The role of postoperative prophylactic antibiotics in the treatment of facial fractures: a randomised, double-blind, placebo-controlled pilot clinical study. Part 1: orbital fractures in 62 patients

Reconstruction of Orbital Wall Fractures with a Combination of Resorbable Plates and Antibiotic-Impregnated Collagen Sheets

(1) Background: Orbital wall fractures are common in maxillofacial trauma, and artificial implants are often used for reconstruction. However, there has always been concern about infection because implants are directly exposed to the airway. This study was conducted to determine the effectiveness of a combination of resorbable plates and antibiotic-impregnated collagen sheets in reconstructions of orbital fractures and to determine whether it had an effect in reducing postoperative antibiotic use. (2) Methods: The retrospective study was conducted on 195 patients who underwent orbital wall reconstruction from March 2019 to August 2022. The 176 patients in the control group underwent reconstruction using only resorbable plates and were administered postoperative antibiotics for 5 to 7 days. On the other hand, the 19 patients in the experimental group underwent reconstruction using a combination of resorbable plates and antibiotic-impregnated collagen sheets and only received antibiotics once before surgery. The occurrence of ocular complications, the length of hospitalization, the infection incidence rate, and the adverse effects of antibiotics were investigated. (3) Results: significant ocular complications were observed in the experimental group during a follow-up period of more than 1 year. Regarding postoperative infections, there were two cases of infection in the control group (infection rate: 1.14%), while no infection was found in the experimental group. The hospitalization period of the experimental group was significantly shorter than that of the control group (p < 0.01), and the incidence of total adverse effects of antibiotics, especially nausea, was lower in the experimental group (p = 0.02). (4) Conclusions: The combined use of resorbable plates and antibiotic-impregnated collagen sheets allows effective orbital wall reconstruction without infection, with a shorter hospital stay, and with fewer antibiotic adverse effects.

Evidence-Based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-Site Infections in Plastic and Reconstructive Surgery

BACKGROUND

After nearly a decade of new data, the Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons was updated for prophylactic systemic antibiotics to prevent surgical-site infections (SSI). Pharmacotherapeutic concepts using antimicrobial stewardship were applied for clinical interpretation and management to optimize patient outcomes and minimize resistance.

METHODS

PRISMA, Cochrane, and GRADE certainty of evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched for randomized controlled trials (RCTs). The authors included patients who had plastic and reconstructive surgery and were treated with prophylactic systemic antibiotics administered perioperatively (preoperatively, intraoperatively, or postoperatively). Comparisons were made between active interventions and nonactive interventions (placebo) at different prespecified durations to determine the development of an SSI. Meta-analyses were performed.

RESULTS

The authors included 138 RCTs that met eligibility criteria. RCTs consisted of 18 breast, 10 cosmetic, 21 hand/peripheral nerve, 61 pediatric/craniofacial, and 41 reconstructive studies. The authors examined bacterial data extracted from studies for patients who did or did not take prophylactic systemic antibiotics for prevention of SSI. Clinical recommendations were provided using level I evidence.

CONCLUSIONS

Surgeons have long been overprescribing systemic antibiotic prophylaxis in plastic and reconstructive surgery. Evidence supports antibiotic prophylaxis to prevent SSI for specific indications and durations. Prolonged antibiotic use has not been linked to reductions in SSIs, and misuse may increase the bacterial diversity of infections. Greater efforts should focus on transitioning from practice-based to pharmacotherapeutic evidence-based medicine.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Comparing the Efficacy of Postoperative Antibiotic Regimens in the Treatment of Maxillofacial Fractures: A Prospective Study

AIM

The present study was designed to investigate the difference in the effectiveness of a 3 day postoperative course and a single perioperative dose of antibiotics on the incidence of postoperative infection in the management of maxillofacial trauma patients.

MATERIALS AND METHODS

About 183 maxillofacial trauma patients requiring open reduction and internal fixation (ORIF) under general anesthesia were divided based on the type of fracture sustained, i.e., mandibular fractures, Le Fort fractures, and zygomaticomaxillary complex fractures. Patients from each fracture type were randomized into two groups, A and B. All patients were administered amoxicillin/clavulanate 1.2 grams intravenously 8 hours from the time of admission till the patient was taken up for surgery. Once the patients were taken up for surgery, a perioperative dose was administered. No antibiotics beyond this point were given to patients in Group A. Patients in Group B were administered the same antibiotic for 3 postoperative days additionally. Outcomes in terms of purulent discharge from the surgical site, an abscess or any other sign of infection, and wound dehiscence requiring reopening of the surgical site were considered. Patients were reviewed at 1 week, 2 weeks, 1 month, 2 months, and 3 months.

