Antibiotics for Surgical Procedures in Patients with Lymphoedema

Antibiotics for surgical procedures in patients with lymphoedema – summary of BLS / LSN guidelines

By Professor Dominic Furniss, Department of Plastic and Reconstructive Surgery, Oxford University Hospitals NHS Trust

This article is taken from the Summer 2017 issue of LymphLine, the LSN’s quarterly newsletter available to all LSN members. For details of how to become a member, click here.

Why do patients with lymphoedema get infections?

We know that patients with lymphoedema are predisposed to getting infections of the affected area. This is most commonly “cellulitis”, a spreading infection of the skin and subcutaneous fat. It usually causes redness, swelling and heat, and often makes the area tender to touch. It can also cause systemic upset, with fevers, sweating, shivers, muscular aches and pains, headache, nausea, vomiting – it feels like you are getting flu.

Why is this the case? People with lymphoedema are particularly susceptible to infections as one of the key functions of the lymphatic system is to ward off infection. In lymphoedema, the system is damaged, reducing the patient’s ability to fight infection.

What causes cellulitis?

Cellulitis is usually caused by bacteria that live normally on the surface of the skin getting inside of the body, usually through a break in the skin. This can happen through a scratch or insect bite, through a pre-existing wound or ulcer, or through an area of skin inflammation, such as eczema or athlete’s foot.

What about minor skin surgery?

An operation, by necessity, creates a break in the skin, and therefore there is a risk that bacteria from the surface of the skin can get inside the body. However, surgery on the skin of the limbs is slightly different to a scratch in the garden or a bite from an insect. It is performed in the clean environment of an operating theatre, after cleaning the skin with antiseptic solution, using sterilized instruments. This means that the risk of infection after minor surgery (such as mole removal) is likely to be small.

For this reason, the British Lymphology Society / LSN guidelines do not routinely recommend antibiotics to cover this type of surgery. However, if you have previously had an episode of cellulitis in the area that is being operated on, we recommend a single dose or a short course of antibiotics. You should discuss this with your surgeon. If you take antibiotic prophylaxis because of repeated attacks of cellulitis, it is recommended that you receive a course of antibiotics as described in the table below.

‘We know that patients with lymphoedema are predisposed to getting infections of the affected area.’

What about more major surgery?

More major surgery would include any surgery on the affected part where the surgeon will be operating more deeply than the subcutaneous fat. Commonly performed procedures might be a hip or knee replacement, carpal tunnel surgery, surgery to treat broken bones, or to repair cut tendons or nerves. This category would also include surgery to treat lymphoedema, like lymphaticovenular anastomosis or lymphoedema liposuction.

Here the risks and consequences of infection are higher, so more care is needed. We recommend that patients undergoing these procedures in the area affected by lymphoedema be treated with a therapeutic course of antibiotics. These antibiotics should begin just before surgery, and are usually continued for around five days after surgery. The type and duration of antibiotics required depends on the type of surgery being undertaken, and should be discussed with your surgeon.