Antibiotics and maxillofacial fractures

1. ORIGINAL ARTICLE
Prophylactic Antibiotics in Maxillofacial
Fractures: A Requisite?
S. Adalarasan, MDS, Alexander Mohan, MDS, MOMSRCPS(Glasgow),
and Sanjay Pasupathy, MDS, DNB, MOMSRCPS(Glasgow)
Abstract: The role of prophylactic antibiotics to prevent surgical
wound infection (SWI) in the management of maxillofacial fractures
is controversial. We carried out a retrospective study in 67 patients
with 114 maxillofacial fractures, of which 9 patients each were in
group 1 (no antibiotic) and group 3 (cefotaxime) and 49 in group 2
(penicillin). We had an overall SWI rate of 16.66%, of which 3 of
group 1 (33.33%), 12 of group 2 (24.48%), and 2 of group 3 (22.22%)
constituted the SWIs. Statistical analysis showed no significant dif-ference
between the infection rates. A strong positive correlation was
found between infection rate and the delay in treatment, and a similar
correlation was found in the use of catgut and SWI. Our study sug-gests
that prophylactic antibiotic therapy may not alter the incidence
of surgical wound infection.
Key Words: Prophylactic antibiotics, maxillofacial fractures,
penicillin, maxilla, mandible
(J Craniofac Surg 2010;21: 1009Y1011)
Management of facial fractures is an important component of
the practice of maxillofacial surgery. With the advent of im-proved
armamentarium, open reductionYinternal fixation has gained
increased popularity. As with any other surgical procedure, infection
is one of the major factors complicating the healing process.
Antibiotics have been used not only in the management of
postsurgical infections, but also prophylactically to prevent them.
With the scare of antibiotic resistance, the use of antibiotics for pre-vention
of infections needs to be reviewed.
In this context, a retrospective study was carried out to evaluate
the necessity of routine antibiotic administration for prevention of
infections in the management of patients with maxillofacial fractures.
MATERIALS AND METHODS
Patients who visited the department of maxillofacial surgery
in our institution for the management of maxillofacial fractures
between April 2002 and February 2005 were included in the study.
Patients, irrespective of sex, with maxillofacial fractures re-quiring
surgical treatment and patients who were willing to give
informed consent were included in the study. Patients with pre-existing
infections at the site of fracture, medically compromised
patients, patients allergic to penicillin and cephalosporin group of
drugs, and patients with a history of antibiotic intake during the
preceding 30 days were excluded.
Patients were divided into 3 groups as follows:
& group 1: Control group (no antibiotic group),
& group 2: crystalline penicillin 2 million units intravenously 30 min
before surgery, or
& group 3: cefotaxime 2 g intravenously 30 minutes before surgery.
A total of 67 patients who fulfilled the previously mentioned
criteria were included in the study. Of these, 9 patients were in group
1, 49 in group 2, and 9 in group 3.
Surgical procedures were performed under general anesthe-sia.
The surgical site was thoroughly prepared with povidone-iodine,
and all universal aseptic measures were adhered to. Access to the
surgical site was obtained intraorally, extraorally, or both, depending
on the type and site of fracture. Open reductionYinternal fixation
using miniplates was done in all the cases. The number of miniplates
differed according to site of fracture and the adequacy of fixation.
RESULTS
The mean age in the study group was 33.4 years, ranging
from 14 to 72 years. There were 62 males and 5 females in the study.
A total of 38 patients had multiple fractures, whereas the remaining
patients had fracture at a single site only, resulting in a total of 114
fractures. The distribution of fractures and the postoperative infec-tion
rates in the corresponding sites are shown in Figure 1. The eti-ology
of the fractures and their distribution are shown in Figure 2.
Of the 114 fractures, 19 developed surgical wound infection
(SWI), resulting in an overall infection rate of 16.66%. The age-wise
distribution of fractures and the corresponding infection rates are
shown in Figure 3.