RESULTS

No statistically significant difference was found between the two groups across all three fracture types in terms of postoperative outcomes. However, increased numbers of complications were noted in the patients treated with an intra-oral approach in each fracture type irrespective of group. All complications were managed with local measures.

CONCLUSION

A single perioperative dose of antibiotics is effective in minimizing postoperative complications following ORIF of maxillofacial fractures and there is no significant benefit in prolonging the course of antibiotics postoperatively with the need for further studies to be conducted considering comminuted, complex fractures and old fractures.

CLINICAL SIGNIFICANCE

In maxillofacial trauma, fractures frequently communicate with contaminated indigenous flora on the skin surface, oral cavities, or sinus cavities. Surgery is frequently performed using an approach across a contaminated area, even in closed fractures. Postoperative infections can be significantly decreased by using antibiotics in surgical procedures to treat facial fractures.

Open Mandible and Maxillary Fractures Associated with Higher Risk of Infection in Victims of Assault

Background: Victims of assault (VOA) often present with fractures of the mandible and maxilla. They represent a complex challenge because of possible compromise of the airway, and infection-related complications because of potential involvement of the oral cavity. We hypothesized that open mandible and maxillary fractures in VOA are associated with a higher rate of infection compared with non-VOA patients with open facial fractures. Patients and Methods: Patients admitted to our level 1 trauma center from 2005 to 2020 with a diagnosis of open mandible and maxillary fractures were included. Demographics, mechanisms of injury, fracture location, cultures, infectious complications, antibiotic treatments, and clinical outcomes were abstracted. Patients were stratified by their mechanism of injury into VOA or non-VOA and were compared using χ2 and Student t-test using SPSS (IBM Corp, Armonk, NY). Results: We identified 316 patients with open mandible and maxillary fractures. There were 198 patients categorized as being VOA, and 118 as non-VOA. Nineteen of 316 patients were diagnosed with infection related to the fracture (3.8% abscesses, 1.9% cellulitis, and 1.9% osteomyelitis). Although the Injury Severity Score (ISS) was higher in non-VOA patients (5.8 ± 2.6 vs. 4.9 ± 1.8; p < 0.013), most of the infections were in the VOA cohort (17/19; 89.5%; p < 0.013). Conclusions: Open fractures of the mandible and maxilla in VOA are associated with a greater risk of infection compared with non-victims of assault. The relation between VOA and poor SDH has been studied recently; clinicians should be aware of this association and implement special considerations and appropriate follow-up visits to decrease the rate of infection in this currently expanding population.

The Role of Antibiotics in Nasal Fractures after Closed Reduction

Nasal fractures represent the most common fracture in facial trauma. The role of prophylactic antibiotics in these injuries is debated, given low infection rates and demonstrated risks of antibiotics. We studied the isolated effect of prophylactic antibiotics on infection rate in patients with nasal fracture after closed reduction.

Methods

Retrospective cohort study of a prospectively maintained facial trauma database was conducted. Demographics, comorbidities, fracture classifications, and management of patients who received antibiotics at the time of closed nasal reduction were compared against those who did not receive antibiotics. Infection rates between groups were analyzed. Multivariate analysis was conducted to control for confounding variables. Qualitative analysis was performed for patients who experienced infection following nasal fracture.

Results

A total of 282 patients met inclusion criteria (n = 144, antibiotic; n = 138, nonantibiotic). Six patients experienced infection. There was no difference in infection rate between antibiotic and nonantibiotic groups (2.0% versus 2.2%; P = 0.90). On multivariate regression, antibiotics did not significantly decrease odds of infection (OR 1.7 [0.17-13.6]; P = 0.64). Moreover, patients with open nasal fractures did not have significantly higher odds of infection (OR 1.9 [0.08-20.8]; P = 0.64). Similarly, increasing severity of injury based on Rohrich classification did not significantly impact odds of infection (OR 0.68 [0.23-1.9]; P = 0.46). All six infections were managed at the bedside, with zero infections following operating room management (P = 0.32).

Conclusions

Prophylactic antibiotics do not decrease infection rates following nasal fractures managed by closed reduction. Bedside management may be a risk factor for the development of infection; however, this finding requires further evaluation.

