Antibiotic prophylaxis in clean-contaminated head and neck oncological surgery

doi:10.1016/j.jcms.2006.10.006

Journal of Cranio-Maxillofacial Surgery

Volume 35, Issue 1, January 2007, Pages 15-20

https://doi.org/10.1016/j.jcms.2006.10.006 Get rights and content

Summary

Background

Perioperative antibiotic prophylaxis has significantly reduced wound infection rates in clean-contaminated head and neck surgical procedures but controversy still remains regarding the optimal antibiotic regime.

Objective

To examine the efficacy of different antibiotics in head and neck oncological surgery prophylaxis.

Patients and methods

In this prospective, double-blind clinical trial, 189 patients with carcinoma of the upper aerodigestive tract were randomized to receive amoxicillin-clavulanate or cefazolin intravenously up to 1 h before surgery and at 8-h intervals for an additional three doses.

Results

An overall wound infection rate of 22% was observed. The infection rate in patients receiving cefazolin was 24% (22/92) vs. 21% (20/97) in those receiving amoxicillin-clavulanate; the difference was not statistically significant. Postoperative overall non-wound infection developed in 12% (22/189) patients; the rate of infection was 9.8% (9/92) in patients receiving cefazolin vs. 13.4% (13/97) in those receiving amoxicillin-clavulanate, without a statistically significant difference between the two groups. Gram-negative bacteria were more often isolated with Pseudomonas aeruginosa as the dominant species. The risk of postoperative infection was more influenced by the type of surgical procedure than by disease stage.

Conclusion

In clean-contaminated head and neck oncologic surgery amoxicillin-clavulanate prophylaxis was at least as efficient as cefazolin. However, when taking into account the fact that beta-lactamase containing strains have recently been spreading, amoxicillin-clavulanate should be the logical first choice.

Introduction

Cancer of the upper aerodigestive tract constitutes approximately 4% of all malignancies (Muir and Weiland, 1995) and the main treatment in the management of these patients remains surgical.

Significant morbidity in the immediate postoperative period is caused by wound, and by non-wound infections.

There is general agreement that perioperative antibiotic prophylaxis for 24-h reduces the risk of colonization/super-infection (Kaiser, 1990).

Cephalosporins have emerged as the drug of choice for perioperative prophylaxis because of their (wide) antibacterial spectrum and low incidence of allergy and side effects (Kaiser, 1990). The Antimicrobial Agents Committee of the Surgical Infection Society of the United States of America recommends cefazolin for prophylaxis in clean-contaminated head and neck surgery, although it has Gram-positive aerobic coverage only (Rodrigo et al., 1997). To date, it remains the mainstay for prophylaxis in clean-contaminated head and neck surgery (Shinagawa et al., 2003; Rodrigo et al., 2004).

The purpose of the present study was to compare the efficacy of amoxicillin plus clavulanic acid with the cefazolin regime, and to identify the risk factors for postoperative infections in patients who had undergone head and neck tumour surgery.

Section snippets

Patients and methods

A prospective, randomized, double-blind clinical trial of patients was conducted at the Department of Otolaryngology and Head and Neck Surgery, Zadar General Hospital, Croatia, from January 2000 to December 2003. The protocol had been reviewed and approved by the local Ethics Committee.

Patients eligible to be included in this trial were those scheduled to undergo oncological surgery involving a clean-contaminated wound. Clean-contaminated wounds were defined as sterile initially, but the

Results

The study comprises data from 189 patients who were enrolled into the study and received drug therapy: 92 received cefazolin, and 97 received amoxicillin/clavulanic acid. No antibiotic toxicity was identified.

In total, only 22% (42/189) patients developed postoperative wound infections. The infection rate was 24% (22/92) in patients receiving cefazolin and 21% (20/97) in the other group. There was no statistically significant difference between the two (p>0.05).

Postoperative non-wound

Discussion

The so-called clean-contaminated head and neck surgical procedure has long been recognized as having a risk of postoperative wound infections. The incidence of these without administration of perioperative antibiotics ranges from 24% to 87% (Weber and Callender, 1992). This stems primarily from the gross and often extensive and prolonged contamination of the neck wound with oropharyngeal secretions.

Recently, the use of perioperative antibiotics has been shown to significantly reduce

Conclusion

Amoxicillin/clavulanic acid is at least as safe and effective as cefazolin in preventing infections in oncologic head and neck surgery. If it were to demonstrate a statistically significant difference, more than 1000 patients would have been necessary for a study of this type and meta-analyses should be performed to give the most scientifically accurate answer to this problem (Rosenfield, 2004).

