The efficacy of postoperative prophylactic antibiotics in orthognathic surgery: a prospective study in Le Fort I osteotomy and bilateral intraoral vertical ramus osteotomy

Impact of long-term vs. short-term and single day vs. single dose of antibiotic prophylaxis in reducing infection rates after orthognathic surgery: a systematic review and meta-analysis

BACKGROUND

This review was designed to examine the effect of long-term (≥2 days) vs. short-term (1 day) and single-day vs. single preoperative doses of antibiotic prophylaxis on surgical site infection (SSI) rates after orthognathic surgery.

MATERIAL AND METHODS

PubMed, Web of Science, Embase, and Scopus were searched for randomized controlled trials (RCTs) without any date or language restriction till 1st September 2023. SSI rates were pooled to generate risk ratio (RR).

RESULTS

Eight RCTs comparing long-term vs. short-term and three RCTs comparing single day vs. single preoperative dose of antibiotic prophylaxis were included. Meta-analysis showed that the use of long-term antibiotic prophylaxis significantly reduced the risk of SSI after orthognathic surgery as compared to short-term antibiotics [RR:0.42 (95% CI: 0.23, 0.76) I2=0%]. Meta-analysis also noted that patients receiving a single day of antibiotic prophylaxis had significantly reduced risk of SSI as compared to those receiving only a preoperative single dose of antibiotics [RR:0.28 (95%: 0.09, 0.82) I2=0%].

CONCLUSIONS

Evidence from a limited number of RCTs with moderate to high risk of bias shows that two to seven days of long-term antibiotic prophylaxis reduces the risk of SSI as compared to single-day antibiotic therapy. Also, a single day of antibiotics may be more beneficial than a single pre-operative dose of antibiotic.

Optimizing drug regimens and supplementation in orthognathic surgery: A comprehensive and practical guide

OBJECTIVE

This study aimed to comprehensively review the literature and provide a practical guide for optimizing drug regimens and supplementation related to orthognathic surgery.

METHODS

The authors conducted a thorough review of the existing literature, following the PRISMA-ScR guidelines. Various types of studies except case reports and reviews were included. The study applied specific inclusion criteria, focusing on perioperative and/or postoperative drugs, medications, or supplementation related to orthognathic surgery.

RESULTS

This guide included 78 studies on various medications in orthognathic surgery. It encompasses clinical trials, cohort studies, cross-sectional studies, prospective and retrospective studies. The topics covered include antibiotics, analgesics, corticosteroids, antiemetics, hemostatic agents, local anesthetics, herbal medicine, and botulinum toxin. Pain and edema control involved specific medications, while local anesthesia utilized ropivacaine and bupivacaine. The guide also discusses mineral and vitamin supplementation. The effectiveness of hemostatic agents and antiemetics was highlighted.

CONCLUSION

Pain management, reduced swelling, enhanced wound healing, and faster recovery are among the advantages. In addition to the standard drugs and medications, the inclusion of vitamin and mineral supplements, tranexamic acid, postoperative anesthetic blocks, and preemptive antiemetics is anticipated to offer various benefits in orthognathic surgery, despite the limited available evidence.

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.

Antibiotic prophylaxis and surgical site infections in orthognathic surgery - a retrospective analysis

BACKGROUND

This study was conducted to determine surgical site infection (SSI) rates and potential risk factors as well as to evaluate antibiotic prophylaxis in orthognathic surgery.

METHODS

This retrospective observational study included patients who received orthognathic surgery. SSIs and their management were assessed for up to one year post-operatively. The applied antibiotic regime and other possible influencing factors (smoking, age, site of infection, drainage, duration of surgery, displacement distances, craniofacial malformations) were assessed.

RESULTS

In total 291 patient met the inclusion criteria (56.7% female). The mean age at surgery was 25.5 ± 8.5 years. Fifty-four patients (18.6%) were diagnosed with a craniofacial malformation. Relevant previous surgeries were documented in about one quarter of included patients (n = 75). Ninety-two percent of patients (n = 267) received intraoperative single-dose antibiotic prophylaxis. Surgical site infections occurred in 12.4% (n = 36) of patients. There was a significant association between postoperative infections and type of surgery (P = .037) as well as type of drainage (P = .002). Statistical analyses also revealed a higher prevalence of smokers (P = .036) and previous surgically assisted rapid palatal expansion (SARPE) (P = .018) in the infection group. Furthermore, no significant relationships were observed between postoperative infections and various co-factors (i.e. antibiotic regime, age at surgery, gender, associated craniofacial malformations, surgery duration, displacement distances, mandibular setback vs. advancement).

