Surgical prophylaxis with gram-negative activity for reduction of surgical site infections after microvascular reconstruction for head and neck cancer

Enhanced Recovery After Surgery for Head and Neck Oncologic Surgery Requiring Microvascular Reconstruction

It has been demonstrated since the 1990's that surgical outcomes can be improved through protocolized perioperative interventions. Since then, multiple surgical societies have engaged in adopting Enhanced Recovery After Surgery (ERAS) Societal recommendations to improve patient satisfaction, decrease the cost of interventions, and improve outcomes. In 2017, ERAS released consensus recommendations detailing the perioperative optimization of patients undergoing head and neck free flap reconstruction. This population was identified as a high resource demand, oftentimes burdened with challenging comorbidity, and poorly described cohort for which a perioperative management protocol could help to optimize outcomes. The following pages aim to further detail perioperative strategies to streamline patient recovery after head and neck reconstructive surgery.

Antibiotic Use in Patients Undergoing Complex Clean-Contaminated Head and Neck Surgery: A Prospective Study

Aims and Objectives

Oncological surgery of the upper aerodigestive tract is a complex procedure and often includes neck dissection and flap reconstruction. It can be complicated by severe surgical site infection (SSI) leading to flap necrosis, delayed wound healing, and increasing mortality and morbidity. The purpose of this study is to perform a systematic descriptive analysis and to evaluate the effect of our adapted antibiotic regimen strategy on postoperative outcomes.

Materials and Methods

A prospective cohort analysis of 47 patients undergoing major clean-contaminated head and neck surgery was conducted at the Cervicomaxillofacial Surgery Department (Saint-Pierre Hospital), between 2019 and 2022. The patients were divided into two groups: group I, which received a short-term postoperative antibiotic regimen for 24 h, and group II, which received a more extended postoperative antibiotic course for more than 24 h. Antibioprophylaxy amoxicillin and clavulanate were administered intravenously 30-60 min before making the incision. The antibiotic regimen was continued after surgery. The prognostic significance of the antibiotic regimen on postoperative outcomes, including clinical signs of infection and biological markers such as white blood cells count, and C-reactive protein levels was evaluated using univariate analysis.

Results

Eighteen patients developed SSIs. All of these infections were grade 2 and were treated with antibiotics. After univariate analysis, only a history of hypothyroidism seems to be a predictor of SSI (P = 0.038). No significant difference was found in terms of onset and hospital stay when we compared the patients who received antibiotics for 24 h or more. Moreover, the rate of multidrug-resistant bacteria was not different in both groups.

Conclusions

Our results suggest that postoperative antibiotics for more than 24 h do not confer benefit in terms of SSI. Oncological patients undergoing complex clean-contaminated head and neck surgery are often suffering from infectious complications and, despite the absence of guidelines, practicians should consider these findings in their decision-making.

Restarting Therapeutic Antibiotics Following Postoperative Prophylaxis in Head and Neck Microvascular Free Tissue Transfer

OBJECTIVE

To determine factors associated with restarting therapeutic antibiotics within 30 days of head and neck microvascular free tissue transfer (HN-MFTT).

STUDY DESIGN

Retrospective study of consecutive HN-MFTTs performed from January 2015 to July 2020.

SETTING

Tertiary academic medical center.

METHODS

Thirty-day postoperative antibiotic use and post-HN-MFTT surgical and medical complications were assessed. Univariable analyses and multivariable logistic regression were used to evaluate risk factors associated with restarting antibiotics.

RESULTS

overall 482 patients with 501 HN-MFTTs were stratified by duration of prophylaxis: ≤24 hours (n = 136, 27.1%), 25-72 hours (n = 54, 10.8%), and >72 hours (n = 311, 62.1%). Antibiotics were restarted in 199 patients (209 procedures, 42%). The most common indications for antibiotic reinitiation were flap recipient site infection (n = 59, 28%); hospital-acquired pneumonia (n = 44, 21%); and wound dehiscence, fluctuance, or change in quality of drain output (n = 44, 21%). Shorter antibiotic prophylaxis (≤24 hours) (odds ratio [OR], 1.95; 95% CI, 1.2-3.0; P = .003), osteocutaneous flaps (OR, 2.15; 95% CI, 1.3-3.4; P = .001), and prior immunotherapy/chemotherapy (OR, 2.29; 95% CI, 1.2-4.3; P = .01) were associated with reinitiation of antibiotics for surgical infections. Restarting antimicrobials for nosocomial infections was associated with aerodigestive defects (OR, 2.45; 95% CI, 1.1-5.2; P = .019), cardiovascular disease (OR, 3.00; 95% CI, 1.5-5.9; P = .001), and medical comorbidities approximated by American Society of Anesthesiologists class 3 or 4 (OR, 2.83; 95% CI, 1.5-5.4; P = .002).