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Antibiotic prophylaxis is frequently used in plastic surgery procedures, despite the generally low rates of infection and few guidelines on the practice. The increasing prevalence of bacterial resistance to antibiotics calls for a reduction in unnecessary antibiotic use. The aim of this review was to create an updated summary of the available data on the effectiveness of antibiotic prophylaxis in reducing the postoperative infection in clean and clean-contaminated plastic surgery. A systematic literature search was performed on the databases Medline, Web of Science, and Scopus, limited to articles published January 2000 onward. Randomized controlled trials (RCTs) were included in the primary review, whereas older RCTs and other studies were sought if 2 or fewer relevant RCTs were identified. Overall, 28 relevant RCTs, 2 nonrandomized trials, and 15 cohort studies were identified. Although the number of studies for each type of surgery is limited, the data suggest that prophylactic systemic antibiotic may be unnecessary in noncontaminated facial plastic surgery, reduction mammaplasty, and breast augmentation. In addition, no benefit is apparent from extending the antibiotic prophylaxis over 24 h in rhinoplasty, aerodigestive tract reconstruction, and breast reconstruction. No studies assessing the necessity of antibiotic prophylaxis in abdominoplasty, lipotransfer, soft tissue tumor surgery, or gender affirmation surgery were identified. In conclusion, limited data are available on the effectiveness of antibiotic prophylaxis in clean and clean-contaminated plastic surgery. More studies on this topic are needed before strong recommendations can be made on the use of antibiotics in this setting.
Impact of the practical guideline on appropriate usage of antimicrobial treatments for surgical site infections in reconstructive surgery of head and neck cancer
2022, Journal of Infection and Chemotherapy
In 2016, Japanese Society of Chemotherapy and Japan Society for Surgical Infection presented the practical guideline for appropriate usage of antimicrobial agents to prevent postoperative infections. This study aims to exhibit the validity of the guideline as a series of effective strategies for prevention of surgical site infections (SSIs) during reconstructive surgery of the head and neck cancer.
We retrospectively evaluated patients who underwent head and neck reconstructive surgery with free or pedicle flaps in a single institute in Japan between July 2010 and July 2020. We evaluated the incidence of SSIs, patient backgrounds, and microbiological characteristics on the basis of antimicrobial prophylaxis recommended by the guideline.
Enrolled in this study were 102 patients in our institution who underwent head and neck reconstructive surgery with free or pedicle flaps between July 2010 and July 2020. In the period between January 2018 to July 2020 after the SSI guideline was advocated (SSI guideline period), the ratio of administration of sulbactam/ampicillin (SBT/ABPC) was significantly higher (P < 0.001) and the duration of prophylactic antimicrobial treatment was significantly shorter than in the period between July 2010 to December 2017 before the SSI guideline was advocated (Pre-SSI guideline period) (P < 0.001). Incidence of SSIs were similar, even when antibiotic use was changed to be short-term single-agent administration in accordance with the practical guideline.
Adherence to the current Japanese practical guideline on appropriate antimicrobial prophylaxis for SSIs can shorten the duration of usage of antimicrobial treatment without increasing the risk for occurrence of SSIs.
Microbiology of wound infection after oral cancer surgery
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Citation Excerpt :
On the other hand, in patients treated with antibiotic prophylaxis, the incidence is around 40%, far more than expected (Brown et al., 1987; Girod et al., 1995; Fraioli and Johnson, 2004; Penel et al., 2005; Liu et al., 2007, 2011; Lotfi et al., 2008). In clean-contaminated surgical procedures, perioperative antibiotic prophylaxis is generally accepted (Skitarelic et al., 2007; Langerman et al., 2016). However, the main problem of antibiotic prophylaxis, in surgical treatment of oral cancer, is the absence of a generally accepted choice of antibiotic, as well as its dosage and how often and how long it should be administrated (Robbins et al., 1990).
The aim of present study is to investigate the most common infection pathogen found in the postoperative wounds, following surgical treatment of oral and oropharyngeal cancer, in order to identify the most suitable antibiotic treatment.
We analyzed patients with squamous cell cancer of oral and oropharyngeal region. In patients who developed postoperative wound infection, wound swabs were taken from three different sites: the cannula, wounds on the neck and wounds in the oral cavity.
In total 195 patients were included. The postoperative wound infection was detected in 115 patients (59%). In average, the swabs were taken 8 days after the surgery. The similar bacterial species from all three sites were detected in 24 patients (12,3%). In comparison, we found that there was statistically significant difference in the bacteria abundance from all three sites (p=0,031). There were significantly more bacteria in the wounds of the neck than cannula (p=0,007) and in the wounds in the oral cavity than cannula (p=0,002). No statistically significant difference between the wound on the neck and in the oral cavity was found. The most frequently isolated bacterial family was Enterobacteriaceae. Other more commonly isolated bacteria species were Staphylococcus spp. (G+), Pseudomonas aeruginosa (G-), Corynebacteruim spp. (G +) and Acinetobacter baumanii (G-).
Based on the most commonly isolated groups of pathogens we concluded that probably the best empiric antibiotic treatment of wound infections until antibiogram is completed might be achieved from the group of aminoglycosides or quinolones. Antibiotic therapy should be reviewed if necessary when antibiogram is completed.
Nutrition and Perioperative Care for the Patient with Head and Neck Cancer
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In the field of reconstructive head and neck surgery, surgical site infections (SSI) are commonly investigated for the recipient site of various reconstructive procedures. Data about SSI of the donor site of different flaps raised for reconstruction are rare.
With regard to the bacterial donor site infections, we retrospectively investigated the medical data, surgical reports and wound management protocols of 267 patients who received reconstruction of the head and neck after ablative surgery. All patients underwent reconstruction with one of the following flaps: free fasciocutaneous radial forearm flap (RFFF), free fasciocutaneous anterolateral thigh flap (ALTFF), pedicled myocutaneous latissimus dorsi flap (PLDF), pedicled myocutaneous pectoralis major flap (PPMF), free osteocutaneous fibula flap (FFF). Follow-up was conducted for 12 months.
The lowest detection ratio (DR: number of infected sites/flaps raised from the respective donor site) was calculated for the radial forearm, 0.087. Pedicled flaps presented a moderate DR (PLDF: 0.27, PMMF:0.35). Donor sites of the leg possessed the highest DR (ALTFF:0.61, FFF: 045). Mainly gram-positive facultative anaerobic bacteria (n = 41) were detected and gram-negative bacteria (aerobe/anaerobe) were present in 27 cases. The most frequently detected bacteria were Staphylococcus spp., Viridans Streptococci, Pseudomonas aeruginosa and Escheria coli. Continuous wound management for in-hospital patients was able to prevent any local spreading or a prolonged length of in-hospital stay.
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Citation Excerpt :
Different studies have investigated the postoperative wound infections of the head and neck area; however most of them are not completely comparable because of limited tumor area such as tumors of the larynx, thyroid, salivary glands, etc (Girod et al., 1995; Skitarelic et al., 2007; Ogihara et al., 2009). Previously it was shown that the extensiveness of the surgery in general, and the possibility of contamination of the wound with microflora, vary (Robbins et al., 1990; Girod et al., 1995; Skitarelic et al., 2007). In this study, we analyzed the occurrence of wound infection exclusively in patients with carcinoma of the oral cavity and oropharynx who underwent surgery (Penel et al., 2005; Warnakulasuriya, 2009).
The goal of this study was to identify risk factors for wound infections in patients with oral cancer who underwent surgical procedures.
This study included 195 patients who underwent surgical treatment of oral and oropharyngeal cancer over a 7-year period. Wound infection was defined as the occurrence of purulent content from the wound or as an appearance of exudate with signs of local infection and positive cultures taken from the wound. For every patient who was suspected to have a wound infection, a swab from the wound was taken, and microbiological analysis was performed. The patients were divided into 2 groups: patients with postoperative wound infections, and patients with postoperative wound infection.
Wound infection was present in 155 patients (59%). Univariate analysis indicated that the following factors were significantly related to the occurrence of wound infection: gender, smoking, tumor localization, size and stage of the tumor, type of surgery, neck dissection, type of reconstruction, nasogastric sonde, gastrostomy and tracheotomy. On multivariate analysis, statistically significant predictors of wound infection were gender, tumor localization and type of reconstruction.
The occurrence of wound infection is high despite antibiotic prophylaxis. To minimize the risk of wound infection and for prompt recognition of risk factors, surgeons managing oral tumor patients should have a better understanding of the risk factors such as gender, tumor localization and type of reconstruction.

