1. Purpose & Scope

To provide a step-by-step protocol for preventing, recognising, and managing infections related to cosmetic injectables (botulinum toxin and dermal fillers) at Newcastle Cosmetic Doctor (NCD), aligned with current Australian guidance and international best practice. This protocol applies to all clinical staff and covers immediate care, escalation, documentation, and regulatory reporting.

2. Governance & Key References

This protocol aligns with Ahpra’s Non-Surgical Cosmetic Procedure Guidelines (effective 2 Sep 2025); Australian skin-infection guidance (e.g., NSW/ARC/RACGP resources); ACE Group World infection/biofilm guidance; and TGA adverse-event reporting requirements. See the hyperlinked Harvard-style bibliography at the end.

3. Definitions & Risk Factors

• Early infection: within days of treatment – typically erythema, warmth, tenderness, purulent discharge (cellulitis/abscess).
• Delayed infection/biofilm: weeks to months later – tender nodules, fluctuance, recurrent swelling, erythema that waxes/wanes; may follow dental work, illness, or re-injection.
• Atypical infection: non-tuberculous mycobacteria (e.g., M. abscessus) – indurated nodules, sinus tracts, poor response to standard antibiotics.

4. Prevention & Asepsis

• Pre-procedure screening: recent dental work, active acne/dermatitis at site, immunosuppression; defer if needed.
• Skin prep: remove makeup; chlorhexidine 2% in alcohol (avoid mucosa/eyes); sterile gloves; no-touch technique; single-use needles/cannulas.
• Consumables: open on tray immediately before use; avoid cross-contamination; dispose correctly.
• Post-care: written instructions on hand hygiene, makeup avoidance 12–24 h, avoid picking, and when to contact clinic.

5. Recognition: Red Flags & Triage

Red flags (urgent review): rapidly spreading erythema, fever, severe pain, fluctuance/abscess, lymphangitis, systemic symptoms, ocular involvement (periorbital), or signs of vascular compromise (follow VO protocol if suspected).

For periorbital/orbital signs → same-day ED referral (RANZCO 2024 Filler Blindness Guideline).

6. Step-by-Step Management

6.1 Immediate Assessment (All Suspected Infections)

• History: onset relative to injection, systemic symptoms, prior antibiotics, dental work, comorbidities.
• Exam: map erythema, measure lesion, check for fluctuance, regional nodes; photos.
• Baseline observations: temp, HR, BP; screen for sepsis in unwell patients.

6.2 Early Cellulitis (No Abscess, Localised, Non-facial Severe)

• Start empiric oral antibiotics per Australian guidance for non-purulent cellulitis (e.g., a beta-lactam for streptococci/MSSA) and review in 48–72 h. Typical community courses are 5–7 days; extend if slow response (Australian Prescriber – Bacterial skin and soft tissue infections).
• Elevation, analgesia; strict return advice.
• If deterioration/no response or facial/periorbital involvement → escalate (consider IV therapy/ED).

6.3 Purulent Infection / Abscess

• Incision and drainage (I&D) is primary therapy when safe to do so; send pus for MCS (aerobic/anaerobic) prior to antibiotics. Add empiric MRSA-active oral therapy if risk factors/high MRSA prevalence per local guidance (NSW ED factsheet – Cellulitis (general principles)).

6.4 Suspected Biofilm / Delayed Nodules after HA Filler

• Avoid further filler injections into the area. Consider ultrasound if available to define pockets.
• Obtain swabs/aspirate for culture if fluctuant; request prolonged culture for atypical organisms. Discuss with dermatology/infectious diseases if atypical features.
• Start targeted antibiotics per clinician judgement (often combination covering staphylococci and anaerobes) and reassess.
• Consider hyaluronidase to reduce HA load when biofilm suspected, alongside antibiotics (ACE Group – Infection/Biofilm guidance).
• See CMAC/JCAD – Delayed onset nodules (overview).

6.5 Atypical Mycobacterial Infection (NTM)

• Suspect when: Chronic indurated nodules, sinus tracts, minimal systemic upset, poor response to standard antibiotics. Send tissue/aspirate for AFB stain, mycobacterial culture, and PCR. Management requires infectious diseases input; prolonged multi-drug therapy is typical (Pessoa et al. 2023 – Mycobacterium abscessus case series).

