Submitted Successfully!
To reward your contribution, here is a gift for you: A free trial for our video production service.
Thank you for your contribution! You can also upload a video entry or images related to this topic.
Version Summary Created by Modification Content Size Created at Operation
1
Femke Goormans
 -- 1418 2022-06-21 13:18:16 |
2 Reference format revised.
Lindsay Dong
 -7 word(s) 1411 2022-06-22 03:23:05 |

Video Upload Options

Do you have a full video?
Send video materials Upload full video

Confirm

Are you sure to Delete?
Yes No
Cite
If you have any further questions, please contact Encyclopedia Editorial Office.
Goormans, F.;  Coropciuc, R.;  Vercruysse, M.;  Spriet, I.;  Willaert, R.;  Politis, C. Systemic Antibiotic Prophylaxis in Maxillofacial Trauma. Encyclopedia. Available online: https://encyclopedia.pub/entry/24276 (accessed on 19 April 2024).
Goormans F,  Coropciuc R,  Vercruysse M,  Spriet I,  Willaert R,  Politis C. Systemic Antibiotic Prophylaxis in Maxillofacial Trauma. Encyclopedia. Available at: https://encyclopedia.pub/entry/24276. Accessed April 19, 2024.
Goormans, Femke, Ruxandra Coropciuc, Maximilien Vercruysse, Isabel Spriet, Robin Willaert, Constantinus Politis. "Systemic Antibiotic Prophylaxis in Maxillofacial Trauma" Encyclopedia, https://encyclopedia.pub/entry/24276 (accessed April 19, 2024).
Goormans, F.,  Coropciuc, R.,  Vercruysse, M.,  Spriet, I.,  Willaert, R., & Politis, C. (2022, June 21). Systemic Antibiotic Prophylaxis in Maxillofacial Trauma. In Encyclopedia. https://encyclopedia.pub/entry/24276
Goormans, Femke, et al. "Systemic Antibiotic Prophylaxis in Maxillofacial Trauma." Encyclopedia. Web. 21 June, 2022.
Systemic Antibiotic Prophylaxis in Maxillofacial Trauma
Edit
This entry is adapted from the peer-reviewed paper 10.3390/antibiotics11040483

Infection after maxillofacial trauma remains an important complication, with a significant socio-economic impact. While consensus exists that systemic antibiotic prophylaxis reduces the risk of infection in the management of maxillofacial fractures, the type, and duration remain controversial. 

antibiotic prophylaxis anti-bacterial agents maxillofacial injuries bone fractures infections

1. Introduction

Infection after maxillofacial trauma remains an important complication [1], leading to significant morbidity and increased healthcare costs [2]. Overall, infection rates after maxillofacial fractures vary widely across studies and range from 0% to 62% [3][4]. Accurately estimating the incidence and impact of this complication is hampered by the lack of a clear definition, and the variability in outcome parameters renders existing studies difficult to evaluate and compare [5].
Systemic antibiotic prophylaxis is an accepted strategy to prevent infection in daily clinical practice [6]. However, the optimal type and duration remain controversial [7]. An awareness of the need for standardized, evidence-based guidelines has increased in recent years [8]. Furthermore, antimicrobial resistance (AMR) is increasing, and physicians are becoming aware of the importance of limiting antibiotic use [9].
Contemporary guidelines state that antibiotic prophylaxis should be provided for no longer than 24 h [10]. However, these recommendations are mainly based on a handful of clinical studies and uncertainty persists regarding the optimal antibiotic regimen for infection prevention. Previously published systematic reviews often included studies with a significant risk of bias, leading to a misrepresentation of the currently available evidence [1][3][6][7][11][12][13][14][15][16][17]. For these reasons, and on a worldwide scale, heterogeneity in infection prevention protocols still exist. Recent international surveys among maxillofacial trauma surgeons indeed concluded that most surgeons continue antibiotic prophylaxis longer than proposed, which leads to an important overuse of antibiotics [16][17]. Similar issues are currently encountered in infection prevention protocols for long-bone fractures [18][19].

