Prospective comparison of perioperative antibiotic management protocols in oncological head and neck surgery

https://doi.org/10.1016/j.jcms.2017.04.001Get rights and content

Abstract

Objectives

The adequate perioperative antibiotic prophylaxis in head and neck cancer surgery is an important and easy applicable tool to decrease nosocomial morbidity and mortality by reducing the rate of infections. In the study a strictly perioperative antibiosis is compared with an extended postoperative prophylactic antibiosis. We aim to clarify the value of postoperative prophylactic antibiosis for the recovery and clinical course of patients.

Material and methods

In this prospective study 75 consecutive patients, who underwent major oncological head and neck surgery were included and divided in three groups, each containing 25 patients. The first group received peri- and postoperative antibiotic prophylaxis (POAP) from the day of operation until the fifth day postoperatively. The second group was treated with perioperative antibiotic prophylaxis (PEAP) only. The third group received perioperative antibiotic prophylaxis and increased local antiseptic care (PAPAC). General anamnestic data was collected, as well as duration of hospitalisation, stay on intensive care unit, rate and type of infections, surgical closure of the tracheostomy, and postoperative blood parameters.

Results

There were no statistically significant differences in general diseases or extent of surgery between the groups. There were statistically significant fewer patients suffering from surgical site infections in subjects with POAP (n = 1) in comparison to PEAP (n = 9; p = 0.011) and PAPAC (n = 9; p = 0.011). In contrast, other nosocomial infections (pneumonia, urinary tract infection, sepsis) did not decrease under a prolonged antibiotic prophylaxis.

Conclusion

Based on findings of the study, we recommend an extended postoperative antibiotic prophylaxis for patients undergoing major oncological head and neck surgery.

Introduction

Major head and neck oncological surgery is an essential part of maxillofacial surgery, but patients are prone to higher levels of medical and surgical morbidity and increased risk of complications. They are not only described intraoperatively, but also postoperatively, which can lead to an increased risk of morbidity and mortality as well as prolonged hospitalisation, with consequently higher expenses. Nosocomial infections are particularly known to lead to a protracted clinical course. Therefore, hygienic standards and anti-infective measures are crucial for uneventful recovery of patients (Lee et al., 2011, Li et al., 2016).

Head and neck cancer patients in particular are at high risk of developing postoperative infections due to large wound areas, prolonged operation time, existing underlying general comorbidities and postoperative immobilisation. The necessities of tumour resection, neck dissection, tracheotomy and additional donor site morbidity caused by microvascular free flaps in head and neck cancer patients lead to the development of multiple wound areas with diverse local flora and, subsequently, a high potential for surgical wound contamination and infection. The above-mentioned procedures are routinely performed in head and neck cancer surgery; therefore, appropriate anti-infective therapy and antibiotic prophylaxis are essential measures in the postoperative course, and have a high impact on treatment outcomes (Kucur et al., 2015).

A prophylactic antibiotic regimen during surgical procedures is a well-established and frequently implemented practice (Ariyan et al., 2015, Marquet et al., 2015, Nelson et al., 2009). Current studies from various surgical specialities suggest no significant difference between the administration of only intraoperative antibiotic dosages or short (less than 24 h) postoperative prophylactic antibiotic regimens and a prolonged (more than 24 h) postoperative antibiotic prophylaxis (Ariyan et al., 2015, Ren and Malmstrom, 2007, Zhang et al., 2014). However, in head and neck oncology there is still discussion on whether intra-, peri- or postoperative prophylactic antibiotics are adequate to decrease the incidence of wound infections, and there is a broad range of suggested durations for antibiotic prophylaxis. Some authors advise a 3–5 day administration of prophylactic antibiotics postoperatively, whereas others describe a strict intraoperative administration of antibiotics and re-administration of the antibiotics only in case of any clinical signs or symptoms of infection (Garnier et al., 2013, Zhang et al., 2014).

The aim of the restricted usage of antibiotics is to avoid over-treatment and to prevent the development of antibiotic-resistant bacterial strains. According to the American Center for Disease Control and prevention (CDC), up to 50% of all administered antibiotics are inappropriate or unnecessary (www.cdc.gov, 2015). Triggering bacterial resistance by selecting the wrong antibiotic, or causing direct side-effects as a result of the treatment are possible drawbacks of a prolonged duration of antibiotic prophylaxis. Adverse effects range from mild symptoms, like rash or itch, to severe diseases like pseudomembranous colitis (Richardson and Hammert, 2014). The latter microbiological pathology has an incidence of 8–12 in 100,000 persons and can lead to a fulminant clinical course in 1–8% of patients (Riddle and Dubberke, 2009).

Since the optimal peri- and postoperative antibiotic prophylaxis is still under discussion, easy to apply, and has a great impact on the clinical course, we aim to shed light on this important objective by prospectively comparing three distinct types of peri- and postoperative antibiotic therapy regimen. We have set a prolonged postoperative antibiotic prophylaxis as a standard protocol and hypothesized a decrease of postoperative infections when compared with strictly intraoperative antibiosis. Thus, it was compared with a strictly intraoperative administration of prophylactic antibiotics with and without increased utilisation of local antiseptic measures and an elaborate operative site cleaning protocol postoperatively.

Section snippets

Material and methods

This study was conducted in accordance with our local ethical committee (EK 36-915).

In this study we compared three distinct perioperative antibiotic prophylactic regimens in patients undergoing major head and neck cancer surgery. All patients were suffering from squamous cell carcinoma.

The subjects of the first group were exposed to a combined peri- and postoperative antibiotic prophylaxis, which was administered until the fifth postoperative day (postoperative antibiotic prophylaxis = POAP).

Results

Preoperative data show that there were no significant differences in age, gender, ASA classification, and laboratory values (CRP, Leu, Hb) between patients who received POAP, PEAP, or PAPAC treatment regimes, as can be seen in Table 1. The duration of the surgical procedure also did not show any significant differences between the groups (Table 1).

There was an overall flap-failure rate of 4% (n = 3). One flap failed in the POAP group, two in PAPAC, and none in PEAP.

The overall rate of

Discussion

Onset and length of antibiotic prophylaxis should always be well considered in patients undergoing major surgery, especially in those with compromised general condition and extended operations. Side-effects and ineffective use of antibiotics can undermine arguments for utilising perioperative antibiotic prophylaxis, sometimes with questionable advantages. In a meta-analysis including 15,306 patients, Marquet et al. report an inappropriate use of antibiotics in 14.1%–78.9% of the cases, leading

Conclusion

Our data showed a significant decrease in surgical site infections in major head and neck cancer surgery by application of a postoperative antibiotic prophylaxis regimen. We thus recommend postoperative antibiotic prophylaxis. For additional evaluation, especially of the duration of the postoperative application, further studies with higher patient numbers will be needed.

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