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ONE DAY VERSUS FIVE DAY REGIMEN OF POSTOPERATIVE ANTIBIOTICS IN THE MANAGEMENT OF FACIAL FRACTURES

Raichoor Anil Kumar1

1Professorand HOD (Maxillofacial Surgery), Department of Dentistry, Lt. BRKM Government Medical College, Jagdalpur.

ABSTRACT

BACKGROUND

Appropriate antibiotic regimensfor prevention of infection in open fractures of the facial region are controversial. Although, many randomised and retrospective studies have been performed to evaluate the effect of antibiotic prophylaxis, unfortunately important information is lacking regarding the type, duration, dosage, route of administration, and the time between injury and definitive treatment.

AIM

The main aim of this study is to evaluate and compare the efficacy of one day versus five day regimens of postsurgical antibiotics in the management of open facial fractures.

SETTING AND DESIGN

The participants were randomly divided into Group A (35) and Group B (35) based on the duration of receiving postoperative antibiotics. Group A patients received antibiotics for not more than 24 hours postsurgically whereas Group B patients received antibiotics for 5 days postoperatively. Patients in both groups were followed up at 7th, 14th, and 21 days postsurgery and any patient having signs of infection such as pus discharge and fever were counted as infected.

METHODS AND MATERIAL

70 patients with open facial fractures requiring open reduction and internal fixation were enrolled for this study. Written and informed consent was taken from the patients regarding the purpose of this study and also the risks involved.

STATISTICAL ANALYSIS

Chi-square test was applied for comparing categorical variables and student unpaired t test was used to analyse the duration between injury and surgery (In days).

RESULTS

Postoperative infection rate in Group A was seen in two patients and in one patient in Group B, which was found to be statistically not significant at 0.5 value. In adverse habits, smoking was found to be significant at 0.01.

CONCLUSION

Preoperative and intraoperative prophylactic antibiotics have proven to be efficacious in lowering infection rates postoperatively, but there is no added advantage if they are continued for more than 24 hours. In the surgical management of open facial fractures, use of postoperative antibiotics does not have a statistically significant effect on postoperative infection rates.

KEYWORDS

Antibiotic Prophylaxis, Ceftriaxone, Open Facial Fractures, Infection.

HOW TO CITE THIS ARTICLE:Kumar RA.One day versus five day regimen of postoperative antibiotics in the management of facial fractures. J.Evolution Med. Dent. Sci. 2016;5(56):3814-3817, DOI: 10.14260/jemds/2016/873

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INTRODUCTION

Head and neck surgeons commonly treat facial fractures and open fractures of the facial region constitute a major source of morbidity in adult trauma.1 Apart from open reduction and internal fixation (ORIF) of facial fractures, antibiotics are an adjunctive, but important component of standard therapy. Wound infection is a serious complication associated with open fractures of the face; however, the role of prophylactic

Financial or Other, Competing Interest: None.

Submission 20-06-2016, Peer Review 05-07-2016,

Acceptance 07-07-2016, Published 12-07-2016.

Corresponding Author:

Dr. Raichoor Anil Kumar,

Quarters No. 9, Type V,

Lt. BRKM Government Medical College Campus,

Dimradal, Jagdalpur-494001, Chhattisgarh.

E-mail:

DOI: 10.14260/jemds/2016/873

antibiotics remains controversial.2 In an era of increased antibiotic resistance and to reduce healthcare costs attributable to infections, it is important to prevent postsurgical complications, especially infections. Till date, no protocol exists for the duration of prophylactic antibiotics following surgery. Apart from selection of the most-effective antibiotics, the duration of postsurgical antibiotics administration is also one of the most important factor that has to be considered.

METHODS

70 patients with maxillofacial trauma diagnosed clinically and radiographically suffering from open maxillofacial fractures requiring ORIF were enrolled for this study. Written and signed consent was taken from all the subjects. They were also informed about the purpose of the study and the risks involved. All the patients agreed for postoperative follow up on the 7th, 14th, and 21st days.