Three patients of group 1 (33.33%), 14 of group 2 (24.48%),
and 2 (22.22%) of group 3 were diagnosed with SWI. Although all
the cases of SWI in groups 1 and 3 contained multiple fractures, only
9 of 14 patients in group 2 had multiple fractures. Except for 2 pa-tients
in group 2 inwhomboth the fractureswere infected, all the others
had only a single fracture site infected.
With the exception of one, all the other 18 infected patients
had an average delay in treatment of 6 or more days (5Y15 days). The
overall delay in treatment averages around 3.94 days (2Y15 days) for
all the 67 cases. This delay in treatment could be attributed to delay
in referral from other hospitals. Approximately 39% patients in-cluded
in the study had a period of delay of more than 4 days. A
positive correlation (r = 0.44) between the delay in treatment and
infection was observed.
Of the 67 patients, an extraoral incision was required in 16,
intraoral incisions in 15, and a combined approach in 36 patients. Of
the 16 patients requiring extraoral approach, 3 patients (18.75%) had
SWI, whereas only 2 (13.33%) of the 15 patients needing intraoral
From Sri Manakula Vinayagar Medical College and Hospital, Pondicherry,
India.
Received December 16, 2009.
Accepted for publication January 24, 2010.
Address correspondence and reprint requests to Sanjay Pasupathy, MDS,
DNB, MOMSRCPS(Glasgow), No. 16, Cannon St, Priyadarshini Nagar,
Gorimedu, Pondicherry, India 605006; E-mail: sanjaypasupathy@
yahoo.co.in
The authors report no conflict of interest.
Copyright * 2010 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e3181e47d43
The Journal of Craniofacial Surgery & Volume 21, Number 4, July 2010 1009
Copyright © 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

2. Adalarasan et al The Journal of Craniofacial Surgery & Volume 21, Number 4, July 2010
incisions developed SWI. Twelve (33.33%) of 36 patients in whom
acombined approach was required developed SWI. Of these 12,
both incisions were infected in 2 patients (16.66%), whereas intraoral
incisions alone were infected in 7 patients (58.33%), and extraoral
incisions alone were infected in the remaining 3 patients (25%).
In a majority of patients with SWI (10/19), the duration of
surgery were more than 90 minutes, ranging from 50 to 200 minutes.
Also, no correlation was found between number of miniplates and
screws used and SWI.
In 7 (41.18%) of 19 patients with SWI, catgut sutures
were used for wound closure. There is a positive correlation (r = 1)
between the use of catgut suture material and infection in the sur-gical
site.
In the management of SWI, 9 patients required deliberate
opening of the incision by the surgeon to evacuate pus and were
prescribed concomitant antibiotic therapy. Seven patients needed
antibiotic therapy alone. Only one required readmission for incision
and drainage.
Statistical analysis was done with Pearson W2 test. The infection
rates in all the 3 groups were found to be not statistically significant
(the P values for groups 1, 2, and 3 were 0.71, 0.85, and 0.43, re-spectively),
and also, intergroup evaluation did not reveal any statis-tical
significance.
DISCUSSION
The use of antibiotics in the management of maxillofacial
fractures is widespread with questionable rationale. Antibiotics have
been used preoperatively to decrease the risk of SWI, but its role in
preventing infection has not been evaluated properly. The main goals
of antibiotic prophylaxis are to reduce incidence of SWI and to min-imize
the adverse effect of antibiotics, especially the emergence of
resistant microorganisms.
In his landmark animal study that defined the scientific basis
for prophylaxis, Burke1 clearly demonstrated that the use of post-operative
antibiotics alone actually violates the basic tenets of pro-phylaxis,
as there is no antibiotic either in the systemic circulation or
at the site of surgery when the microorganisms invade the wound.
This has been supported by other research articles in the litera-ture.
2Y5 Hence, use of postoperative antibiotics in the name of pro-phylaxis
seems to have no role in the prevention of SWI.