The outcome of prolonged postoperative antibiotics on wound healing in orthognathic surgery: A meta-analysis

We conducted a meta-analysis to assess the outcome of prolonged postoperative antibiotics (PA) on wound healing in orthognathic surgery (OS). A systematic literature search up to January 2023 was performed and 1021 related studies were evaluated. The chosen studies comprised 1057 OS subjects who participated in the selected studies' baseline, 446 of them used short-term PA, and 611 used long-term PA. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of prolonged PA on wound infection after OS by the dichotomous methods with a random or fixed effect model. The short-term PA resulted in significantly higher wound infection (OR, 4.27; 95% CI, 2.97-6.14, P < 0.001) with low heterogeneity (I²  = 27%) compared to the long-term PA in OS. The short-term PA resulted in significantly higher wound infection compared to the long-term PA in OS. Though care should be taken when dealing with the results since a large number of the selected studies had <100 subjects as a sample size.

Do Postinjury Prophylactic Antibiotics Reduce Infection for Isolated Midface Fractures: A Cohort Study

PURPOSE

Fractures of the midface are a core component to the practice of contemporary oral and maxillofacial trainees and surgeons. As such, in an era where antibiotic resistance is increasing it is important to investigate if antibiotics are required after midface fractures to prevent infections before follow-up in an outpatient setting. The purpose of this study is to determine whether postinjury prophylactic preoperative antibiotics reduce rates of infection after midface fracture.

METHODS

A retrospective multicenter cohort study was conducted in Queensland, Australia. Patients who presented to Royal Brisbane Hospital and Townsville Hospital with isolated midface fractures between January 2017 and January 2019 were included. Clinical and demographic data of patients who received postinjury prophylactic antibiotics were compared to those who did not using the χ² test. Logistic regression was used to determine factors associated with increased odds of postinjury prophylactic antibiotic prescription.

RESULTS

In total, 1,353 patients with midfacial fractures over the 2-year period were included. In addition, 724 (53.5%) patients received postinjury antibiotics and 629 (46.5%) patients did not. The overall rate of infection was very low: 1 patient who received postinjury prophylactic antibiotics (0.1%) developed infection compared to 2 patients (0.3%) who did not receive postinjury prophylactic antibiotics, and this difference was not significant (χ² = 0.49; P = .48). Male sex (odds ratio 1.4; 95% confidence interval, 1.1 to 1.7; P = .02) and tobacco use (odds ratio 1.4; 95% confidence interval, 1.1 to 1.7; P = .008) were associated with an increased odds of postinjury prophylactic antibiotic prescription in the univariate analyses, but were no longer significant once site, age, and fracture type were adjusted for in the multivariate model.

CONCLUSIONS

The rate of infection after midface fracture was low and there was no significant difference in infection rates for patients who received postinjury prophylactic antibiotics compared to those who did not. Use of postinjury prophylactic preoperative antibiotics for midfacial fractures should be reconsidered.

Systemic Antibiotic Prophylaxis in Maxillofacial Trauma: A Scoping Review and Critical Appraisal

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. Therefore, the purpose of this scoping review was to provide an overview of the current evidence that supports the use of prophylactic antibiotics in the treatment of maxillofacial fractures. A comprehensive literature search on 1 January 2022, in PubMed, Web of Science, Embase, and Cochrane, revealed 16 articles. Most studies focused on the duration of systemic antibiotic prophylaxis and compared a one-day to a five-day regimen. Included studies showed considerable variability in design and research aims, which rendered them difficult to compare. Furthermore, a variety of antibiotic regimens were used, and most studies had a short follow-up period and unclear outcome parameters. This scoping review demonstrates the lack of well-constructed studies investigating the type and duration of systemic antibiotic prophylaxis in the treatment of maxillofacial trauma. Based on the included articles, prolonging antibiotic prophylaxis over 24 h for surgically treated fractures does not appear to be beneficial. Furthermore, there is no evidence for its use in conservatively treated fractures. These results should be interpreted with caution since all included studies had limitations.

An evidence-based approach to antibiotic use in maxillofacial trauma

A patient with craniomaxillofacial (CMF) trauma often receives consultations from multiple medical and surgical services. Antibiotics are sometimes prescribed without consistent evidence. This article reviews current literature regarding antibiotic prophylaxis of patients with CMF fractures. This article also presents the guidelines for the appropriate use of antibiotics for patients with CMF fractures at 2 level I trauma centers.

