Systemic Preoperative Antibiotics with Mandible Fractures: Are They Indicated at the Time of Injury?

Surgical site infections in maxillofacial trauma surgery - Single-dose versus prolonged antibiotic prophylaxis

Open reduction with internal fixation (ORIF) for facial fractures has frequently been associated with the occurrence of surgical site infections (SSIs). Perioperative antibiotic prophylaxis is customarily recommended for ORIF. Thus, the comparison of two different antibiotic regimens (i.e., single-dose and prolonged antibiotic prophylaxis) concerning the rate and severity of SSIs in facial fracture patients undergoing ORIF was the main purpose of this study. This retrospective analysis included patients who underwent ORIF for facial fractures. They were distributed into two groups. The single-dose antibiotic prophylaxis group (SDAP) received single-dose perioperative antibiotic prophylaxis, whereas the prolonged antibiotic prophylaxis group (PAP) were administered prophylactic antibiosis over a course of 5 days. 122 patients were included in the study. Nine patients in the SDAP group and 15 patients in the PAP group were affected by SSIs; no significant difference in the incidence of SSIs was found (p = 0.218). Moreover, the severity of SSIs did not significantly differ between the two groups (p = 0.982).

Limited Efficacy of Empiric Antibiotics for Pediatric Facial Fractures

BACKGROUND

Controversies exist regarding the role of perioperative antibiotic use in pediatric craniomaxillofacial fracture repair.

PURPOSE

This study aims to identify factors associated with antibiotic prescribing patterns and measures the association between antibiotic exposure and postoperative infections.

STUDY DESIGN, SETTING, SAMPLE

In this retrospective cohort study, TriNetX, a research database, was used to gather data on patients under 18 years of age who underwent repair of facial fractures. The records were obtained from 2003 to 2021. Current Procedural Terminology codes for facial fracture procedures were used to identify patients.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

Antibiotic use, defined as a binary categorical variable of whether or not patients received perioperative antibiotics. The secondary predictor variable was timing of antibiotic administration, categorized by pre, intra, and postoperative administration.

MAIN OUTCOME VARIABLES

Postoperative infection, determined by International Classification of Diseases, 9th and 10th Revision codes within patient charts.

COVARIATES

Covariates included demographic variables such as age, sex, race, ethnicity, geographic location, and fracture characteristics, such as number of fractures and location of fracture.

ANALYSES

χ2 analyses were used for categorical variables and two sample t tests for quantitative variables. Multivariable logistic regression was used to evaluate patient infection and antibiotic use with adjustment for covariates. P-values were 2-tailed and statistical significance was defined as P < .05.

RESULTS

This cohort included 5,413 patients of which 70.4% were male, 74.4% identified as white, and 83.3% identified as non-Hispanic or Latino. There were no differences in postoperative infections in patients who received antibiotics compared to those who did not (0.9 vs 0.5%, respectively, P = .12). Nevertheless, antibiotic prescriptions have increased over the years. After controlling for relevant covariates, antibiotic use did not decrease the odds of infection (adjusted odds ratio 1.1, 95% CI 0.53 to 2.34, P = .79). There was a significant association between the timing of antibiotic use and infection (P = .044), with increased odds of infection when antibiotics were given postoperatively (adjusted odds ratio 3.8, 95% CI 1.2 to 12.07, P = .023).

CONCLUSION AND RELEVANCE

While antibiotic prescriptions have increased over the years, this study demonstrates there is no difference in postoperative infection rates for pediatric patients prescribed antibiotics and those where were not.

Measuring Adherence to Antibiotic Use Guidelines in Managing Mandible Fractures

PURPOSE

Due to variability in practice patterns when managing patients with facial fractures, the Surgical Infection Society's Therapeutics and Guidelines Committee (SIS) released guidelines in June 2020 concerning antibiotic use in the treatment of patients with facial fractures. The purpose of this study was to measure adherence to SIS guidelines among patients treated for isolated mandibular fractures and to identify factors associated with deviation from SIS guidelines.

MATERIALS AND METHODS

The authors designed and implemented a retrospective cohort study and enrolled a sample derived from the population of patients treated for isolated mandibular fractures at Harborview Medical Center (Seattle, WA) and University of Washington Medical Center-Montlake (Seattle, WA) from June 2020 through October 2021. The primary outcome variable was adherence to SIS antibiotic guidelines (yes or no). Covariates were grouped into the following categories: demographic (age, gender), treatment (operative treatment, primary service, transfer status), and risk factor (Charlson Comorbidity Index, tobacco use, alcohol use, drug use other than marijuana, mandibular injury severity score). Descriptive and bivariate statistics were computed to measure the association between adherence and the study variables. The level of statistical significance was set at a P-value ≤.05.

