The foundations of surgical antibiotic prophylaxis were well-established by the 1970s. These principles state that an adequate concentration of the prophylactic antibiotic must be present in both the serum and the wound tissue when bacteria is inoculated into the wound by a surgical procedure. The concentration of the protein-free active fraction that can diffuse into the dermal interstitial space from the vascular compartments is critical for successful antibiotic prophylaxis. The standard delivery modes, i.e., intravenous, intramuscular, and topical have not changed in 50 years. 

In the late 1970s, a group of dedicated general surgeons from the United Kingdom,¹ followed by surgeons in Greece^2,3 and Spain⁴, began a journey to optimize the delivery of antibiotics for surgical antibiotic prophylaxis (SAP). Dr Pollock and Greenall¹ (Scarborough Hospital in North Yorkshire) advocated placing antibiotics directly into the wound during surgery. Although no needle was used to deliver antibiotics, this technique was termed intra-incisional. The rationale and groundwork for direct needle intralesional injection of antibiotics is attributed to Taylor⁵ and others at the Manchester Royal Infirmary. He advocated that the antibiotic would be more effective if injected directly into the sidewall of the abdominal cavity. 

Taylor,^5,6 Armstrong, and Reeves⁶ were the first to publish in support of pre-incisional injection of an antibiotic, followed closely by Rodriguez et al.⁴ from Spain, Porteous⁷ in Scotland, and Dillon⁸ from the United States. These surgeons advocated using a 20 ml syringe containing a local antibiotic injection 10 minutes before an operation. They used a 22-gauge spinal needle inserted into the muscle, fat, and skin of the intended incision, depositing the antibiotic directly.

The report by Dillon identified 34 legs that were at risk for amputation due to peripheral arterial insufficiency, osteomyelitis, and soft tissue infections in ischemic diabetic legs. The author utilized local antibiotic injections and stated, “Of the 34 legs, 31 were spared amputation. Pain was lessened or relieved in all lesions within a few days of the local injections of antibiotics.” The walking capacity also improved in many patients. This report signifies the importance of local antibiotic therapy beyond its use in general surgery.⁸

In 1984, Tanner published a letter titled, “Is preoperative intra-incisional intra-parietal injection of antibiotics the ideal mode of administration as prophylaxis in abdominal surgery?” ⁹The author stated that on a theoretical basis, this approach would appear to be the ideal mode of antibiotics, producing very high levels of antibiotics present in the wound at the time of potential contamination.” It was noted that adequate serum levels were obtained to minimize the risk of serious systemic complications.

Clinical trials followed throughout the 1980s and 1990s, with John Zitelli, Robert Griego,^10,11 and David Brodland¹¹ spearheading the direct delivery of antibiotics in dermatologic surgery. Their initial work, utilizing nafcillin, was published in 1998.¹⁰ This group now has more than 12,000 cases of intra-incisional delivery in cutaneous surgery with an infection rate of less than 1%.