Inclusion Criteria

  1. Patients with open maxillofacial fractures who were required to be treated by ORIF.
  2. Patients who came under ASA I and ASA II status.
  3. Patients in the age group between 18-40 years.

Exclusion Criteria

  1. Patients who were on intravenous antibiotics for more than 2-3 days prior to surgery.
  2. Patients with polytrauma.
  3. Patients with grossly contaminated facial fractures.

Study Design

70 patients who were enrolled for this study were randomly divided into Group A (35) and Group B (35) based on the duration (one day or five days) of postoperative antibiotics. Patients in Group A received intravenous ceftriaxone 1 gm 12 hourly and intravenous metronidazole 100 mL every 8th hourly for not more than 24 hours postoperatively. Group B patients also received intravenous ceftriaxone 1 gm 12 hourly and intravenous metronidazole 100 mL every 8th hourly for 5 days postoperatively. Both groups of patients were administered with intravenous ceftriaxone 1 gm and intravenous metronidazole 100 mL on the day of surgery. All the patients also received parenteral dexamethasone 8mg intraoperatively and anti-inflammatory drugs in the postoperative period. The treatment modality that was used in open facial fractures was open reduction and internal fixation using non-rigid stainless steel mini plates and screws and Erich arch bar wherever indicated. All the patients were advised Betadine mouthwash oral rinse in pre and postoperative period. In both the groups, all the patients were followed up on the 7th, 14th, and 21st day respectively and the findings were recorded in a self-designed format.

Criteria to Assess Infection

The operative site was classified as infected if there were any signs and symptoms of purulent discharge from the surgical site and evidence of localized infection within three weeks in the postsurgical period. If there was any evidence of infection, the patient was treated with empirical antibiotics. Data on other related variables was also collected from all the patients like:

  • Fracture location.
  • Adverse habits like smoking, alcohol consumption, and tobacco chewing.
  • Oral hygiene status was assessed and categorized as good, average, and poor.
  • Tooth in fracture line.
  • Duration between injury and surgery in days.

Statistical Procedures

Chi-square test was done for non-parametric parameters and student unpaired t test was used to analyse the duration between injury and surgery (In days).

Ethics

All the procedures followed were in accordance with the ethical standards of the responsible ethical committee and with the Helsinki Declaration of 1975, revised in 2000.

RESULTS

70 patients age ranging for 18-40 years participated in this study. Of these, 67 were male and 3 were female patients. In Group A, the mean age was 26.2 years with a standard Deviation (SD) of 5.7 and in Group B the mean was 24.7 years with a standard deviation of 4.9.

Postoperative infection rate in Group A was seen in two patients and in one patient in Group B, which was found to be statistically not significant at 0.5 value (Table I). For both the groups, parameters like fracture location and tooth in fracture line were also found to be not significant statistically. The results were expressed in percentile (%) and p value was considered significant at 5% level.

In adverse habits, smoking was found to be significant at 0.01. The likelihood ratio was also calculated for all the parameters. Oral hygiene was considered not significant statistically for both the groups at 0.45 with likelihood ratio of 1.59.

Duration between injury and surgery in days was analysed by using student unpaired t test. In Group A for Zygomatico-Maxillary Complex (ZMC) fractures, the mean was found to be 0.77 with a SD of 1.33. For mandibular fractures, the mean was 1.20 with a SD of 0.99 and for combination fractures, the mean was 0.43 with a SD of 1.07 respectively. In Group B for ZMC fractures, the mean was found to be 0.91 with a SD of 1.01; for mandible fractures, the mean was 0.86 with a SD of 1.00; and for combination fractures, the mean was 0.34 with a SD of 0.97 respectively. The p value was found to be non-significant at 5% level for both the groups.