RESULTS

The study sample was composed of 114 patients with a mean age of 41.8 ± 19.0 years and 72% were males. The frequency of adherence to SIS antibiotic protocol was 91.2%. Variables associated with deviation from SIS antibiotic protocol were operative treatment (P-value = .03 - relative risk (RR) not calculable), current drug use other than marijuana (RR = 4.1; 95% confidence interval, 1.3-12.8; P-value = .01), and transfer from an outside facility (RR = 4.1; 95% confidence interval, 1.3-12.8; P-value = .01).

CONCLUSIONS

The findings of this study suggest that the SIS antibiotic guidelines in the management of isolated mandible fractures were translated well into practice at our institution as evidenced by the high level of compliance (>90%). To improve adherence, additional research is indicated to better understand how factors such as treatment choice, drug exposure, and transfer status adversely affect adherence to guidelines.

Isolated favorable compound mandibular body fractures: A retrospective review of two cohorts of patients based on the timing of treatment

BACKGROUND/AIM

Treatment delays in the management of mandible fractures are often unavoidable and, as a result, the timing of treatment of mandibular fractures has remained a contentious issue in clinical practice as the optimal treatment delay for minimizing complications remains unknown. The aim of this study was to determine the rate and types of complications between two cohorts of patients designated as early and late treatment groups and estimate an optimal time threshold for treatment delay after closed reduction and maxillomandibular fixation.

MATERIAL AND METHODS

Demographic and clinical data were collected retrospectively about patients who were treated for isolated, unilateral, favorable, and compound mandibular body fractures between 1999 and 2019 to answer the question of whether treatment delay is an independent variable impacting post-operative mandible body fracture complications. Descriptive and bivariate statistics were computed.

RESULTS

One hundred and seventy subjects were evaluated (n = 87 in the control/early group and n = 83 in the study/late group). The mean time lapses from injury to treatment were: early (5.8 ± 0.4 days) and late (10.3 ± 0.7 days). The overall complication rate was 14.1%. However, the complication rates of the early and late groups were 13.8% and 14.5%, respectively, with no significant difference (p = 0.89).

CONCLUSIONS

There was no difference between early and late treatment groups. Treatment delay was not an independent variable impacting post-operative mandible body fracture complications if treatment is done between 3 and 12 days after the injury.

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.

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.

Use of antibiotics in traumatic mandibular fractures: a systematic review and meta-analysis

The treatment of traumatic mandibular fractures constitutes a significant part of the oral and maxillofacial trauma service's workload. There are potential variations in how they are managed. Patients are often admitted and given intravenous antibiotics prior to their definitive treatment. The evidence behind this is inconclusive. We performed a systematic review as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance/ PROSPERO Registered (CRD:42020201398) on the use of antibiotics in the management of mandibular fractures. We identified studies using a search algorithm within the OVID Gateway (including MEDLINE, PubMed, and Cochrane Collaborative). Studies analysing the possible impact of prophylactic antibiotics on traumatic mandibular fractures were eligible. The primary outcome was surgical site infection requiring any treatment beyond the normal postoperative protocol. Secondary outcomes included any complication requiring further intervention. From the 16 studies identified (3,285 patients), seven were randomised controlled clinical trials (RCTs) and nine were retrospective observational studies. We have identified significant between-study variation in choice of antibiotic regimen (timing, dosage, duration) and in reporting both primary and secondary outcomes. There was significant between-study heterogeneity (p = 0.02, I² = 69%) and none of the assessed interventions was found to be superior. The evidence behind the use of prophylactic antibiotics in mandibular fractures is weak. A properly designed and powered RCT is needed, in order to standardise practice for the benefit of patients and healthcare systems.

Cutting Edge Craniomaxillofacial Trauma Reconstruction

Facial injuries remain a significant source of morbidity in trauma. Due to the variety and unpredictable patterns of injuries associated with either blunt or ballistic mechanisms, advanced diagnostic imaging and complex management options are necessary. Multidisciplinary collaboration is essential to optimize the care of craniomaxillofacial trauma.

Complications after osteosynthesis of craniofacial fractures-an analysis from the years 2015-2017

BACKGROUND

Complications mean a recurring problem in everyday clinical practice. Complication rates between 6 and 13% are described for the treatment of bony injuries to the head and neck area. This paper aims to provide a detailed analysis of the complications after osteosynthesis in facial skull fractures.

