A Systematic Review of Prophylactic Antibiotics in the Surgical Treatment of Maxillofacial Fractures

doi:10.1016/j.joms.2006.02.032

Journal of Oral and Maxillofacial Surgery

Volume 64, Issue 11, November 2006, Pages 1664-1668

https://doi.org/10.1016/j.joms.2006.02.032 Get rights and content

Purpose

A systematic review was performed to find evidence for prophylactic administration of antibiotics in relation to treatment of maxillofacial fractures.

Methods

Four studies were retrieved that fulfilled most of the requirements of being randomized controlled clinical trials.

Results

An analysis of these studies showed a 3-fold decrease in the infection rate of mandibular fractures in the antibiotic treated groups compared with the control groups. A variety of antibiotics had been used with an apparently uniform effect. A “1-shot” regimen or a 1-day treatment course had a similar or perhaps even better effect than 7 days of treatment. No infections were related to condylar, maxillary, or zygoma fractures.

Conclusion

A 1-shot or 1-day administration of prophylactic antibiotics seem to be the best documented to reduce infections in the management of mandibular fractures not involving the condylar region.

Section snippets

Analysis of the literature

The databases MEDLINE and Cochrane were searched for relevant studies, using the following key words: jaw fractures, mandibular fractures, maxillary fractures, antibiotic treatment, infection, and randomized studies. This search was supplemented by a hand search of relevant German journals not electronically listed and by a review of reference lists of potentially eligible studies.

For each retrieved study, the following questions were asked (Table 1):

1
Were the patients randomly allocated to the

Results

Four randomized studies8, 12, 13, 14 were retrieved concerning the possible benefit of prophylactic antibiotics in the treatment of maxillofacial fractures. Two clinical randomized studies were found that compared different antibiotic regimens without including a control group.15, 16 A critical analysis of these showed that none of them fulfilled all the requirements for a randomized controlled trial. The shortcomings of the studies are presented in Table 1. However, as these studies represent

Discussion

In maxillofacial fracture treatment a multitude of external sources exist for contamination of the wound. In this aspect the fracture can, in most cases, be considered contaminated, implying an elevated risk of infection.¹⁷

From this perusal of the literature, it appears strongly indicated to use a short-term antibiotic coverage to decrease the infection rate in relation to the treatment of compound mandibular fractures. Approximately a 4-fold reduction in the number of infections was found. It

References (25)

L. Peterson
Antibiotic prophylaxis against wound infection in oral and maxillofacial surgery
J Oral Maxillofac Surg
(1990)
J.M. Heit et al.
Comparison of ceftriaxone with penicillin for antibiotic prophylaxis for compound mandible fractures
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(1997)
A.O. Abubaker et al.
Postoperative antibiotic prophylaxis in mandibular fractures: A preliminary randomized, double-blind, and placebo-controlled clinical Study
J Oral Maxillofac Surg
(2001)
W.R. Sandusky
Use of prophylactic antibiotics in surgical patients
Surg Clin North Am
(1980)
S.A. Zijderveld et al.
Preoperative antibiotic prophylaxis in orthognathic surgery: A randomized, double-blind, and placebo-controlled clinical study
J Oral Maxillofac Surg
(1999)
R.H. Haug et al.
Infection in the maxillofacial trauma patient
G.W. Chodak et al.
Use of systemic antibiotics for prophylaxis in surgeryA critical review
Arch Surg
(1977)
H.H. Stone et al.
Prophylactic and preventive antibiotic therapyTiming, duration and economics
Ann Surg
(1979)
B.J. Guiglimo et al.
Antibiotic prophylaxis in surgical procedures: A critical analysis of the literature
Arch Surg
(1983)
A.B. Kaiser
Medical intelligenceDrug Therapy. Antimicrobial prophylaxis in surgery
N Engl J Med
(1986)

J.A. Paterson et al.

An examination of antibiotic prophylaxis in oral and maxillofacial surgery

J Oral Surg

(1970)

R.A. Chole et al.