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Variables / Group-A
(n=35) / Group-B
(n=35) / Likelihood Ratio / Significant
Groups at 5% Level
Yes / No / % / Yes / No / %
Postop
Infection Rate / 2 / 33 / 94.2 % / 01 / 34 / 97.14% / 0.35 / NS 0.5
Fracture Location / ZMC / 10 / 25 / 71.4% / 16 / 19 / 54.2% / 2.21 / NS 0.13
Mandible / 20 / 15 / 42.8% / 15 / 20 / 57.1% / 1.43 / NS 0.23
Combination / 05 / 30 / 85.7% / 04 / 31 / 88.57% / 0.12 / NS 0.72
Tooth in
Fracture line / 26 / 09 / 25.7% / 24 / 11 / 31.4% / 0.28 / NS 0.59
Adverse
Habits / Smoking / 10 / 25 / 71.42% / 02 / 33 / 94.2% / 6.92 / Sig 0.01
Alcohol / 05 / 30 / 85.7% / 08 / 27 / 77.1% / 0.85 / NS 0.35
Tobacco / 20 / 15 / 42.8% / 25 / 10 / 28.5% / 1.56 / NS 0.21
Table 1: Comparison of Group A and Group B with Variables like Post-operative Infection, Fracture Location,
Tooth in Fracture Line and Adverse Habits

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Note: Results are expressed as percentile (%). P value is considered significant at 5% level. NS: Non-Significant. Sig: Significant. ZMC: Zygomaticomaxillary complex.

DISCUSSION

Open facial fractures can span a range of wound classifications including clean (Class I), clean contaminated (class II), contaminated (class III), and dirty/infected (Class IV). Most of the surgical procedures for the management of facial fractures or transoral surgery are considered to be in clean contaminates (Class II). However, the basic principle of antibiotic prophylaxis cannot be adhered to if antibiotics are administered before any bacterial contamination occurs in facial fractures. In fact, this raises a serious issue whether or not prophylactic antibiotic administration in these patients is justified. As a result, there is widespread variability in the type and duration of prophylactic antibiotic use.3,4 Not many studies have been conducted to compare the efficacy and cost effectiveness of ceftriaxone as prophylactic antibiotic in the management of open facial fractures.5

Apart from choosing the right type of antibiotic for prophylaxis, the other most important principle is to obtain maximum concentration of the drug in blood and tissue at the time of anticipated bacterial contamination of the wound.

Studies have proven that for short procedures.A single dose of antibiotic preoperatively is sufficient to prevent wound infections and for longer procedures apart from intraoperative doses. Asingle postoperative dose is sufficient for maximum infection control.6 In this study, the postoperative infection rates had a p value, which was statistically not significant suggesting that prophylactic antibiotics do not have a significant role in the surgical management of open facial fractures, which is consistent with other similar studies.7,8,9,10

Adverse habits such as smoking tobacco have a potential role to alter the immune system and homeostasis causing alterations that effect recovery in the postsurgical phase. Trauma patients who have habit of smoking tobacco could contribute to postsurgical complications. In this study, it was a significant finding that patients who had this adverse habit developed more infection when compared to the patients who did not smoke.11,12,13

Duration or time between injury and definitive treatment also contribute to developing infection. The mean duration between time of injury and surgery in this study was 0.77 to 1.20 days. One of the main reason that can be attributed to delayed treatment is improper diagnosis by other non-specialist clinicians and also patients often present with other systemic injuries that merit more consideration than treatment of facial fractures. Delay in treatment can also be attributed to developing postoperative infection. It was observed in this study that the patients were operated upon within three days of injury, which could be the reason to the low incidence of postoperative infection.14,15

Management of tooth in the fracture line is controversial. Of the 70 patients in this study, 50 patients had tooth in the line of fracture. Studies have shown that the tooth in the fracture line can act as a portal of infection and if the tooth is mobile, carious, or has periodontal or periapical pathology, it should be extracted.16,17 All those teeth which were mobile or interfered with fracture reduction were extracted in this study.