6.6 Anti-wrinkle (Botulinum toxin) Injection Site Infection

• True infection is uncommon; manage as for superficial cellulitis when erythema/tenderness develops post-procedure. Differentiate from expected local reactions. Escalate promptly if systemic features or orbital involvement (glabellar/forehead).

6.7 When to Refer / Escalate

• ED/Hospital: systemic toxicity, rapidly progressive cellulitis, facial/periorbital involvement, sepsis, immunocompromised host, failure of oral therapy.
• Dermatology/Plastics/ID: recurrent or delayed nodules, suspected biofilm/NTM, non-response to first-line therapy, need for imaging/I&D in complex sites.

7. Wound Care & Dressings

For erosions/ulceration, use non-adherent dressings, protect periwound skin, and photograph at each review; follow local NSW wound protocols where applicable (SESLHD – Wound assessment & management protocol).

8. Documentation & Regulatory Reporting

• Record history/exam, photographs with measurements, antibiotic(s) and doses, procedures (I&D), cultures ordered, and safety-net advice.
• Log batch/lot numbers of products used (toxin/filler) and consumables where relevant.
• Report suspected significant adverse events related to medicines/biologicals to the TGA; provide patient information and arrange follow-up.

9. Clinic Readiness & Training

• Stock: antiseptics, dressings, swabs/containers for MCS & AFB culture, analgesics, MRSA-active antibiotics as per prescriber scope/local formulary.
• Monthly checks: kit completeness and expiries.
• Drills: quarterly scenario (biofilm nodule, abscess requiring I&D, periorbital cellulitis → ED).

Summary

1. Assess & photograph → screen red flags.
2. If cellulitis (non-purulent): start oral antibiotics per local guideline; review 48–72 h.
3. If abscess: I&D + send MCS; add MRSA-active agent if indicated.
4. Delayed tender nodule/biofilm: cultures ± ultrasound; antibiotics; consider hyaluronidase for HA filler; avoid re-injection.
5. Suspected NTM: AFB/PCR; urgent ID referral.
6. Facial/periorbital involvement, systemic toxicity, failure of therapy → ED/hospital.
7. Document, report to TGA if applicable; schedule follow-up.

Sources

1. Australian Health Practitioner Regulation Agency (Ahpra) 2025, Guidelines for practitioners who perform non-surgical cosmetic procedures (advance copy – effective 2 Sep 2025), viewed 3 Oct 2025, https://www.ahpra.gov.au/sitecore/content/Dental/News/2025-06-03-New-cosmetic-procedure-guidelines.aspx
2. Aesthetic Complications Expert (ACE) Group World 2021, Infection Control in Aesthetic Medicine, viewed 3 Oct 2025, https://uk.acegroup.online/wp-content/uploads/2021/01/ACE-Group-Infection-Control-Guideline.pdf
3. Complications in Medical Aesthetics Collaborative (CMAC) 2022, Delayed-onset nodules and their treatment following dermal fillers, JCAD, viewed 3 Oct 2025, https://jcadonline.com/cmac-delayed-onset-nodules/
4. NSW Agency for Clinical Innovation – Emergency Care Institute 2027 (review date), Cellulitis factsheet, viewed 3 Oct 2025, https://aci.health.nsw.gov.au/networks/eci/clinical/ed-factsheets/cellulitis
5. Australian Prescriber 2016, Bacterial skin and soft tissue infections, viewed 3 Oct 2025, https://australianprescriber.tg.org.au/articles/bacterial-skin-and-soft-tissue-infections.html
6. Royal Children’s Hospital Melbourne 2024, Clinical practice guideline: Cellulitis and other bacterial skin infections, viewed 3 Oct 2025, https://www.rch.org.au/clinicalguide/guideline_index/Cellulitis_and_Skin_Infections/
7. RANZCO 2024, Filler blindness guideline (context for peri-orbital red flags), viewed 3 Oct 2025, https://ranzco.edu/wp-content/uploads/2024/06/RANZCO-Filler-Blindness-Guidelines_2024.pdf
8. Pessoa et al. 2023, Guidance on the treatment of rare deep subcutaneous mycobacterium infections post-cosmetic procedures, Eur J Plast Surg, viewed 3 Oct 2025, https://link.springer.com/content/pdf/10.1007/s00238-023-02053-5.pdf
9. Therapeutic Goods Administration (TGA) 2025, Report adverse events for medicines and biologicals, viewed 3 Oct 2025, https://www.tga.gov.au/how-we-regulate/monitoring-safety-and-shortages