CONCLUSION

Low rates of SSIs occurred following an intraoperative single-dose antibiotic regime. None of the SSIs had a significant effect on the final surgical outcome. Present data do not warrant escalation of the antibiotic regimen. Postoperative smoking and capillary drainage should be avoided.

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.

Systematic mapping review of orthognathic surgery

STUDY DESIGN

Systematic mapping review AIM AND SCOPE: The objective of this mapping review was to identify, describe, and organize clinical research currently available from systematic reviews and primary studies regarding co-interventions and different surgical modalities used in orthognathic surgery (OS) and their outcomes.

METHODS

Systematic reviews (SRs), randomized controlled trials, and observational studies that evaluated perioperative OS co-interventions and surgical modalities were identified in an exhaustive search of MEDLINE, EMBASE, Epistemonikos, Lilacs, Web of Science, and CENTRAL. Grey literature was also screened.

RESULTS

Included were 35 SRs and 253 primary studies, 103 from SRs, and another 150 identified in our search. Overall, SR quality was rated as critically low, with only two SRs rated as of high quality. 19 questions on population, interventions, comparisons, and outcomes (PICO) extracted from the SRs focused on osteosynthesis methods, surgical cutting devices, and use of antibiotics, corticosteroids, and induced hypotension. Also identified were 15 research gaps. Evidence bubble maps were created to graphically depict the available evidence.

CONCLUSION

Future high-quality research, both primary and secondary, is needed to address the knowledge gaps identified in this systematic mapping review.

Does Penicillin Allergy Increase the Risk of Surgical Site Infection after Orthognathic Surgery? A Multivariate Analysis

This study aimed to demonstrate an association between the occurrence of surgical site infection (SSI) after orthognathic surgery and penicillin allergy and to assess whether other factors could be associated with the occurrence of SSI. A 10-year monocentric retrospective study was conducted to identify possible risk factors for SSI in orthognathic surgery. Bivariate analyses were performed using Fisher, Student, or Wilcoxon tests and multivariate analyses using logistic regression. Two hundred and sixty-six patients were included, and 3.5% had SSI. Bivariate analyses revealed a significant association between SSI and age at surgery (p = 0.01), penicillin allergy (p = 0.02), and postoperative antibiotic therapy by Clindamycin (Dalacine^®) (p = 0.02). Multivariate analyses confirmed the association between the occurrence of SSI and treatment with Clindamycin (Dalacine^®) or Clindamycin (Dalacine^®) and Metronidazole (Flagyl^®) postoperatively (p = 0.04). Antibiotic therapy with Clindamycin (Dalacine^®) seems to be associated with a higher rate of SSI, and the mandible was the only site affected by SSI.

Winds of Change in Antibiotic Therapy following Orthognathic Surgery

Background and objectives: This retrospective cohort study aimed to compare three postoperative antibiotic protocols of different durations on surgical-site-infection (SSI) rates following orthognathic surgery for the correction of jaw deformities. Materials and methods: An analysis on data collected from the medical files of 209 patients who underwent orthognathic surgery between 2010 and 2019 was conducted. The patients were divided into three groups according to the postoperative antibiotic protocol—Group 1 (24 h), Group 2 (2–3 days), and Group 3 (>3 days). Dependent and independent variables were collected, analyzed, and compared between the three groups. Results: Group 1 included 30 patients (14.3%), Group 2 included 123 patients (58.9%), and Group 3 included 56 patients (26.8%). The vast majority of the postoperative antibiotics were amoxicillinand clavulanic acid (87.1%). The duration of the surgery and the use of a feeding tube were significantly different between Groups 1 and 3 (p < 0.001 and p = 0.005, respectively). There was no significant difference in SSI rates between the three groups (p = 0.642). The use of antibiotics beyond the immediate postoperative period provides no increased benefit regarding infection prevention. Conclusions: In young and healthy patients undergoing orthognathic surgery, a 24hregimen of postoperative antibiotics may be sufficient.