2. Systemic Antibiotic Prophylaxis in Maxillofacial Trauma

2.1. Duration of Systemic Antibiotic Prophylaxis

Prolonged antibiotic prophylaxis does not appear to be beneficial in the prevention of infection. For mandibular fractures, continuing antibiotic prophylaxis for 24 h after wound closure is advised, but not beyond this time frame [20][21][22][23][24][25][26][27][28][29]. For upper and midface fractures, the benefit of continuing antibiotic prophylaxis for 24 h is questioned [22]. For conservatively treated fractures of the middle and upper facial third, there is no evidence for the use of systemic antibiotic prophylaxis at all [30].

2.2. Antibiotic Type and Duration

Although most studies administered β-lactam antibiotics, the antibiotic agents that were prescribed varied widely. In retrospective studies, a wide variety of antibiotics or combinations was often administered without specifying the reasoning for administering the different antibiotic types to different patients [23][24][29][31]. Future trials should be based on a single regimen to avoid possible confounding. Furthermore, the duration of antibiotic prophylaxis varied and none of the studies had the same research question.

2.3. Causal Pathogens

The selection of prophylactic antibiotics for infection prevention should consider the susceptibility of potential pathogens to these antibiotics [32]. Therefore, knowledge of the type of causative pathogens in infection related to the treatment of maxillofacial trauma is required. When the source of pathogens is skin flora, cefazolin is the antibiotic of choice as it covers Gram-positive cocci (i.e., Staphylococcal species) [32]. In maxillofacial trauma surgery, where pathogens may include oropharyngeal flora (Streptococcal species; oropharyngeal anaerobes (i.e., Peptostreptococcus species)), broad-spectrum antibiotics may be indicated (amoxicillin with clavulanic acid, or cephazolin with metronidazole) [33].
The gold standard for a diagnosis of infection remains the deep tissue cultures, obtained from intraoperative samples [34]. Data on other techniques, such as a culture of sonication fluid from hardware, polymerase chain reaction (PCR), and histopathology (i.e., the presence of polymorphonuclear neutrophils (PMNs)) have not been described with respect to the diagnosis of infection after a maxillofacial trauma. For long-bone fractures, sonication of the osteosynthesis material and subsequent inoculation of sonication fluid has already proven to be useful in diagnosing infection [34]. Using low-intensity ultrasound, sonication is deployed to dislodge the biofilm from the osteosynthesis material. The sonication fluid is then cultured onto bacterial media for further analysis [34]. Sonication may be a way to avoid the contamination of tissue cultures with oral flora, and high-quality studies are needed to substantiate the utility of sonication in the treatment of infection after maxillofacial fractures.
Future trials should thoroughly describe the causal pathogens related to infection after maxillofacial trauma, identified by culture. High quality, uncontaminated, deep tissue and implant samples are essential to validate culture outcomes [35]. Furthermore, to avoid false-negative culture results, it is generally advised to stop antimicrobial therapy two weeks before sampling [35].

2.4. Fracture Type

A mandibular fracture is considered open when the fracture site communicates either intraorally through the mucosa or extraorally through a laceration or avulsive injury of the overlying skin. Therefore, all fractures involving the tooth-bearing areas of the jaws are regarded as open fractures [36]. Any mandibular fracture that does not have extraoral communication and/or involves the tooth-bearing area is considered a closed fracture (e.g., condylar fracture) [36]. Numerous studies have shown that an open fracture is considered a significant risk for infection [23][37][38]. Therefore, not reporting whether the included fractures are open or closed makes the interpretation of the study results almost impossible. As most open fractures are contaminated with microorganisms, immediate antibiotic administration, wound debridement, soft-tissue coverage, and fracture stabilization are necessary [39]. While an immediate antibiotic administration at admission is the standard of care for long-bone open fractures [39], evidence is lacking for maxillofacial fractures and studies have not been able to objectify this benefit [40], possibly due to the limited number of included patients and insufficient follow-up. There is a need for high-quality studies evaluating the benefit of starting antibiotic prophylaxis at admission for open maxillofacial fractures.