One of the main limitations to this study was that the sample size was not large enough to detect differences in infection rates between the two groups necessary to reach statistical significance.

CONCLUSION

Preoperative and intraoperative prophylactic antibiotics have proven to be efficacious in lowering infection rates postoperatively, but there is no added advantage if they are continued for more than 24 hours. In the surgical management of open facial fractures, use of postoperative antibiotics does not have a statistically significant effect on postoperative infection rates.

ACKNOWLEDGMENTS

I would like to sincerely thank Dr. Rama Krishna Ph.D. for his expert opinion on the statistical analysis for this study.

REFERENCES

  1. Rodriguez L, Jung HS, Goulet JA, et al. Evidence-based protocol for prophylactic antibiotics in openfractures: Improved antibiotic stewardship with no increase in infection rates. J Trauma Acute Care Surg 2013;77(3):400-8.
  2. Lisa MM, Robert MK. Are prophylactic antibiotics useful in the management of facial fractures? Laryngoscope 2014;124(6):1282-4.
  3. Andreasen JO, Jensen SS, Schwartz O, et al. A systematic review of prophylactic antibiotics in the surgical treatment of maxillofacial fractures. J of Oral MaxilloFac Surg 2006;64(11):1664-8.
  4. Kyzas PA. Use of antibiotics in the treatment of mandible fractures: a systemic review. J Oral Maxillofac Surg 2011;69(4):1129-45.
  5. James MH, Mark RS, Keith J. Comparison of ceftriaxone with penicillin for antibiotic prophylaxis for compound mandible fractures. Oral Surg Oral Med Oral Path and Oral Radiol 1997;83(4):423-6.
  6. Stone IE, Dodson TB, Bays RA. Risk factors for infection following operative treatment of mandibular fractures - a multivariate analysis. PlastReconstr Surg 1993;91(1): 64-8.
  7. Miles BA, Potter JK, Ellis E. The efficacy of postoperative antibiotic regimens in the open treatment of mandibular fractures: a prospective randomized trial. J Oral Maxillofac Surg 2006;64(4):576-82.
  8. Lovato C, Wagner JD. Infection rates following perioperative prophylactic antibiotics versus postoperative extended regimen prophylactic antibiotics in surgical management of mandibular fractures. J Oral Maxillofac Surg 2009;67(4):827-32.
  9. Iizuka T, Lindqvist C, Hallikeinen D, et al. Infection after rigid internal fixation of mandibular fractures: a clinical and radiologic study. J Oral Maxillofac Surg 1991;49(6):585-93.
  10. Gordan PE, Lawler ME, Kaban LB, et al. Mandibular fracture severity and patient health status are associated with postoperative inflammatory complications. J Oral Maxillofac Surg 2011;69(8):2191-7.
  11. Passeri LA, Ellis E, Sinn DP. Relation of substance abuse to complications with mandibular fractures. J Oral Maxillofac Surg 1993;51(1):22-5.
  12. Furr AM, Schweinfurth JM, May WL. Factors associated with long-term complications after repair of mandibular fractures. Laryngoscope 2006;116(3):427-30.
  13. Serena GE, Passeri LA. Complications of mandibular fractures related to substance abuse. J Oral Maxillofac Surg 2008;66(10):2028-34.
  14. Webb LS, Makhijani S, Khanna M, et al. A comparison of outcomes between immediate and delayed repair of mandibular fractures. Can J Plast Surg 2009;17(4):124-6.
  1. Maloney PL, Lincoln RE, Coyne CP. A protocol for the management of compound mandibular fractures based on the time from injury to treatment. J Oral Maxillofac Surg 2001;59(8):879-84.
  2. Shetty V, Freymuller R. Teeth in fracture line. J Oral Maxillofac Surg 1989;47:1303.
  3. Kamboozia AH, Poonia MA. The fate of teeth in mandibular fracture lines. A clinical and radiographic follow up study. Int J Oral Maxillofac Surg 1993;22(2): 97-101.

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