Antibiotic practices in non-condylar mandibular fractures: a Maxillofacial Trainee Research Collaborative (MTReC) UK-wide survey

Non-condylar mandibular fractures are consdered 'open' fractures and as such are thought to require prophylactic antibiotics. There is no overall consensus on the optimal regimen or choice of antibiotic in the preoperative and postoperative periods due to a lack of high-quality evidence. We therefore set out to ascertain the current UK-wide practice of antibiotic prescribing for non-condylar mandibular fractures. We used a web-based online survey (Google Forms) that was disseminated via email and social media platforms to oral and maxillofacial surgery (OMFS) consultants and trainees of all grades. The questions focused on usual antibiotic practices and typical clinical management of non-condylar mandibular fractures. We gathered information on preoperative antibiotics, and on perioperative and postoperative periods. We collected data from 50 different UK OMFS units representing a broad snapshot of national practice. The majority of responders were speciality trainees (36%) followed by dental core trainees (34%). A total of 45/50 centres routinely admitted patients, and preoperative intravenous antibiotics were commenced on admission by 77/89 respondents, intravenous being the chosen route in all cases. In the preoperative period 81% prescribe co-amoxiclav. In 91% of cases, open reduction and internal fixation (ORIF) was on general emergency (CEPOD) operating lists, whilst dedicated OMFS trauma lists accounted for 9%. With respect to timing, 49% aimed to carry out ORIF within 24 hours from the time of admission, 44% aimed for surgery within 24 - 48 hours, and 6% aimed for surgery on a semielective basis (48 hours or more). Postoperative antibiotics were prescribed routinely by 88% of responders. Preoperative intravenous prophylactic antibiotics are commonplace in non-condylar mandibular fractures. This UK-wide survey demonstrated significant variability in antibiotic prescribing practices, especially in the postoperative period. Most units still rely on CEPOD emergency theatres to provide the capacity for ORIF in this patient group.

Antibiotic prophylaxis in orthognathic surgery: an overview of systematic reviews

The purpose of this overview was to assess different antibiotic regimens used in orthognathic surgery and to establish an evidence-based protocol so that beneficial and adverse effects can be determined. A comprehensive literature search for systematic reviews and/or meta-analyses was conducted in MEDLINE (PubMed), EMBASE, and the Cochrane Library until March 2020. Grey literature was investigated in Google Scholar, and a manual search was done of references lists. Two meta-analyses and four systematic reviews met the inclusion criteria. The AMSTAR-2-tool was used to ascertain the potential risk of bias in the included studies, which presented moderate to high methodological quality. Lower infection rates were associated with long-term therapies of penicillin, cefazolin-cephalexin, and amoxicillin-clavulanic-acid, with rates varying from 0% - 3.13%. Higher rates were reported in placebo groups (52.6%) and short-term penicillin therapy (60%). Side effects were reported with cefazolin, clindamycin, and penicillin therapies, including nausea, pain, swelling, headache, vomiting, and skin rash. Evidence suggests that long-term antibiotics can reduce the risk of a surgical site infection (SSI) in orthognathic surgery, but there is uncertainty regarding the effects of one dose of antibiotics preoperatively versus short-term antibiotics. In the same way, intravenous penicillin, cefazolin, clindamycin, and amoxicillin-clavulanic acid kept the infection rates associated with bimaxillary procedures under 3.5%.

Antibiotics in orthognathic surgery: a retrospective analysis and identification of risk factors for postoperative infection

This study was undertaken to evaluate the infection rate following orthognathic surgery and to identify possible risk factors. A retrospective study was conducted. Patients undergoing orthognathic surgery from August 1, 2017 to July 31, 2018 were included. The outcome variable was surgical site infection (SSI). All data were analysed with respect to demographics and procedure specifications. A total of 137 patients (mean age 28.5±12.69 years) were included in this study, of whom 20 (14.6%) developed a SSI. The only risk factor identified was the type of surgery: those undergoing mandibular osteotomies (in bilateral sagittal split osteotomy (BSSO) or bimaxillary osteotomies) were far more likely to develop infections. Third molar teeth were removed during orthognathic surgery in 28.5% of the procedures, and a genioplasty was performed in 10.9%. Removal of osteosynthesis material because of infectious reasons was necessary in 10.2% of patients, with a strong association to previous SSI. In conclusion, this study showed an infection rate of 14.6% with no link to any demographic risk factor. Neither the simultaneous removal of third molar teeth nor genioplasty was found to be a risk factor for SSI. For literature comparison purposes, there is a clear need for the international guidelines defining SSI to be used.