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Antibiotic prophylaxis in clean-contaminated head and neck oncological surgery

Summary

Background

Objective

Patients and methods

Results

Conclusion

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusion

Am J Surg

Am J Infect Control

J Am Coll Surg

Br J Plast Surg

Pseudomonas aeruginosa infections in cancer patients: have they gone away?

Curr Opin Infect Dis

Extended-spectrum beta-lactamases in the 21st century: characterization, epidemiology and detection of this important resistance threat

Clin Microbiol Rev

Antibiotic prophylaxis in head and neck oncologic surgery: the role of Gram-negative coverage

Int J Antimicrob Agents

Bacteriologic profile of surgical infection after antibiotic prophylaxis

Head Neck

A predictive model for wound sepsis in oncologic surgery of the head and neck

Otolaryngol Head Neck Surg

Empiric therapy for pneumonia in the surgical intensive care unit

Am J Surg

AJCC Cancer Staging Handbook

Risk factors for complications in clean-contaminated head and neck surgical procedures

Head Neck

An assessment of the need for Gram-negative bacterial coverage in antibiotic prophylaxis for oncological head and neck surgery

J Infect Dis

Comparison of ampicillin/sulbactam versus clindamycin in the prevention of infection in patients undergoing head and neck surgery

Head Neck

Postoperative infections and antimicrobial prophylaxis