2.5. Surgical Treatment

Fracture stability is of the utmost importance in the prevention of infection. Instability leads to ongoing soft-tissue trauma, interruption of neo-vascularity and osteolysis of bone, which creates a supportive environment for bacterial proliferation [41]. However, both surgical therapy (e.g., fracture stability) and the timing of fracture fixation were poorly described [20][22][23][24][25][26][27][29][30][31][37].
Surgical treatment of mandibular fractures is performed using ORIF or CR and maxillomandibular fixation (MMF). Standard MMF methods are either tooth-supported (arch bars, interdental wires, or Ernst ligatures), or bone-supported devices such as intermaxillary fixation (IMF) screws [36]. An open procedure may lead to a four-fold higher rate of infection [23][42]. 

2.6. Outcome Description

The lack of a uniform definition for infection after maxillofacial trauma also contributed to the scarcity of comparable data. Using inadequate outcome parameters risks underestimating or overestimating the actual number of complications, resulting in misleading study conclusions [5]. The absence of a universally accepted definition of infection after maxillofacial trauma mirrors the situation for fracture-related infection (FRI) in long-bone fractures and prosthetic joint infection (PJI) identified many years ago [43].
To date, the term FRI has not been used to describe infection following maxillofacial trauma. Although general treatment principles may differ, and significant differences exist with respect to the blood supply at the fracture site and the bacterial flora present at the site of injury, the basic diagnostic principles are similar. The definition of FRI is based on clinical, laboratory and radiological features that confirm or exclude the presence of infection. The described confirmatory and suggestive criteria could also apply to maxillofacial trauma and possibly be utilized to diagnose (and define) infection [5]. The term FRI covers both surgically treated as well as conservatively treated fractures, which is why scholars prefer to use the standardized term of FRI even though it has not yet been widely accepted within oral and maxillofacial surgery practice.

2.7. Implications of Antibiotic Overuse

Antibiotics are a worldwide leading cause of adverse drug reactions and emergency department visits [44]. Prolonged systemic antibiotic prophylaxis can be associated with, rash, diarrhea and Clostridioides difficile infection, nausea, vomiting and abdominal pain, malaise, and fatigue [45][46].
Furthermore, prolonged antibiotic prophylaxis could possibly contribute to delayed infectious complications. Zosa et al. described a significantly increased infection risk for patients receiving prolonged antibiotic prophylaxis over seven days [29], and Miles et al. found that patients who received extended antibiotic prophylaxis developed late infectious complications [25].
Finally, the overuse and improper use of antibiotics are considered important drivers for the emergence and spread of AMR [47]. AMR occurs as a natural evolutionary response to antimicrobial exposure, whereby microorganisms acquire the ability to withstand antimicrobial drugs via mutations in chromosomal genes and by horizontal gene transfer [47]. The global spread of AMR may compromise our ability to treat existing and emerging common infectious diseases, as well as undermining many other improvements in health care. Maxillofacial surgeons, like all healthcare workers, should realize that AMR is a global health problem. Antimicrobial stewardship promotes the appropriate use of antibiotics based on internationally accepted guidelines, leading to effective prevention and treatment of infections while avoiding the harmful effects of antibiotic use [47].