Antibiotic prophylaxis for sagittal split ramus osteotomy using resorbable plate and screw fixation: a randomised trial to compare extended dual-agent and inpatient single-agent regimens

Resorbable materials are used to fix bony fragments after sagittal split ramus osteotomy (SSRO), but to our knowledge, there is no clear regimen for antibiotic prophylaxis when such materials are used. The purpose of this study therefore was to compare inpatient single-agent and extended dual-agent antibiotic prophylaxis for the prevention of surgical site infections (SSI) in patients after SSRO. This prospective study included 100 patients who underwent SSRO for deformities of the jaw. Cephalometric analysis was performed preoperatively, and at one month and one year postoperatively. Patients were divided into two groups of 50 each. Group A was given cefazolin sodium 1g preoperatively and every eight hours for 48 hours postoperatively. Group B was given cefazolin sodium 1g preoperatively and every eight hours for 48 hours postoperatively, after which they were provided with oral amoxicillin for three days. Both groups were assessed for SSIs for one year postoperatively using the Clavien-Dindo classification. SSIs were documented in seven patients in Group A and six in Group B, with no significant difference between the groups. The two regimens had no significant association with SSI. In conclusion, our results suggest that the inpatient, single-agent, postoperative antibiotic regimen is sufficient to prevent SSI in patients who have SSRO with resorbable plate and screw fixation.

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.

Severity and long-term complications of surgical site infections after orthognathic surgery: a retrospective study

Surgical site infections (SSI) occur in 1.4% to 33.4% of cases after orthognathic surgery. This type of complication is a major concern to surgical teams, but there is no consensus for the prevention and treatment of SSI in orthognathic surgery. The purpose of this descriptive study was to evaluate the severity and the consequences of postoperative infections. The charts of all the patients operated on by the orthognathic surgery team between January 2015 and July 2017 were collected. All types of orthognathic procedures (Le Fort I maxillary osteotomy, bilateral sagittal split mandibular osteotomy, and genioplasty) were screened, and patients diagnosed with SSI were included. Demographic data, timing and severity of the infection, as well as long-term complications were recorded. Five hundred and twelve patients were screened. Forty-one patients (8%) presenting with SSI were included. There were 18 men and 23 women. The site of the infection was mandibular for 38 patients (92.7%) and maxillary for 3 patients (7.3%). The average time between surgery and infection was 31.5 days. Twenty-four patients received isolated oral antibiotics for inflammatory cellulitic reaction (58.8%), 15 patients had a localized collection treated by incision and drainage under local anesthesia (36.6%), and 2 patients had an extensive collection requiring surgical drainage under general anesthesia (4.9%). Five patients (12.2%) needed hardware removal for plate loosening, and 2 patients (4.9%) developed chronic osteomyelitis. Infection following orthognathic surgery is easily treated most of the time with no long-term complications. In cases of patients with potential risk factors for severe infection, antibiotics may be given with curative intents.

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.

Surgical Antimicrobial Prophylaxis and Incidence of Surgical Site Infections at Ethiopian Tertiary-Care Teaching Hospital

BACKGROUND

Surgical site infections (SSIs) are infections that develop within 30 days after an operation or surveillance of surgical wound infection implementation within 90 days after surgery when an implant is placed. The objective of this study was to assess preoperative and postoperative antimicrobial use in St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia.

METHODS

A hospital-based cross-sectional study was undertaken in surgery wards of SPHMMC for 4 months by reviewing 413 patients' charts. All patients 13 years and older who were admitted and underwent different types of surgical procedures were included in the study. Epi info 7 was used for data entry, and then data were exported to Statistical Package for Social Sciences (SPSS) version 20.0 software for analysis. Descriptive analyses were computed and rate of SSI was calculated in this study. Moreover, bivariate analysis was done to examine the relationship between the outcome variable and predictor variables with a value of P < .2 retained for subsequent multivariate analyses using multiple logistic regressions. P value of <.05 was considered as statistically significant.