Algorithmic Approach to Antibiotic Prophylaxis for Traumatic Craniomaxillofacial Injuries

ABSTRACT

Prophylactic antibiotics are commonly used in the management of traumatic injuries to the maxillofacial complex, yet there are no set guidelines for when and when not to prescribe. The purpose of this review is to present the evidence for antibiotic prophylaxis in different clinical scenarios and to propose algorithms to facilitate the decision making process with the ultimate goal of improving antibiotic prescribing practices. A number of databases were searched using a wide range of keywords to ensure the topic was fully encapsulated. The review is divided into 3 sections: soft tissue trauma, maxillofacial fractures, and ballistic injuries. The algorithms were constructed using the current evidence as well as pathophysiologic principles, especially when there were insufficient studies. This review found the literature on antibiotic prophylaxis to be highly varied and not standardized. Creating an algorithm for providers to follow will help to set a standard of care and decrease the misuse of antibiotics.

Antibiotic prophylaxis for traumatic facial fractures

WHAT IS KNOWN AND OBJECTIVE

The purpose of this paper is to discuss the limitations of the evidence supporting the SIS recommendations for antibiotic prescribing in patients with traumatic facial fractures and to provide suggestions for clinical decision-making and further research in this area given the wide variation in prescribing practices.

COMMENT

The Surgical Infection Society (SIS) recently published guidelines on antibiotic use in patients with traumatic facial fractures. The guidelines recommend against the use of prophylactic antibiotics for all adult patients with mandibular or non-mandibular facial fractures undergoing non-operative or operative procedures. Despite the available evidence, surveys conducted in the United States and the United Kingdom prior to the publication of the SIS guidelines demonstrate substantial preoperative, intraoperative and postoperative prophylactic prescribing of antibiotics for patients with facial fractures undergoing surgery.

WHAT IS NEW AND CONCLUSION

With the exception of strong recommendations based on moderate-quality evidence to avoid prolonged postoperative antibiotic prophylaxis, the weak recommendations in the guidelines are a function of low-quality evidence. A logical choice for a narrow-spectrum antibiotic is cefazolin administered within 1 h of surgery and no longer than 24 h after surgery, since it is the gold standard of comparison based on clinical practice guidelines concerning antibiotic prophylaxis.

Evaluation of Antibiotic Prophylaxis for Acute Nonoperative Orbital Fractures

PURPOSE

The use of antibiotic prophylaxis for the prevention of infection in nonoperative orbital fractures is controversial, with limited high-quality evidence and inconsistent recommendations in the current scientific literature. Our primary study objective was to identify the prophylactic antibiotic prescribing pattern at our institution for nonoperative orbital fractures and to determine the effect of antibiotic prophylaxis.

METHODS

We retrospectively reviewed 16 years of data from a single institution on patients with acute traumatic fractures of the orbital floor or medial orbital wall. Prophylactic administration of antibiotics and complication rates were evaluated, and complication rates and patient characteristics analyzed.

RESULTS

Of 154 patients with nonoperative orbital fractures, 17 patients (group 1) received IV or oral antibiotics and 137 patients (group 2) did not. No patient in either group had documented infectious orbital complications following their orbital injury. Patients receiving antibiotics were more likely to have a concurrent periorbital laceration (58.8% ± 11.9% vs. 28.5% ± 3.9%; P = 0.01).

CONCLUSION

We present the largest cohort yet reported of patients managed without antibiotic prophylaxis for nonoperative orbital fractures, with no infectious complications identified. Currently there is no evidence of utility to prophylactic antibiotics in the setting of nonoperative traumatic orbital fractures. Rather than prescribing antibiotics, we recommend clinicians educate patients on return precautions and offer close follow up for the rare, but potentially severe infectious complications of orbital trauma.

Antibiotic prophylaxis in oral and maxillofacial surgery: a systematic review

Surgical site infections are a complication of oral and maxillofacial procedures, with the potential for significant morbidity and mortality. Use of preoperative, perioperative, and postoperative antibiotic prophylaxis to reduce the incidence of surgical site infections must be balanced with considerations of a patients' risk of antibiotic-related adverse events. This review aimed to provide evidence-based recommendations for antibiotic prophylaxis. Searches were conducted using MEDLINE, the Cochrane Library, EMBASE, and PUBMED for maxillofacial procedures including: treatment of dental abscesses, extractions, implants, trauma, temporomandibular joints, orthognathics, malignant and benign tumour removal, and bone grafting, limited to articles published since 2000. A total of 98 out of 280 retrieved papers were included in the final analysis. Systematic reviews were assessed using AMSTAR criteria. Randomised controlled trials were assessed for bias using Cochrane Collaborative tools. The overall quality of evidence was assessed using GRADE. Prophylactic antibiotic use is recommended in surgical extractions of third molars, comminuted mandibular fractures, temporomandibular joint replacements, clean-contaminated tumour removal, and complex implants. Prophylactic antibiotic use is not routinely recommended in fractures of the upper or midface facial thirds. Further research is required to provide recommendations in orthognathic, cleft lip, palate, temporomandibular joint surgery, and maxillofacial surgical procedures in medically-compromised patients.