References

  1. Dawoud, B.E.S.; Kent, S.; Henry, A.; Wareing, J.; Chaudry, H.; Kyzas, P. Use of antibiotics in traumatic mandibular fractures: A systematic review and meta-analysis. Br. J. Oral Maxillofac. Surg. 2021.
  2. Badia, J.M.; Casey, A.L.; Petrosillo, N.; Hudson, P.M.; Mitchell, S.A.; Crosby, C. Impact of surgical site infection on healthcare costs and patient outcomes: A systematic review in six European countries. J. Hosp. Infect. 2017, 96, 1–15.
  3. Kyzas, P.A. Use of antibiotics in the treatment of mandible fractures: A systematic review. J. Oral Maxillofac. Surg. 2011, 69, 1129–1145.
  4. Jang, N.; Shin, H.W. Are postoperative prophylactic antibiotics in closed reduction of nasal bone fracture valuable?: Prospective study of 30 cases. Arch. Craniofac. Surg. 2019, 20, 89–93.
  5. Metsemakers, W.J.; Morgenstern, M.; McNally, M.A.; Moriarty, T.F.; McFadyen, I.; Scarborough, M.; Athanasou, N.A.; Ochsner, P.E.; Kuehl, R.; Raschke, M.; et al. Fracture-related infection: A consensus on definition from an international expert group. Injury 2018, 49, 505–510.
  6. Andreasen, J.O.; Jensen, S.S.; Schwartz, O.; Hillerup, Y. A systematic review of prophylactic antibiotics in the surgical treatment of maxillofacial fractures. J. Oral Maxillofac. Surg. 2006, 64, 1664–1668.
  7. Delaplain, P.T.; Phillips, J.L.; Lundeberg, M.; Nahmias, J.; Kuza, C.M.; Sheehan, B.M.; Murphy, L.S.; Pejcinovska, M.; Grigorian, A.; Gabriel, V.; et al. No Reduction in Surgical Site Infection Obtained with Post-Operative Antibiotics in Facial Fractures, Regardless of Duration or Anatomic Location: A Systematic Review and Meta-Analysis. Surg. Infect. 2020, 21, 112–121.
  8. Djulbegovic, B.; Guyatt, G.H. Progress in evidence-based medicine: A quarter century on. Lancet 2017, 390, 415–423.
  9. Murray, C.J.; Ikuta, K.S.; Sharara, F.; Swetschinski, L.; Aguilar, G.R.; Gray, A.; Han, C.; Bisignano, C.; Rao, P.; Wool, E.; et al. Global burden of bacterial antimicrobial resistance in 2019: A systematic analysis. Lancet 2022, 399, 629–655.
  10. Anderson, D.J.; Sexton, D.J.; Post, T. Antimicrobial Prophylaxis for Prevention of Surgical Site Infection in Adults. UpToDate. 2016. Available online: https://www.uptodate.com/contents/antimicrobial-prophylaxis-for-prevention-of-surgical-site-infection-in-adults (accessed on 17 January 2022).
  11. Asokan, C.; Ebenezer, V.; Ramalingam, B. Role of prophylactic antibiotics in the surgical treatment of maxillofacial fractures. Indian J. Public Health Res. Dev. 2019, 10, 2848–2852.
  12. Blatt, S.; Al-Nawas, B. A systematic review of latest evidence for antibiotic prophylaxis and therapy in oral and maxillofacial surgery. Infection 2019, 47, 519–555.
  13. Chaudhry, H.; Hennedige, A.; Patel, M. Review of prophylactic prescribing of antibiotics during the management of fractured mandibles. Surgeon 2021, 19, e519–e525.
  14. Habib, A.M.; Wong, A.D.; Schreiner, G.C.; Satti, K.F.; Riblet, N.B.; Johnson, H.A.; Ossoff, J.P. Postoperative prophylactic antibiotics for facial fractures: A systematic review and meta-analysis. Laryngoscope 2019, 129, 82–95.
  15. Milic, T.; Raidoo, P.; Gebauer, D. Antibiotic prophylaxis in oral and maxillofacial surgery: A systematic review. Br. J. Oral Maxillofac. Surg. 2020, 59, 633–642.
  16. Mundinger, G.S.; Borsuk, D.E.; Okhah, Z.; Christy, M.R.; Bojovic, B.; Dorafshar, A.H.; Rodriguez, E.D. Antibiotics and facial fractures: Evidence-based recommendations compared with experience-based practice. Craniomaxillofac. Trauma Reconstr. 2014, 8, 64–78.
  17. Shridharani, S.M.; Berli, J.; Manson, P.N.; Tufaro, A.P.; Rodriguez, E.D. The Role of Postoperative Antibiotics in Mandible Fractures: A Systematic Review of the Literature. Ann. Plast. Surg. 2015, 75, 353–357.