RESULTS

Out of 413 patients, 152 (36.8%) were operated for general surgery, and the remaining were for other types of surgeries. Most of the patients, 196 (79.7%), were managed by a single surgical antibiotic agent, followed by 2 agents (20.3%) for surgical prophylaxis indication. Surgical site infections occurred in 46 (11.1%) patients before discharge from the hospital. In those patients who need treatment for SSIs, almost half of them (49.5%) received combination therapy of ceftriaxone and metronidazole. Emergency surgical cases were 2.647 times more likely to develop SSIs than the elective surgical cases (adjusted odds ratio [AOR] = 2.647; 95% confidence interval [CI] = 1.406-4.983; P = .003). Patients who did not receive antibiotic prophylaxis were 2.572 times more likely to develop SSIs compared to those who received antibiotic prophylaxis (AOR = 2.572; 95% CI = 1.02-6.485; P = .045). Clean-contaminated and contaminated types of wound were a protective factor against SSI in our study.

CONCLUSIONS

This study indicated that most of the patients (72.1%) received surgical antimicrobial prophylaxis. The overall incidence rate of SSIs was 11.1% in the studied hospital. Ceftriaxone was the most commonly used drug. Being not receiving prophylaxis, wound class, and surgery types were significantly associated with the development of SSI.

New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective

Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.

Surgical Site Infections Following Bimaxillary Orthognathic, Osseous Genioplasty, and Intranasal Surgery: A Retrospective Cohort Study

PURPOSE

Frequency estimates of surgical site infection (SSI) after orthognathic surgery vary considerably. The purpose of this study was to determine the incidence and site of SSIs and associated risk factors after bimaxillary orthognathic, osseous genioplasty, and intranasal surgery.

MATERIALS AND METHODS

The authors executed a retrospective cohort study of patients with a bimaxillary developmental dentofacial deformity (DFD) and symptomatic chronic obstructive nasal breathing. All patients underwent at a minimum Le Fort I osteotomy, bilateral sagittal ramus osteotomies (SROs), septoplasty, inferior turbinate reduction, and osseous genioplasty. The primary outcome variable studied was the incidence and site of SSI. Predictor variables were type and extent of prophylactic antibiotic used, demographic (age and gender), and anatomic (pattern of DFD, surgical site, and presence of third molar).

RESULTS

Two hundred sixty-two patients met the inclusion criteria. Their average age at surgery was 25 years (range, 13 to 63 yr) and there were 134 female patients (51%). The major presenting patterns of DFD included long face (30%) and maxillary deficiency (25%). Forty percent of patients undergoing an SRO and 47% of those undergoing a Le Fort I osteotomy underwent simultaneous removal of a third molar. Ninety percent of patients received cefazolin or cephalexin antibiotics. Overall, 5 of 1,048 (0.5%) osteotomy sites sustained an infection, including 1 chin and 4 ramus SSIs. There were no delays in bone healing. Fixation hardware removal was not required in any patient who developed an infection. Two of the 25 patients (8%) given clindamycin prophylaxis developed an SSI, whereas 3 of 237 patients (1%) receiving cefazolin did. Three of the 4 patients who developed an SRO SSI underwent simultaneous removal of an erupted or partially erupted mandibular third molar (P < .05).

CONCLUSIONS

In this study, the incidence of SSI was limited to 1% of patients who were given cefazolin or cephalexin extended for 5 days. The removal of an erupted or partially erupted mandibular third molar in conjunction with an SRO was associated with risk of SSI, but the incidence remains low.

Prevalence of Surgical Site Infections Following Orthognathic Surgery: A Retrospective Cohort Analysis

PURPOSE

The purpose of this retrospective study was to determine the prevalence of surgical site infection (SSI) after orthognathic surgery at the Department of Oral and Maxillofacial Surgery of Capital Health and Dalhousie University (Halifax, NS, Canada).

PATIENTS AND METHODS

A retrospective chart review of all patients undergoing orthognathic surgery from October 2005 through April 2013 was performed. The outcome variable was SSI. The primary predictor variable was the antibiotic used for prophylaxis. The secondary predictor variables were patient demographics, such as age, gender, medical comorbidities, and smoking status; duration of surgery; wisdom teeth extractions; single-jaw or bimaxillary surgery; and type of surgery. Data also were gathered on the diagnosis of SSIs and the treatment to resolve these infections.

