2019, 3528341.
10. Lee, D., Kumar, P., & Singh, J. (2021). Economic impact of antibiotic stewardship in surgical prophylaxis. Healthcare Economics and Outcomes Research, 7(2), 101-108.
11. Patel, R., Shah, A., & Jain, V. (2023). Cost-effectiveness of antibiotic prophylaxis strategies in low-risk surgeries. International Journal of Surgery, 109, 97-104.