  18. Puetzler, J.; Zalavras, C.; Moriarty, T.F.; Verhofstad, M.H.J.; Kates, S.L.; Raschke, M.J.; Rosslenbroich, S.; Metsemakers, W.J. Clinical practice in prevention of fracture-related infection: An international survey among 1197 orthopaedic trauma surgeons. Injury 2019, 50, 1208–1215.
  19. Declercq, P.; Zalavras, C.; Mertens, B.; Van der Linden, L.; Nijs, S.; Spriet, I.; Metsemakers, W.J. Perioperative antibiotic prophylaxis in long bone open fractures: The need for randomized controlled trials. Arch. Orthop. Trauma. Surg. 2021. epub ahead of print.
  20. Abubaker, A.O.; Rollert, M.K. Postoperative antibiotic prophylaxis in mandibular fractures: A preliminary randomized, double-blind, and placebo-controlled clinical study. J. Oral Maxillofac. Surg. 2001, 59, 1415–1419.
  21. Baliga, S.D.; Bose, A.; Jain, S. The evaluation of efficacy of post-operative antibiotics in the open reduction of the zygomatic and mandibular fracture: A prospective trial. J. Maxillofac. Oral Surg. 2014, 13, 165–175.
  22. Campos, G.B.; Lucena, E.E.; da Silva, J.S.; Gomes, P.P.; Germano, A.R. Efficacy assessment of two antibiotic prophylaxis regimens in oral and maxillofacial trauma surgery: Preliminary results. Int. J. Clin. Exp. Med. 2015, 8, 2846–2852.
  23. Domingo, F.; Dale, E.; Gao, C.; Groves, C.; Stanley, D.; Maxwell, R.A.; Waldrop, J.L. A single-center retrospective review of postoperative infectious complications in the surgical management of mandibular fractures: Postoperative antibiotics add no benefit. J. Trauma Acute Care Surg. 2016, 81, 1109–1114.
  24. Lovato, C.; Wagner, J.D. Infection rates following perioperative prophylactic antibiotics versus postoperative extended regimen prophylactic antibiotics in surgical management of mandibular fractures. J. Oral Maxillofac. Surg. 2009, 67, 827–832.
  25. Miles, B.A.; Potter, J.K.; Ellis, E., III. The efficacy of postoperative antibiotic regimens in the open treatment of mandibular fractures: A prospective randomized trial. J. Oral Maxillofac. Surg. 2006, 64, 576–582.
  26. Mottini, M.; Wolf, R.; Soong, P.L.; Lieger, O.; Nakahara, K.; Schaller, B. The role of postoperative antibiotics in facial fractures: Comparing the efficacy of a 1-day versus a prolonged regimen. J. Trauma Acute Care Surg. 2014, 76, 720–724.
  27. Perepa, A.; Sinha, R.; Agarwal, A.; Khan, T.A. Protocol for Antibiotic Administration in Mandibular Trauma: A Prospective Clinical Trial. J. Maxillofac. Oral Surg. 2018, 17, 19–23.
  28. Schaller, B.; Soong, P.L.; Zix, J.; Iizuka, T.; Lieger, O. The role of postoperative prophylactic antibiotics in the treatment of facial fractures: A randomized, double-blind, placebo-controlled pilot clinical study. Part 2: Mandibular fractures in 59 patients. Br. J. Oral Maxillofac. Surg. 2013, 51, 803–807.
  29. Zosa, B.M.; Ladhani, H.A.; Sajankila, N.; Elliott, C.W.; Claridge, J.A. Pre-Operative Antibiotic Agents for Facial Fractures: Is More than One Day Necessary? Surg. Infect. 2021, 22, 516–522.
  30. Malekpour, M.; Bridgham, K.; Neuhaus, N.; Widom, K.; Rapp, M.; Leonard, D.; Baro, S.; Dove, J.; Hunsinger, M.; Blansfield, J.; et al. Utility of Prophylactic Antibiotics in Nonoperative Facial Fractures. J. Craniofac. Surg. 2016, 27, 1677–1680.
  31. Reiss, B.; Rajjoub, L.; Mansour, T.; Chen, T.; Mumtaz, A. Antibiotic Prophylaxis in Orbital Fractures. Open Ophthalmol. J. 2017, 11, 11–16.
  32. Leekha, S.; Terrell, C.L.; Edson, R.S. General principles of antimicrobial therapy. Mayo Clin. Proc. 2011, 86, 156–167.
  33. Mangram, A.J.; Horan, T.C.; Pearson, M.L.; Silver, L.C.; Jarvis, W.R. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am. J. Infect. Control. 1999, 27, 97–132.