CONCLUSION

Aerodigestive reconstruction, 24-hour postoperative antimicrobial prophylaxis, American Society of Anesthesiologists class 3 and 4, prior chemotherapy/immunotherapy, cardiovascular disease, and osteocutaneous flaps are associated with reinitiation of antibiotics within 30 days of HN-MFTT.

Prevalence of Multidrug-Resistant Organisms in Patients Undergoing Free Flap Reconstruction

OBJECTIVES/HYPOTHESIS

The purpose of this study is to evaluate the relationship between antibiotic prophylaxis and prevalence of multidrug-resistant organisms (MDRO) in patients undergoing head and neck cancer reconstruction.

STUDY DESIGN

Retrospective Chart Review.

METHODS

Retrospective review of patients who underwent head and neck free flap reconstruction at our institution between 2009 to 2016.

RESULTS

Of the 145 patients that underwent head and neck tumor removal surgery using free tissue flaps to cover the defect and therafter received antibiotic prophylaxis, 30 (20.7%) developed postoperative surgical site (n = 17, 55.7%) or distant (n = 13, 43.4%) infections. Seven had a multidrug-resistant infection, the most common with Methicillin-Resistant Staphylococcus aureus (MRSA). There was no significant relationship between antibiotic spectrum or duration to the development of postoperative infections or MDRO. Pseudomonas and MRSA infections were low overall with only one multidrug-resistant Pseudomonas infection.

CONCLUSIONS

The choice of antibiotic prophylaxis should cover organisms these patients are at highest risk for including anaerobes and Gram-negative organisms. A shorter duration of antibiotic prophylaxis should be considered given no increased risk of postoperative infection nor MDRO. Finally, one must be aware of the potential threat of multidrug-resistant Pseudomonas and MRSA amongst this vulnerable population and identity these with culture driven treatment.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1881-E1887, 2021.

Remote ischemic preconditioning does not influence lectin pathway protein levels in head and neck cancer patients undergoing surgery

BACKGROUND

Cancer patients who undergo tumor removal, and reconstructive surgery by transfer of a free tissue flap, are at high risk of surgical site infection and ischemia-reperfusion injury. Complement activation through the lectin pathway (LP) may contribute to ischemia-reperfusion injury. Remote ischemic preconditioning (RIPC) is a recent experimental treatment targeting ischemia-reperfusion injury. The study aims were to investigate LP protein plasma levels in head and neck cancer patients compared with healthy individuals, to explore whether RIPC affects LP protein levels in head and neck cancer surgery, and finally to examine the association between postoperative LP protein levels and the risk of surgical site infection.

METHODS

Head and neck cancer patients (n = 60) undergoing tumor resection and reconstructive surgery were randomized 1:1 to RIPC or sham intervention administered intraoperatively. Blood samples were obtained preoperatively, 6 hours after RIPC/sham, and on the first postoperative day. LP protein plasma levels were measured utilizing time-resolved immunofluorometric assays.

RESULTS

H-ficolin and M-ficolin levels were significantly increased in cancer patients compared with healthy individuals (both P ≤ 0.02). Conversely, mannan-binding lectin (MBL)-associated serine protease (MASP)-1, MASP-3, collectin liver-1 (CL-L1), and MBL-associated protein of 44 kilodalton (MAp44) levels were decreased in cancer patients compared with healthy individuals (all P ≤ 0.04). A significant reduction in all LP protein levels was observed after surgery (all P < 0.001); however, RIPC did not affect LP protein levels. No difference was demonstrated in postoperative LP protein levels between patients who developed surgical site infection and patients who did not (all P > 0.13).

CONCLUSIONS

The LP was altered in head and neck cancer patients. LP protein levels were reduced after surgery, but intraoperative RIPC did not influence the LP. Postoperative LP protein levels were not associated with surgical site infection.

Systematic review of international guidelines for perioperative antibiotic prophylaxis in Head & Neck Surgery. A YO-IFOS Head & Neck Study Group Position Paper

BACKGROUND

Surgical site infection (SSI) is defined as an infection that occurs after a surgical incision or organ manipulation during surgery. The frequency reported for clean head and neck surgical procedures without antimicrobial prophylaxis is <1%. In contrast, infection rates in patients undergoing complicated cancer surgery are high, ranging from 24% to 87% of patients without antimicrobial prophylaxis.

METHODS

Guidelines and recommendations about the use of antibiotics in head and neck surgery from 2004 to 2019 were reviewed.

RESULTS

Four guidelines from Oceania, 5 from South America, 5 from North America, 2 from the United Kingdom, 11 from Europe, 1 from Africa, 1 from the Middle East, and 3 from Asia were included. A total of 118 papers were included for analysis and recommendation.

CONCLUSION

Antibiotic prophylaxis can decrease the incidence of SSI. However, the risks associated with antibiotic exposure and the risk of antibiotic resistance need to be taken into consideration.