MATERIAL AND METHOD

In this retrospective study, we reviewed all patient records of injured treated in the Department of Cranial and Maxillofacial Surgery at the Dortmund General Hospital between 2015 and 2017.

RESULTS

Of the 22,031 head and neck injuries, 685 were treated with osteosynthesis. A clinically significant complication was reported in 32 patients (4.76%). The number of total complications was 63. In total, 66.7% of all complications have been identified in the paramedian mandible (44%), median mandible, mandibular angle, and in the collar area (each 12.7%). Eleven implants (in 5 patients) showed a cancellous bone impaction. Broken implants have been recognized in two cases. In 8 cases, there was a pseudarthrosis in the fracture area; in one case, there was a broken implant and pseudarthrosis in combination.

CONCLUSION

Osteosynthesis is a safe method of treating facial skull fractures, which is why we consider it the gold standard of therapy. The complication rate is well below 5%. The 3-dimensional adaptation (bending) and shortening of the osteosynthesis implants do not lead to an increase in complications.

Surgical Infection Society Guidelines for Antibiotic Use in Patients with Traumatic Facial Fractures

Background: Facial fractures are common in traumatic injury. Antibiotic administration practices for traumatic facial fractures differ widely. Methods: The Surgical Infection Society's (SIS's) Therapeutics and Guidelines Committee convened to develop guidelines for antibiotic administration in the management of traumatic facial fractures. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Pre-operative antibiotics were defined as those administered more than 1 hour before surgery. Peri-operative antibiotics were those administered within 1 hour of the start of surgery depending on the type of antibiotic and as late as ≤24 hours after surgery. Post-operative antibiotics were defined as those administered >24 hours after surgery. Prophylactic antibiotics were those administered for >24 hours without a documented infection. Evaluation of the published evidence was performed with the GRADE system. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: We recommend that in adult patients with non-operative upper face, midface, or mandibular fractures, prophylactic antibiotics not be prescribed and that in adult patients with operative, non-mandibular fractures, pre-operative antibiotics likewise not be prescribed. We recommend that in adult patients with operative, mandibular fractures, pre-operative antibiotics not be prescribed; and in adult patients with operative, non-mandibular facial fractures, post-operative (>24 hours) antibiotics again not be prescribed. We recommend that in adult patients with operative, mandibular facial fractures, post-operative antibiotics (> 24 hours) not be prescribed. Conclusions: This guideline summarizes the current SIS recommendations regarding antibiotic management of patients with traumatic facial fractures.

Gun-related eye injuries: A primer

Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.

No Need to Routinely Remove Titanium Implants for Maxillofacial Fractures

PURPOSE

Titanium implants are typically used to fix maxillofacial fractures and their routine removal is a controversial topic in maxillofacial surgery. This study aimed to estimate the removal rate and risk factors associated with removal.

MATERIALS AND METHODS

The authors designed and implemented a retrospective study. Adult patients who underwent open reduction and internal fixation with titanium implants for maxillofacial fractures were included and those who returned for implant removal were identified from January 2007 to December 2016. The predictor variables were gender, age, preoperative infection, injury time, trauma cause, and fracture site. The primary outcome variable was removal of titanium implants. Descriptive and bivariate statistics were computed. Kaplan-Meier survival methods were used to estimate rate of removal. Univariate and multivariate Cox proportional hazards models were used to identify risk factors associated with removal.

RESULTS

Of 2,325 patients (1,890 men and 435 women; average age, ∼35.49 yr) registered in this study, 163 (7.01%) had their titanium implants removed and 1-, 2-, and 10-year removal rates were 3, 7, and 8%, respectively. The risk factors most closely associated with removal were preoperative infection, injury by a blow from an object, obsolete fracture, and female gender.

CONCLUSIONS

Routinely removing titanium implants in patients with maxillofacial fracture is not necessary. When the risk factors listed earlier are present in these patients, follow-up should be scheduled more frequently.

Antibiotic use in facial plastic surgery

PURPOSE OF REVIEW

The aim of this study was to review and discuss recent literature regarding perioperative use of antibiotics in the context of facial plastic surgery.

RECENT FINDINGS

Despite research efforts, there continues to be insufficient evidence in support of, or against, the use of antimicrobial prophylaxis.

SUMMARY

Current available evidence regarding antibiotic use in facial plastic surgery procedures fails to demonstrate routine benefit. Therefore, the advantages accompanying administration of preoperative antibiotics should be weighed against any potential complications on a case-by-case basis. Future large-scale prospective studies will be beneficial in developing standardized criteria directing appropriate antibiotic use.