RESULTS

In total, 2,521 patients underwent surgery, and 253 patients did not meet the inclusion criteria; therefore, the charts of 2,268 patients were reviewed (mean ± standard deviation, 26.9 ± 11.7 yr of age). Eight percent of patients developed an SSI. None of the patient demographics was associated with an increased risk for infection. Most initial infections (62%) and most recurrent infections (78%) occurred in the mandible. Twenty-six percent of patients who developed SSIs had recurrent infections after antibiotic treatment. SSIs necessitated hardware removal for 14% of patients. Adverse effects from the antibiotics were seen in 4.2% of patients. Infection was most frequently diagnosed 11 to 15 days postoperatively. The average length of surgery for patients who did not have an SSI was 136 minutes compared with an average of 157 minutes for patients who had an SSI (odds ratio = 1.0051; 95% confidence interval, 1.0026 to 1.0076; P < .001). Wisdom teeth were extracted in 49.6% of the 2,268 cases. The mean SSI prevalence for multiple jaw procedures (9.2%) was significantly higher than that for single surgical procedures (5.3%; P = .0013). Isolated Le Fort surgeries had a significantly lower prevalence of infection compared with the mean prevalence (3.9%; P = .02), whether they were single piece or segmented (3.5 and 4.3%, respectively; P = .98). The prevalence of infection was significantly lower in the cefazolin group (6.2%) compared with the penicillin (14.3%; P < .0001) and clindamycin (10.4%; P < .02) groups.

CONCLUSIONS

The prophylactic use of first-generation cephalosporins, such as cefazolin, appears to be more effective than penicillin and clindamycin for preventing SSIs in orthognathic surgery. In addition, bimaxillary surgery, mandibular procedures, and duration of surgery might demand antibiotic prophylaxis that is more effective. The presence of third molars and patient demographics are not risk factors for SSIs. A prospective randomized controlled study is underway to investigate the findings of this study.

Role of Postoperative Antimicrobials in Cleft Palate Surgery: Prospective, Double-Blind, Randomized, Placebo-Controlled Clinical Study in India

BACKGROUND

The purpose of this study was to determine whether administration of postoperative antibiotics affects the incidence of complications after primary cleft palate repair in a developing area.

METHODS

This study was a prospective, double-blind, randomized, placebo-controlled trial composed of 518 consecutive patients who underwent primary cleft palate repair at a single institution. Patients were aged 1 to 43 years at the time of surgery (median, 9 years). The patients were divided randomly into two groups. One group received a 5-day regimen of oral amoxicillin (50 mg/kg/day) postoperatively and the other group received placebo medication. Both groups received a single dose of cefuroxime (30 mg/kg) before incision. Patients and providers were blinded to the randomization. Patients were followed postoperatively for early complications (infection and wound breakdown) and for late complications (palatal fistulas).

RESULTS

The incidence of early complications was 13.8 percent among the patients in the placebo group and 8.7 percent among the patients in the antibiotic group (p = 0.175). Fistulas were noted in 17.1 percent in the placebo group and in 10.7 percent in the antibiotic group (p = 0.085). Logistic regression analysis identified visiting surgeons as the only covariate related to early complications (OR, 3.71; p < 0.001). However, the use of placebo (OR, 2.09; p = 0.037), female sex (OR, 2.04; p = 0.047), and Veau III and IV (OR, 3.31; p = 0.004) were observed as factors associated with the incidence of fistulas.

CONCLUSION

The authors' results indicate that postoperative antibiotic prophylaxis can reduce the incidence of fistulas after primary cleft palate repair in a developing area.

Complex systematic review - Perioperative antibiotics in conjunction with dental implant placement

OBJECTIVES

The aim of this study was to revisit the available scientific literature regarding perioperative antibiotics in conjunction with implant placement by combining the recommended methods for systematic reviews and complex systematic reviews.

MATERIAL AND METHODS

A search of Medline (OVID), The Cochrane Library (Wiley), EMBASE, PubMed and Health technology assessment (HTA) organizations was performed, in addition to a complementary hand-search. Selected systematic reviews and primary studies were assessed using GRADE and AMSTAR, respectively. A meta-analysis was performed.

RESULTS

The literature search identified 846 papers of which 10 primary studies and seven systematic reviews were included. Quality assessment of the systematic reviews revealed two studies of moderate risk of bias and five with high risk of bias. The two systematic reviews of moderate risk of bias stated divergent numbers needed to treat (NNT) to prevent one patient from implant failure. Four of the primary studies comparing antibiotic prophylaxis with placebo were estimated to be of low, or moderate, risk of bias and subjected to meta-analysis. The NNT was 50 (pooled RR 0.39, 95% CI 0.18, 0.84; P = 0.02). None of these four studies individually show a statistical significant benefit of antibiotic prophylaxis. Furthermore, narrative analysis of the studies eligible for meta-analysis reveals clinical heterogeneity regarding intervention and smoking.