  34. Onsea, J.; Depypere, M.; Govaert, G.; Kuehl, R.; Vandendriessche, T.; Morgenstern, M.; McNally, M.; Trampuz, A.; Metsemakers, W.J. Accuracy of Tissue and Sonication Fluid Sampling for the Diagnosis of Fracture-Related Infection: A Systematic Review and Critical Appraisal. J. Bone Jt. Infect. 2018, 3, 173–181.
  35. Trampuz, A.; Zimmerli, W. Diagnosis and treatment of infections associated with fracture-fixation devices. Injury 2006, 37 (Suppl. 2), S59–S66.
  36. AO Surgery Reference—CMF—Trauma—Mandible. Available online: https://surgeryreference.aofoundation.org/cmf/trauma/mandible (accessed on 16 January 2022).
  37. Chole, R.A.; Yee, J. Antibiotic prophylaxis for facial fractures: A prospective, randomized clinical trial. Arch. Otolaryngol.—Head Neck Surg. 1987, 113, 1055–1057.
  38. Zallen, R.D.; Curry, J.T. A study of antibiotic usage in compound mandibular fractures. J. Oral Surg. 1975, 33, 431–434.
  39. Zalavras, C.G.; Marcus, R.E.; Levin, L.S.; Patzakis, M.J. Management of open fractures and subsequent complications. Instr. Course Lect. 2008, 57, 51–63.
  40. Mamthashri, V.; Reddy, B.P. Comparison of Preoperative and Perioperative Antibiotic Prophylaxis Regimen in Compound Facial Fractures. J. Contemp. Dent. Pract. 2018, 19, 214–220.
  41. Foster, A.L.; Moriarty, T.F.; Zalavras, C.; Morgenstern, M.; Jaiprakash, A.; Crawford, R.; Burch, M.A.; Boot, W.; Tetsworth, K.; Miclau, T.; et al. The influence of biomechanical stability on bone healing and fracture-related infection: The legacy of Stephan Perren. Injury 2021, 52, 43–52.
  42. Andreasen, J.O.; Storgård Jensen, S.; Kofod, T.; Schwartz, O.; Hillerup, S. Open or closed repositioning of mandibular fractures: Is there a difference in healing outcome? A systematic review. Dent. Traumatol. 2008, 24, 17–21.
  43. Metsemakers, W.J.; Moriarty, T.F.; Morgenstern, M.; Kuehl, R.; Borens, O.; Kates, S.; Richards, R.G.; Verhofstad, M. Letter to the Editor: New Definition for Periprosthetic Joint Infection: From the Workgroup of the Musculoskeletal Infection Society. Clin. Orthop. Relat. Res. 2016, 474, 2726–2727.
  44. Geller, A.I.; Lovegrove, M.C.; Shehab, N.; Hicks, L.A.; Sapiano, M.R.P.; Budnitz, D.S. National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults—United States, 2011–2015. J. Gen. Intern. Med. 2018, 33, 1060–1068.
  45. Branch-Elliman, W.; O’Brien, W.; Strymish, J.; Itani, K.; Wyatt, C.; Gupta, K. Association of Duration and Type of Surgical Prophylaxis with Antimicrobial-Associated Adverse Events. JAMA Surg. 2019, 154, 590–598.
  46. Oppelaar, M.C.; Zijtveld, C.; Kuipers, S.; Oever, J.T.; Honings, J.; Weijs, W.; Wertheim, H.F.L. Evaluation of Prolonged vs. Short Courses of Antibiotic Prophylaxis Following Ear, Nose, Throat, and Oral and Maxillofacial Surgery: A Systematic Review and Meta-analysis. JAMA Otolaryngol.—Head Neck Surg. 2019, 145, 610–617.
  47. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States. 2019. Available online: https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf (accessed on 17 January 2022).
More
© Text is available under the terms and conditions of the Creative Commons Attribution (CC BY) license; additional terms may apply. By using this site, you agree to the Terms and Conditions and Privacy Policy.
Upload a video for this entry
Information
Subjects: Surgery
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Femke Goormans
,
Ruxandra Coropciuc
,
Maximilien Vercruysse
,
Isabel Spriet
,
Robin Willaert
,
Constantinus Politis
View Times: 367
Entry Collection: Biopharmaceuticals Technology
Revisions: 2 times (View History)
Update Date: 22 Jun 2022
Table of Contents
    1000/1000
    Hot Most Recent
    Feedback