Evaluation of Prolonged vs Short Courses of Antibiotic Prophylaxis Following Ear, Nose, Throat, and Oral and Maxillofacial Surgery: A Systematic Review and Meta-analysis

Importance

Antibiotic prophylaxis is widely used after surgical procedures operating on the mucosal tissues of the aerodigestive tract, but the optimal duration of these prophylactic therapies is often unclear.

Objective

To compare short-course antibiotic prophylaxis (≤24 hours) vs extended-course antibiotic prophylaxis (≥72 hours) after ear, nose, throat, and oral and maxillofacial surgery.

Data Sources and Study Selection

Literature searches of PubMed were completed in October 2017 and included prospective trials that compared antibiotic prophylaxis courses of 24 hours or less vs 72 hours or more after ear, nose, throat, and oral and maxillofacial surgery. Some studies were also handpicked from reference lists of studies found with the initial search terms. All analysis was performed between September 2017 and October 2018.

Data Extraction and Synthesis

All review stages were conducted in consensus by 2 reviewers. Data extraction and study quality assessment were performed with the Cochrane data extraction form and the Cochrane risk of bias tool. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for reporting. The fixed-effects Mantel-Haenszel method was used for meta-analysis.

Main Outcomes and Measures

Relative risk (RR) of surgical site infections, microbial origins of surgical site infections, adverse events, duration of hospital stay, and treatment costs.

Results

Included in the meta-analysis were 21 articles with a cumulative 1974 patients. In patients receiving 24 hours or shorter vs 72 hours or longer antibiotic prophylaxis regimens, no significant difference was found in the occurrence of postoperative infections in the pooled population (RR, 0.90; 95% CI, 0.67-1.19), or in the ear, nose, throat (RR, 0.89; 95% CI, 0.54-1.45), and oral and maxillofacial populations (RR, 0.88; 95% CI, 0.63-1.21), separately. No heterogeneity was observed overall or in the subgroups. Patients receiving extended-course antibiotic prophylaxis were significantly more likely to develop adverse events unrelated to the surgical site (RR, 2.40; 95% CI, 1.20-3.54).

Conclusions and Relevance

No difference was found in the occurrence of postoperative infections between short-course and extended-course antibiotic prophylaxis after ear, nose, throat, and oral and maxillofacial surgery. Therefore, a short course of antibiotic prophylaxis is recommended unless documented conditions are present that would be best treated with an extended course. Using short-course antibiotics could avoid additional adverse events, antibiotic resistance development, and higher hospital costs. Future research should focus on identifying risk groups that might benefit from prolonged prophylaxis.

Clinical Outcome Following Surgical Repair of Small Versus Large Orbital Floor Fractures Using Polyglactin 910/Polydioxanone (Ethisorb®)

The aim of this retrospective study was to evaluate the clinical outcome of surgical management of small versus large, isolated orbital floor fractures (OFFs) using polyglactin 910/polydioxanone (Ethisorb^®). Covering a four-year period (2010-2013), all records concerning midfacial fractures with involvement of the orbit were screened. Isolated fractures of the orbital floor as well as combined injuries of the orbital floor and medial wall that had been treated surgically using polyglactin 910/polydioxanone (Ethisorb^®) were included. Patients underwent a preoperative, a postoperative, and a late ophthalmologic assessment. The clinical outcomes of surgically managed small OFFs up to 2 cm² were statistically analyzed and compared to clinical results in larger defects. The final sample included 61 patients (25 women, 36 men). Fractures up to 2 cm² were found in 33 patients (54.1%), whereas 28 patients (45.9%) suffered from OFFs larger than 2 cm². The clinical outcomes did not significantly differ between both sample categories, and statistical analysis showed a power of 0.91 to detect a potentially existing difference. On final examination, 52 patients were free of any clinical symptoms, whereas minor issues were found in seven subjects, and two patients suffered from severe impairment. In conclusion, polyglactin 910/polydioxanone (Ethisorb^®) seems to be a suitable material for surgical repair of both small and large OFFs.

