How Do Infection Control Practices in Mohs Surgery Affect the Infection Rate?

George J. Hruza, MD


Journal Watch. 2010;30(21) 

In This Article

Abstract and Introduction


Results of two recent studies conflict, but a higher level of sterility may probably be reserved for repairs involving flaps.


Rates of infection after Mohs surgery and the associated reconstruction range from 0.72% to 4.25%. In two recent trials, researchers evaluated the effectiveness of infection-control practices and clean surgical techniques for preventing infection.

In a retrospective study, Martin and colleagues compared infection rates before and after a change in infection prevention and control practices at a single-surgeon academic Mohs practice. Before the change, staff washed hands between stages; wore scrubs, masks, and nonsterile gloves for the Mohs surgery; and wore sterile gloves and drapes for the reconstruction. They used sterile instruments, nonsterile dressings, and chloroxylenol 3% skin prep. The prechange protocol was associated with a 2.5% infection rate in 365 tumors. The new protocol added surgical caps, sterile gowns for the repair, and alcohol-based hand scrub between stages and before repair, and prohibited jewelry except for smooth wedding bands. Sterile gloves and sterile drapes were used for both Mohs surgery and repair. This new practice was associated with a statistically lower infection rate of 0.9% in the 585 tumors treated.

In a prospective study, Rogers and colleagues analyzed wound infection rates in 1204 consecutive tumors treated with Mohs surgery using clean surgical technique and no prophylactic antibiotics. Surgeons wore masks and used hand sanitizer between stages and before repair. They used clean, nonsterile gloves during both Mohs surgery and repair. The same tray, with initially sterile instruments, and the same clean drapes were used throughout. The skin was prepped only once, before the Mohs surgery, with Hibiclens. No additional skin prep was done for additional stages or repair. No oral or topical antibiotics were used; the only exception was vinegar soaks for ear wounds with exposed cartilage healing by second intention. This clean technique was associated with a 0.91% infection rate, all Staphylococcus aureus (methicillin-resistant, 45%). Infections occurred in 2.67% of flaps, 0.78% of primary closures, and 0% of skin grafts and second-intention–healing wounds.