CONCLUSION

Antibiotic prophylaxis in conjunction with implant placement reduced the risk for implant loss by 2%. However, the sub-analysis of the primary studies suggests that there is no benefit of antibiotic prophylaxis in uncomplicated implant surgery in healthy patient.

Antibiotic prophylaxis for preventing infectious complications in orthognathic surgery

BACKGROUND

Orthognathic surgery (OS) is a term that refers to many elective surgical techniques to correct facial deformity; the associated malocclusion and functional disorders related to the stomatognathic system. Whilst such surgery is classed as "clean-contaminated", the usefulness of and the most appropriate regimen for antibiotic prophylaxis in these patients are still debated.

OBJECTIVES

To assess the effects of antibiotic prophylaxis for preventing surgical site infection (SSI) in people undergoing orthognathic surgery.

SEARCH METHODS

In June 2014, we searched the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We also searched Google Scholar and performed manual searches in journals relevant to the topic, conference proceedings and lists of references of potentially included articles. We did not restrict the search and study selection with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) involving people undergoing orthognathic surgery comparing one regimen of antibiotic prophylaxis with any other regimen or placebo. The primary outcome was SSI, and secondary outcomes were systemic infections, adverse events, duration of hospital stay and health-related quality of life. Two review authors screened articles independently.

DATA COLLECTION AND ANALYSIS

Data were abstracted independently by two review authors, and agreement was checked. Risk of bias was assessed using the Cochrane risk of bias tool. Antibiotic regimens were classified as preoperative (one dose before surgery), short-term (before or during surgery and/or during the same day of surgery) and long-term (before or during surgery and longer than one day after surgery) antibiotic prophylaxis. Random-effects meta-analyses using inverse variance methods were undertaken when possible. We report risk ratios (RRs) and their corresponding 95% confidence intervals (CIs).

MAIN RESULTS

A total of 11 trials were included in this review. Most of the studies had an unclear risk of bias prompting us to downgrade the quality of evidence for our outcomes. Seven of these trials provided evidence for the main comparison and the primary outcome and these were pooled. Overall, long-term antibiotic prophylaxis probably reduces the risk of SSI (plausible effects range between a 76% to a 0.26% relative reduction in SSI with long-term antibiotic prophylaxis) (472 participants; RR 0.42, 95% CI 0.24 to 0.74; moderate-quality evidence). There is uncertainty surrounding the relative effects of short-term antibiotics compared with a single dose (220 participants; RR 0.34, 95% CI 0.09 to 1.22; low-quality evidence). No reports described adverse effects associated with the drugs in those trials that reported in this outcome. None of these trials assessed or reported data regarding other outcomes, and information was insufficient to show whether a specific antibiotic is better than another.

AUTHORS' CONCLUSIONS

For people undergoing orthognathic surgery, long term antibiotic prophylaxis decreases the risk of SSI compared with short-term antibiotic prophylaxis and the is uncertainty of whether short-term antibiotic prophylaxis decreases SSi risk relative to a single pre-operative dose of prophylactic antibiotics.

Value of prophylactic postoperative antibiotic therapy after bimaxillary orthognathic surgery: a clinical trial

INTRODUCTION

Antibiotic therapy before or after orthognathic surgery is commonly recommended by surgeons to minimize the risk of wound infection. This article evaluates the value of Prophylactic antibiotic therapy in order to diminish the incidence of postoperative wound infection after orthognathic surgery.

MATERIALS AND METHODS

Fifty candidates for bimaxillary orthognathic surgery were divided into cases and controls. Cefazolin (1g) was administered intravenously to all participants 30 mins prior to surgery followed by a similar dose 4 hours later. Case-group patients ingested amoxicillin (500 mg) orally for 7 days after surgery. Postoperative wound infection was assessed using clinical features, and the P-value significance was set at P<0.05.

RESULTS

Both groups were similar according to gender, age, and operating time. During the follow-up period no infection was observed in either the case or control group.

CONCLUSION

The results of this study suggest that long-term postoperative antibiotic therapy is not essential for the prevention of postoperative infection, and that application of aseptic surgical technique and hygiene instruction after surgery are sufficient.