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

Background: We performed a systematic review of the literature on antibiotic prophylaxis practices in open reduction, and internal fixation of, facial fracture(s) (ORIFfx). We hypothesized that prolonged antibiotic prophylaxis (PAP) would not decrease the rate of surgical site infections (SSIs). Methods: We performed a systematic review of four databases: PubMed, CENTRAL, EMBase, and Web of Science, from inception through January 15, 2017. Three independent reviewers extracted fracture location (orbital, mid-face, mandible), antibiotic use, SSI incidence, and time from injury to surgery. Mantel-Haenszel and generalized estimating equations were carried out independently for each fracture zone. Results: Of the 587 articles identified, 54 underwent full-text review, yielding 27 studies that met our inclusion criteria. Of these, 16 studies (n = 2,316 patients) provided data for mandible fractures, four studies (n = 439) for mid-face fractures, and six studies (n = 377) for orbital fractures. Pooled analysis of each fracture type's SSI rate showed no statistically significant association with the odds ratio (OR) of developing an SSI. For mandible fractures treated with ORIFfx, the OR for an SSI after 24-72 hours of prophylaxis relative to <24 hours was 0.85 (95% confidence interval [CI] 0.62-1.17), whereas for >72 hours compared with <24 hours, the OR was 1.42 (95% CI) 0.96-2.11). For mid-face fractures, there was no improvement in SSI rate from PAP (OR 1.05; 95% CI 0.20-5.63). Conclusions: We did not demonstrate a lower rate of SSI associated with PAP for any ORIFfx repair. Post-operative antibiotics for >72 hours paradoxically may increase the SSI risk after mandible fracture repairs.

Effect of Irrigation Time of Antiseptic Solutions on Bone Cell Viability and Growth Factor Release

Antiseptic solutions are commonly utilized to treat local infection in the oral and maxillofacial region. However, surrounding vital bone is also exposed to antiseptic agents during irrigation and may have a potential negative impact on bone survival. The aim of the present study was therefore to investigate the effect of rinsing time with various antiseptic solutions on bone cell viability, as well as their subsequent release of growth factors important for bone regeneration. The bone samples collected from porcine mandible were rinsed in the following commonly utilized antiseptic solutions; povidone-iodine (0.5%), chlorhexidine digluconate (CHX, 0.2%), hydrogen peroxide (1%), and sodium hypochlorite (0.25%) for 1, 5, 10, 20, 30, or 60 minutes and assessed for cell viability and release of growth factors including vascular endothelial growth factor, transforming growth factor beta 1, bone morphogenetic protein 2, receptor activator of nuclear factor kappa-B ligand, and interleukin-1 beta by enzyme-linked immunosorbent assay. It was found in all the tested groups that the long exposure of any of the tested antiseptic solutions drastically promoted higher cell death. Sodium hypochlorite demonstrated the significantly highest cell death and at all time points. Interestingly, bone cell viability was highest in the CHX group post short-term rinsing of 1, 5, or 10 minutes when compared with the other 4 tested groups. A similar trend was also observed in subsequent growth factor release. The present study demonstrated that of the 4 tested antiseptic solutions, short-term CHX rinsing (ideally within 1 minute) favored bone cell viability and growth factor release. Clinical protocols should be adapted accordingly.

Evidence-Based Medicine in Facial Trauma

This article provides the reader with a comprehensive review of high-level evidence-based medicine in facial trauma and highlights areas devoid of high-level evidence. The article is organized in the order one might approach a clinical problem: starting with the workup, followed by treatment considerations, operative decisions, and postoperative treatments. Individual injuries are discussed within each section, with an overview of the available high-level clinical evidence. This article not only provides a quick reference for the facial traumatologist, but also allows the reader to identify areas that lack high-level evidence, perhaps motivating future endeavors.

Pharmacoeconomic analysis of antibiotic therapy in maxillofacial surgery

Objectives/Aims:

The aim of this study was to investigate the microbial cultures collected in the years 2013–2014 at the craniomaxillofacial department and outpatient clinic to analyse optimisation of the treatment cost of the bacterial infections and present the results.

Design and setting:

We analysed 485 cultures from 263 patients, of which 77.28% consisted of Gram-positive bacteria. On the basis of the antibiotic efficacy, antibiotic price and the cost of entire treatment during hospitalisation, the most useful antimicrobial agents for the most common pathogens were selected.