Antibiotic prophylaxis for facial fractures

Arch Otolaryngol Head Neck Surg

(1987)

Cited by (102)

Pediatric Craniomaxillofacial Fractures: A Review
2024, Facial Plastic Surgery Clinics of North America
Complications of Mandibular Fracture Repair
2023, Otolaryngologic Clinics of North America
Do Antibiotics Prevent Infectious Complications in Critically Injured Patients With Blunt Nonoperative Midfacial Trauma?
2023, Journal of Oral and Maxillofacial Surgery
While recent literature suggests antibiotics are not needed in patients with nonoperative facial fractures involving sinuses, the existing studies do not focus on critically injured patients who are known to be at higher risk for sinusitis and ventilator-associated pneumonia, which could be exacerbated by facial fractures.
The purpose of this study was to determine if antibiotics reduce the rate of infectious complications in critically injured patients who have blunt midfacial trauma treated nonoperatively.
The authors conducted a retrospective cohort study consisting of patients admitted to the trauma intensive care unit who sustained blunt midfacial injuries managed nonoperatively at an urban Level 1 trauma center from August 13th, 2012, to July 30th, 2020. Adults who were critically injured on admission and sustained a midfacial fracture involving a sinus were included in the study. Patients who underwent operative repair of any facial fracture were excluded.
The predictor variable was the use of antibiotics.
The primary outcome variable was the development of infectious complications, such as sinusitis, soft tissue infection, or any type of pneumonia, including ventilator-associated pneumonia (VAP).
The data were analyzed using Wilcoxon rank sum tests, Fisher exact tests, and multivariable logistic regression as appropriate for analysis type with significance level set at <0.05.
The study included 307 patients, with a mean age of 40.6 years. Men accounted for 85.0% of the study population. Antibiotics were administered to 229 (74.6%) of the study population. Complications developed in 13.6% of the patients, which included sinusitis (0.3%), VAP (7.5%), and other types of pneumonia (5.9%). Clostridioides difficile colitis developed in 2 patients (0.6%). Antibiotics were not associated with a decrease in infectious complications in either the unadjusted analysis (13.1% in antibiotic group, 15.4% in no antibiotic group, RR = 0.85 [95% confidence interval = 0.5 to 1.6], P = .7) or the adjusted analysis (odds ratio 0.74 [0.34 to 1.62]).
Even in this critically injured patient population thought to be at elevated risk for infectious complications from their midfacial fractures, the rates of infectious complications in those who received antibiotics and those who did not were no different. These results suggest that consideration of more judicious use of antibiotics is warranted in critically ill patients with nonoperative midface fractures.
Measuring Adherence to Antibiotic Use Guidelines in Managing Mandible Fractures
2023, Journal of Oral and Maxillofacial Surgery
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.
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.
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).
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.
Necessity of antibiotics in the management of surgically treated mandibular osteomyelitis: A systematic review
2023, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Mandibular osteomyelitis remains an incompletely understood entity, and treatment of its various presentations remains diverse. The purpose of this study was to review the necessity of antibiotic therapy after surgical treatment of mandibular osteomyelitis.
A systematic review of published articles on surgical management of mandibular osteomyelitis with or without postoperative antibiotic therapy was performed to answer the question, “Does the use of postoperative antibiotics compared with surgery alone alter the success rate in treating mandibular osteomyelitis?” The most recent evidence was sought by searching PubMed, Embase, and Scopus databases. Article appraisal was performed by 2 reviewers.
Forty-five articles were found that met the inclusion criteria, with all studies being retrospective cohort or case series designs. Only 13 articles used Zurich classification designations of acute osteomyelitis, secondary chronic osteomyelitis, or primary chronic osteomyelitis, and the general heterogeneity of these articles made comparison difficult. No study made an intentional statistical assessment of various antibiotic protocols.
Limited evidence suggested that resection may have better success rates than other forms of surgical intervention, regardless of antibiotic therapy. This systematic review questions the perceived necessity of intermediate- or long-term antibiotic therapy in the management of mandibular osteomyelitis after surgical resection.
Use of antibiotics in traumatic mandibular fractures: a systematic review and meta-analysis
2021, British Journal of Oral and Maxillofacial Surgery
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.

View all citing articles on Scopus

View full text

Current therapyA Systematic Review of Prophylactic Antibiotics in the Surgical Treatment of Maxillofacial Fractures

Purpose

Methods

Results

Conclusion

Section snippets

Analysis of the literature

Results

Discussion

J Oral Maxillofac Surg

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Oral Maxillofac Surg

Surg Clin North Am

J Oral Maxillofac Surg

Infection in the maxillofacial trauma patient

Use of systemic antibiotics for prophylaxis in surgeryA critical review

Arch Surg

Prophylactic and preventive antibiotic therapyTiming, duration and economics

Ann Surg

Antibiotic prophylaxis in surgical procedures: A critical analysis of the literature

Arch Surg

Medical intelligenceDrug Therapy. Antimicrobial prophylaxis in surgery

N Engl J Med

An examination of antibiotic prophylaxis in oral and maxillofacial surgery

J Oral Surg

Antibiotic prophylaxis for facial fractures

Arch Otolaryngol Head Neck Surg

Current therapy
A Systematic Review of Prophylactic Antibiotics in the Surgical Treatment of Maxillofacial Fractures