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Page 8 of 14 Knapp et al. Plast Aesthet Res 2020;7:7 I http://dx.doi.org/10.20517/2347-9264.2019.69

the utility of decolonization prior to a planned operation with significant beneficial results. A randomized
control trial including over 6000 patients evaluated infection rates in those pretreated for 5 days with twice-
[106]
daily nasal mupirocin and daily chlorhexidine showers to a placebo group . The results showed a 44%
decrease in postoperative S. aureus infections in the treated group. Several other prospective trials with
the implementation of a prescreening and eradication protocol showed similar reductions in infections in
[107]
patients undergoing elective orthopedic operations . The logistics of screening and subsequently treating
these patients need streamlining, but it is clearly cost-effective if performed according to a protocol.

According to joint guidelines developed by several professional surgical and pharmacist societies,
prophylactic antibiotics (a first-generation cephalosporin) should be administered within the first hour
before incision to decrease surgical-site infection in patients undergoing routine VHR [108] . Specifically,
antibiotic administration should occur as close to incision as possible according to a recent large study
using NSQIP data [109] . Antibiotics should be re-dosed during the operation, if necessary, taking into
account the half-life of the drug, blood loss, and the use of cell saver. If planned, or inadvertent, violation of
the colon occurs during the operation, additional antimicrobial coverage is warranted to cover for Gram-
negative species and anaerobes (commonly second-generation cephalosporin or a carbapenem). The BMI of
the patient must also be taken into consideration, as many of these VHR patients are obese and therefore
require higher than standard doses of antibiotics to reach effective levels. One large survey showed that
only 66% of patients with a BMI > 30 received adequate prophylactic antibiotic doses [110,111] . Retrospective
and anecdotal literature support continued postoperative antibiotics in the presence of surgical drains,
[112]
but no high quality or Level 1 data validate this practice . It is important to remain cognizant regarding
the drawbacks of prolonged antibiotics use with respect to alteration of the gut microbiome and potential
development of antibiotic-associated diarrhea and Clostridium difficile. While the exact ideal duration of
antibiotics continues to be debated, prospective studies of prophylactic antibiotics support discontinuation
upon skin closure [113-116] .

The gut microbiome has been shown to play a key role in the human stress response to critical illness [117-121] .
When healthy and diverse, the microbiome supports symbiosis, homeostasis, and gut barrier function.
The gut microbiome is affected by numerous factors that often arise in this patient population, including
administration of broad-spectrum antibiotics, proton-pump inhibitors, vasopressors, and opioids, as well
as decreases in luminal nutrient delivery and even changes to the exposed partial pressure of oxygen if the
bowel is opened. Probiotics (live microorganisms which confer beneficial effects to the host when given in
[122]
sufficient quantities) and prebiotics (food ingredients which are largely non-digestible fibers that induce
the growth of beneficial microorganisms in the colon) have emerged as potential treatments to help reduce
postoperative infections by supporting a healthy gut microbiome. Several randomized controlled trials
[123]
using pro- and prebiotics have been conducted in various surgical patient populations in an effort to
[124]
prevent specific infections, e.g., MRSA . Numerous high quality meta-analyses make it clear that the use
of pro- and prebiotics lowers the rates of SSIs, urinary tract infections, and sepsis [125-128] .
Enhanced recovery after surgery, opioid reduction, anxiety, and miscellaneous
Enhanced Recovery After Surgery (ERAS) protocols were first developed in patients undergoing colorectal
surgery, but are now used widely throughout surgical specialties. ERAS protocol has resulted in shorter
hospitalizations, reduced complication rates, lower readmissions, and lower healthcare costs [129-131] . Having
a protocolized and multidisciplinary approach to the care of complex patients, such as AWR patients, in
the pre-, intra-, and postoperative settings is clearly the best strategy for success.

Intraoperative wound protectors in abdominal surgery are employed to protect the wound edges from
bacterial contamination and to minimize mechanical trauma. Several clinical trials have been performed
to investigate their role in preventing SSIs with some success [132-134] . Plastic adhesive skin barriers used to