Results:

The most frequently collected material was pus. The most common pathogens were found to be the Staphylococcus epidermidis (18%), Streptococcus mitis and Str. oralis (14%) and S. aureus (6.5%).

Discussion:

The most frequently isolated bacteria in other studies were the Streptococcus strain. Other authors showed that ceftriaxone is the most cost efficient agent. The use of postoperative antibiotic prophylaxis remains controversial.

Conclusion:

The results of this study suggest that the most useful antibiotics for therapy, from the perspective of the cost minimisation, were gentamycin, trimethoprim with sulfamethoxazole and vancomycin.

Management of orbital fractures: challenges and solutions

Many specialists encounter and treat orbital fractures. The management of these fractures is often challenging due to the impact that they can have on vision. Acute treatment involves a thorough clinical examination and management of concomitant ocular injuries. The clinical and radiographic findings for each individual patient must then be analyzed for the need for surgical intervention. Deformity and vision impairment can occur from these injuries, and while surgery is intended to prevent these problems, it can also create them. Therefore, surgical approach and implant selection should be carefully considered. Accurate anatomic reconstruction requires complete assessment of fracture margins and proper implant contouring and positioning. The implementation of new technologies for implant shaping and intraoperative assessment of reconstruction will hopefully lead to improved patient outcomes.

Inaugural Survey on Practice Patterns of Orbital Floor Fractures for American Oral and Maxillofacial Surgeons

PURPOSE

In recent years, several studies have reported on practitioners' preferences for the treatment of orbital floor fractures, showing widely varying practice patterns. The purpose of the present study was to identify the practice patterns among oral and maxillofacial surgeons involved in the management of orbital floor fractures in the United States and compare them with the available published data.

MATERIALS AND METHODS

An anonymous survey was created and electronically mailed to surgeons. We also reviewed the published data on orbital floor fractures using a PubMed and MEDLINE search. The responses to the survey were analyzed using descriptive statistics.

RESULTS

The factors that had the greatest influence on the surgeon's decision to operate were a defect size > 2 cm2, enophthalmos, entrapment, and persistent diplopia. The most common surgical approach reported was a preseptal transconjunctival approach (32.0%), followed by the subciliary (27.9%) and postseptal transconjunctival (26.2%) approaches. The most commonly reported implant for orbital reconstruction was titanium (65.4%), followed by Medpor (43.7%) and composite Medpor and titanium (26.4%). The review of the published data showed a consensus among many of the operative indications mentioned, including a large defect size, enophthalmos, clinical entrapment, and persistent diplopia.

CONCLUSIONS

Oral and maxillofacial surgeons in the United States have a wide range of practice habits in the management of orbital floor fractures. Although the quality of the available evidence is poor, it supports a consistent approach to the management of orbital floor fractures in terms of the indications and surgical approach. The choice of reconstructive material and timing of repair remain more controversial. A clear need exists for improvement in the available data to help guide and set standards of care for the specialties managing orbital floor fractures.

Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures

BACKGROUND

Basilar skull fractures predispose patients to meningitis because of the possible direct contact of bacteria in the paranasal sinuses, nasopharynx or middle ear with the central nervous system (CNS). Cerebrospinal fluid (CSF) leakage has been associated with a greater risk of contracting meningitis. Antibiotics are often given prophylactically, although their role in preventing bacterial meningitis has not been established.

OBJECTIVES

To evaluate the effectiveness of prophylactic antibiotics for preventing meningitis in patients with basilar skull fractures.

SEARCH METHODS

We searched CENTRAL (2014, Issue 5), MEDLINE (1966 to June week 1, 2014), EMBASE (1974 to June 2014) and LILACS (1982 to June 2014). We also performed an electronic search of meeting proceedings from the American Association of Neurological Surgeons (1997 to September 2005) and handsearched the abstracts of meeting proceedings of the European Association of Neurosurgical Societies (1995, 1999 and 2003).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any antibiotic versus placebo or no intervention. We also identified non-RCTs to perform a separate meta-analysis in order to compare results.

DATA COLLECTION AND ANALYSIS

Three review authors independently screened and selected trials, assessed risk of bias and extracted data. We sought clarification with trial authors when needed. We pooled risk ratios (RRs) for dichotomous data with their 95% confidence intervals (CIs) using a random-effects model. We assessed the overall quality of evidence using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.