Multicenter Assessment of Antibiotic Prophylaxis Spectrum on Surgical Infections in Head and Neck Cancer Microvascular Reconstruction

Objective

To characterize and identify risk factors for 30-day surgical site infections (SSIs) in patients with head and neck cancer who underwent microvascular reconstruction.

Study Design

Cross-sectional study with nested case-control design.

Setting

Nine American tertiary care centers.

Subjects and Methods

Hospitalized patients were included if they underwent head and neck cancer microvascular reconstruction from January 2003 to March 2016. Cases were defined as patients who developed 30-day SSI; controls were patients without SSI at 30 days. Postoperative antibiotic prophylaxis (POABP) regimens were categorized by Gram-negative (GN) spectrum: no GN coverage, enteric GN coverage, and enteric with antipseudomonal GN coverage. All POABP regimens retained activity against anaerobes and Gram-positive bacteria. Thirty-day prevalence of and risk factors for SSI were evaluated.

Results

A total of 1307 patients were included. Thirty-day SSI occurred in 189 (15%) patients; median time to SSI was 11.5 days (interquartile range, 7-17). Organisms were isolated in 59% of SSI; methicillin-resistant Staphylococcus aureus (6%) and Pseudomonas aeruginosa (9%) were uncommon. A total of 1003 (77%) patients had POABP data: no GN (17%), enteric GN (52%), and antipseudomonal GN (31%). Variables independently associated with 30-day SSI were as follows: female sex (adjusted odds ratio [aOR], 1.6; 95% CI, 1.1-2.2), no GN POABP (aOR, 2.2; 95% CI, 1.5-3.3), and surgical duration ≥11.8 hours (aOR, 1.9; 95% CI, 1.3-2.7). Longer POABP durations (≥6 days) or antipseudomonal POABP had no association with SSI.

Conclusions

POABP without GN coverage was significantly associated with SSI and should be avoided. Antipseudomonal POABP or longer prophylaxis durations (≥6 days) were not protective against SSI. Antimicrobial stewardship interventions should be made to limit unnecessary antibiotic exposures, prevent the emergence of resistant organisms, and improve patient outcomes.

Considerations for antibiotic prophylaxis in head and neck cancer surgery

Peri/post-operative antibiotic prophylaxis (POABP) has become standard practice for preventing surgical site infections (SSI) in head and neck cancer patients undergoing microvascular reconstruction, but few data exist on optimal POABP regimens. Current surgical prophylaxis guideline recommendations fail to account for the complexity of microvascular reconstruction relative to other head and neck procedures, specifically regarding wound classification and antibiotic duration. Selection of POABP spectrum is also controversial, and must balance the choice between too narrow, risking subsequent infection, or too broad, and possible unwanted effects (e.g. antibiotic resistance, Clostridium difficile-associated diarrhea). POABP regimens should retain activity against bacteria expected to colonize the upper respiratory/salivary tracts, which include Gram-positive organisms and facultative anaerobes. However, Gram-negative bacilli also contribute to SSI in this setting. POABP doses should be optimized in order to achieve therapeutic tissue concentrations at the surgical site. Antibiotics targeted towards methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa are not warranted for all patients. Prolonged POABP durations have shown no differences in SSI when compared to short POABP durations, but prolonged durations provide unnecessarily antibiotic exposure and risk for adverse effects. Given the lack of standardization behind antibiotic POABP in this setting and the potential for poor patient outcomes, this practice necessitates an additional focus of surgeons and antimicrobial stewardship programs. The purpose of this review is to provide an overview of POABP evidence and discuss pertinent clinical implications of appropriate use.

Literature Review of Criteria for Defining Recipient-Site Infection after Oral Oncologic Surgery with Simultaneous Reconstruction

BACKGROUND

The lack of uniformity of criteria for defining recipient-site infection after oral oncologic surgery with simultaneous reconstruction is problematic despite numerous studies on this issue. This study aimed to investigate the difference in the criteria for defining recipient-site infection after oral oncologic surgery with reconstruction.

METHODS

A Medline search was performed via PUBMED using the following combinations of key terms that were tagged in the title, abstract, or both: "surgical site infection-head neck," "surgical site infection-oral cancer," "antibiotic prophylaxis-head neck," and "surgical site infection-oral carcinoma." Search results were filtered between 2005 and 2017. Articles in which there was no mention of the criteria for definition of surgical-site infection were excluded.

RESULTS

The number of articles that met the inclusion criteria was 24. The lack of uniformity in the criteria for defining recipient-site infection in each article appeared to be attributable mainly to differences in whether an orocutaneous fistula and superficial incisional infection were regarded as recipient-site infection.

CONCLUSION

Reconsideration of the categorization of orocutaneous fistula as infection, regardless of the etiology, and differentiation of superficial and deep incisional infections are necessary for correct assessment of recipient-site infection in oral oncologic surgery.