The criteria to identify SWI have been under a lot of scrutiny
in recent times. Many studies3,4,6,7 have included pain and swelling
as criteria for diagnosing SWI. But these factors are commonly seen
as sequelae of routine inflammatory reaction after any surgical
trauma, and they need not be pure indicators of SWI. Hence, we did
not include these factors in our study for assessing SWI. We in-cluded
systemic increase in temperature and purulent discharge from
wound as the main parameters to diagnose SWI. It is well docu-mented
in literature4,8 that systemic increase in temperature is one of
the reliable indicators of infection, especially on the third postop-erative
day, and the presence of purulent discharge from the wound
within the first month postoperatively will obviously confirm the
presence of SWI.4,8
There are multiple risk factors involved, independent of each
other, which are predictive for subsequent SWI. These factors in-clude
length of preoperative stay in hospital, compromised host
defenses, surgical wound class, and duration of surgery. Garibaldi
et al9 collected prospective epidemiological data, and their analysis
of those data revealed that SWI was related to the length of preop-erative
stay in hospital. A clinical practical evidence-based guide-lines
by the Ministry of Health, Malaysia, suggest that preoperative
stay of more than 3 days is associated with an increased risk of SWI.
But in our institute, we had a standard protocol of admitting the
patients just 1 day before surgery.
Certain medical conditions such as poorly controlled diabe-tes,
AIDS, and so on are said to result in decreased host defenses and
a reduced resistance to infection and a high probability of devel-oping
SWI. But there is no conclusive evidence for compromised
host defenses and increased SWI in literature. Hence, in our study, to
maintain the homogeneity of sample, we excluded patients with
these conditions.
As the overwhelming majority of surgical management of
maxillofacial fractures falls into class 2 (clean contaminated) variety
and all the cases in our study too were class 2 in nature, whether the
routine use of prophylactic antibiotics will fulfill those goals is
controversial. Garibaldi et al9 and Culver et al10 showed that post-operative
wound infection rate was related to the class of surgery.
They also stated that the infection rate associated with class 1 sur-gery
may be sufficiently low as not towarrant the use of prophylactic
antibiotics. The infection rate associated with class 2 surgery,
however, may be high enough to warrant the use of prophylactic
antibiotics. The infection rate in class 2 surgeries varies between 6%
FIGURE 1. Distribution of fractures and the SWI.
FIGURE 2. Etiology of fractures and their distribution.
FIGURE 3. Age-wise distribution of fractures and the
corresponding SWI rates.
1010 * 2010 Mutaz B. Habal, MD
Copyright © 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

3. The Journal of Craniofacial Surgery & Volume 21, Number 4, July 2010 Prophylactic Antibiotics in Maxillofacial Fracture
and 20% in literature. The SWI rate in our study was 16.66%, which
falls well within the SWI range of class 2 surgeries.
The use of preoperative antibiotics for management of max-illofacial
fractures is well documented in literature.4,6,11,12 All these
studies are having wide variance of infection rates, and this may be
attributed to various factors such as patient selection, choice of an-tibiotics,
and so forth. But in our study, the infection rates are much
less (16.66%) compared with those previous studies.
Surgical wound infections in maxillofacial trauma patients
depend on various factors such as the type of fracture, delay in
treatment, number of fractures, and treatment modality. The most
important among these seem to be the type of fracture, whether it is
compound, and the period of delay in treatment.
In the literature, many studies have shown that compound
fractures have more chance of infection than the others.7,13,14 In our
study in group 1, 3 of 14 compound fractures were infected, leading
to an infection rate of 21.42%, and in group 2, 14 of 78 compound
fractures were infected, leading to an infection rate of 17.94%. As
the infection rate in both groups is similar in compound fractures, it
is suggested that antibiotics are not playing much of a role in the
prevention of SWI in this kind of fractures.