MAIN RESULTS

In this update we did not identify any new trials for inclusion. We included five RCTs with 208 participants in the review and meta-analysis. We also identified 17 non-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention in patients with basilar skull fractures. Most trials presented insufficient methodological detail. All studies included meningitis in their primary outcome. When we evaluated the five included RCTs, there were no significant differences between antibiotic prophylaxis groups and control groups in terms of reduction of the frequency of meningitis, all-cause mortality, meningitis-related mortality and need for surgical correction in patients with CSF leakage. There were no reported adverse effects of antibiotic administration, although one of the five RCTs reported an induced change in the posterior nasopharyngeal flora towards potentially more pathogenic organisms resistant to the antibiotic regimen used in prophylaxis. We performed a subgroup analysis to evaluate the primary outcome in patients with and without CSF leakage. We also completed a meta-analysis of all the identified controlled non-RCTs (enrolling a total of 2168 patients), which produced results consistent with the randomised data from the included studies.Using the GRADE approach, we assessed the quality of trials as moderate.

AUTHORS' CONCLUSIONS

Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with basilar skull fractures, whether there is evidence of CSF leakage or not. Until more research is available, the effectiveness of antibiotics in patients with basilar skull fractures cannot be determined because studies published to date are flawed by biases. Large, appropriately designed RCTs are needed.

Surgical complications after implant placement

Placement of dental implants in the maxillofacial region is routine and considered safe. However, as with any surgical procedure, complications occur. Many issues that arise at surgery can be traced to the preoperative evaluation of the patient and assessment of the underlying anatomy. In this article, the authors review some common and uncommon complications that can occur during and shortly after implant placement. The emphasis of each section is on the management and prevention of complications that may occur during implant placement.

Antibiotics and facial fractures: evidence-based recommendations compared with experience-based practice

Efficacy of prophylactic antibiotics in craniofacial fracture management is controversial. The purpose of this study was to compare evidence-based literature recommendations regarding antibiotic prophylaxis in facial fracture management with expert-based practice. A systematic review of the literature was performed to identify published studies evaluating pre-, peri-, and postoperative efficacy of antibiotics in facial fracture management by facial third. Study level of evidence was assessed according to the American Society of Plastic Surgery criteria, and graded practice recommendations were made based on these assessments. Expert opinions were garnered during the Advanced Orbital Surgery Symposium in the form of surveys evaluating senior surgeon clinical antibiotic prescribing practices by time point and facial third. A total of 44 studies addressing antibiotic prophylaxis and facial fracture management were identified. Overall, studies were of poor quality, precluding formal quantitative analysis. Studies supported the use of perioperative antibiotics in all facial thirds, and preoperative antibiotics in comminuted mandible fractures. Postoperative antibiotics were not supported in any facial third. Survey respondents (n = 17) cumulatively reported their antibiotic prescribing practices over 286 practice years and 24,012 facial fracture cases. Percentages of prescribers administering pre-, intra-, and postoperative antibiotics, respectively, by facial third were as follows: upper face 47.1, 94.1, 70.6; midface 47.1, 100, 70.6%; and mandible 68.8, 94.1, 64.7%. Preoperative but not postoperative antibiotic use is recommended for comminuted mandible fractures. Frequent use of pre- and postoperative antibiotics in upper and midface fractures is not supported by literature recommendations, but with low-level evidence. Higher level studies may better guide clinical antibiotic prescribing practices.

Current evidence regarding prophylactic antibiotics in head and neck and maxillofacial surgery

Antibiotic prophylaxis is commonly used to decrease the rate of infections in head and neck surgery. The aim of this paper is to present the available evidence regarding the application of antibiotic prophylaxis in surgical procedures of the head and neck region in healthy patients. A systemic literature review based on Medline and Embase databases was performed. All reviews and meta-analyses based on RCTs in English from 2000 to 2013 were included. Eight out of 532 studies fulfilled all requirements. Within those, only seven different operative procedures were analyzed. Evidence exists for the beneficial use of prophylactic antibiotics for tympanostomy, orthognathic surgery, and operative tooth extractions. Unfortunately, little high-level evidence exists regarding the use of prophylactic antibiotics in head and neck surgery. In numerous cases, no clear benefit of antibiotic prophylaxis has been shown, particularly considering their potential adverse side effects. Antibiotics are often given unnecessarily and are administered too late and for too long. Furthermore, little research has been performed on the large number of routine cases in the above-mentioned areas of specialization within the last few years, although questions arising with respect to the treatment of high-risk patients or of specific infections are discussed on a broad base.