The maximum recommended delay in treatment of mandibular
fractures and the type of treatment rendered have been the subject of
attention of numerous studies.14,15 The literature shows that delayed
treatment of fractures is associated with a greater rate of infection.14
Although Champy et al16 recommended treatment within the first
12 hours of trauma, in our setup this is not practically possible
always because of various factors such as availability of operation
theaters, cost factor associated with open reductions, and so on. The
mean delay in treatment of fractures in our study is 4 days, and there is
a positive correlation (r = +0.44) found between the delay and in-creased
SWI. This could be attributed to the mobility of the frac-tured
segments and concomitant development of infection.
A strong positive correlation (r = +1) was also found between
the use of catgut in multiple layer closures and SWI (7/17), leading
to an infection rate of 41.18%, which is also documented in
literature.17
CONCLUSIONS
Our study suggests that prophylactic antibiotic therapy may
not alter the incidence of SWI. A multicenter, prospective, ran-domized
controlled trial with large sample size is essential to eval-uate
the advantage of prophylactic antibiotic therapy, if any, in the
management of maxillofacial fractures.
REFERENCES
1. Burke JF. The effective period of preventive antibiotic action in
experimental incisions and dermal lesions. Surgery 1961;50:161Y168
2. Laskin DM. The use of prophylactic antibiotics for prevention of
postoperative infections. Oral Maxillofac Surg Clin North Am
2003;15:155Y160
3. Miles BA, Porter 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;64:576Y582
4. Abubaker O, Rollert MK. Post-operative antibiotic prophylaxis in
mandibular fractures: a preliminary randomized, double blind, and
placebo-controlled clinical study. J Oral Maxillofac Surg 2001;59:
1415Y1419
5. Peterson LJ. Principles of antibiotic therapy. In: Topazian RG, ed.
Oral and Maxillofacial Infections. 3rd ed. Philadelphia, PA: WB
Saunders Company, 1994:160Y197
6. Heit JM, Stevens MR, Jeffords K. Comparison of ceftriaxone with
penicillin for antibiotic prophylaxis for compound mandibular fractures.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;83:423Y426
7. Moreno JC, Fernandez A, Ortiz JA, et al. Complication rates associated
with different treatments for mandibular fractures. J Oral Maxillofac
Surg 2000;58:273Y280
8. Larson EL, Pearson ML. Guideline for prevention of surgical site
infection. Infect Control Hosp Epidemiol 1999;20:248Y264
9. Garibaldi RA, et al. Risk factors for post-operative infections. Am J Med
1991;91(suppl 3B):158Y163
10. Culver DH, Horan TC, Gaynes RP, et al. National Nosocomial Infections
Surveillance System: surgical wound infection rates by wound class
operative procedure and patient risk index. Am J Med 1991;91
(Suppl 3B):152Y157
11. Chole RA, Yee J. Antibiotic prophylaxis for facial fractures.
A prospective, randomized clinical trial. Arch Otolaryngol Head Neck
Surg 1987;113:1055Y1057
12. Zallen RD, Curry JT. A study of antibiotic usage in compound
mandibular fractures J Oral Surg 1975;33:431Y434
13. Edwards TJ, David DJ, Simpson DA, et al. The relationship between
fracture severity and complication rate in miniplate osteosynthesis of
mandibular fractures. Br J Plast Surg 1994;47:310Y311
14. Maloney PL, Lincoln RE, Coyne CP. A protocol for management of
compound mandibular fractures based on the time of injury to treatment.
J Oral Maxillofac Surg 2001;60:133Y134
15. Biller JA, Pletcher SD, Goldberg AN, et al. Complications and time to
repair of mandibular fractures. Laryngoscope 2002;115:769Y772
16. Champy, et al. Mandibular osteosynthesis by miniature screwed plates
via buccal approach. J Oral Maxillofac Surg 1978;6:14
17. Gabrielli F, Potenza C, Puddu P, et al. Suture materials and other factors
associated with tissue reactivity, infection, and wound dehiscence
among plastic surgery outpatients. Plast Reconstr Surg 2001;107:38Y45
* 2010 Mutaz B. Habal, MD 1011
Copyright © 2010 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.