Prescription of antibiotics: does it alter the outcome for patients who have fractures of the angle of the mandible?

Risk factors associated with short-term complications in mandibular fractures: the MANTRA study-a Maxillofacial Trainee Research Collaborative (MTReC)

INTRODUCTION

Complications following mandibular fractures occur in 9-23% of patients. Identifying those at risk is key to prevention. Previous studies highlighted smoking, age and time from injury to presentation as risk factors but rarely recorded other possible confounders. In this paper, we use a collaborative snapshot audit to document novel risk factors and confirm established risks for complications following the treatment of mandibular fractures.

METHODS

The audit was carried out by 122 OMFS trainees across the UK and Ireland (49 centres) over 6 months, coordinated by the Maxillofacial Surgery Trainees Research Collaborative. Variables recorded included basic demography, medical and social history, injury mechanism and type, management and 30-day outcome.

RESULTS

Nine hundred and forty-seven (947) patients with fractured mandibles were recorded. Surgical management was carried out in 76.3%. Complications at 30 days occurred 65 (9%) of those who were managed surgically. Risk factors for complications included male sex, increasing age, any medical history, increasing number of cigarettes smoked per week, increasing alcohol use per week, worse oral hygiene and increased time from injury to presentation.

DISCUSSION

We have used a large prospective snapshot audit to confirm established risk factors and identify novel risk factors. We demonstrate that time from injury to presentation is confounded by other indicators of poor health behaviour. These results are important in designing trial protocols for management of mandibular fractures and in targeting health interventions to patients at highest risk of complications.

Measuring Adherence to Antibiotic Use Guidelines in Managing Mandible Fractures

PURPOSE

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.

MATERIALS AND METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Systemic Antibiotic Prophylaxis in Maxillofacial Trauma: A Scoping Review and Critical Appraisal

Infection after maxillofacial trauma remains an important complication, with a significant socio-economic impact. While consensus exists that systemic antibiotic prophylaxis reduces the risk of infection in the management of maxillofacial fractures, the type, and duration remain controversial. Therefore, the purpose of this scoping review was to provide an overview of the current evidence that supports the use of prophylactic antibiotics in the treatment of maxillofacial fractures. A comprehensive literature search on 1 January 2022, in PubMed, Web of Science, Embase, and Cochrane, revealed 16 articles. Most studies focused on the duration of systemic antibiotic prophylaxis and compared a one-day to a five-day regimen. Included studies showed considerable variability in design and research aims, which rendered them difficult to compare. Furthermore, a variety of antibiotic regimens were used, and most studies had a short follow-up period and unclear outcome parameters. This scoping review demonstrates the lack of well-constructed studies investigating the type and duration of systemic antibiotic prophylaxis in the treatment of maxillofacial trauma. Based on the included articles, prolonging antibiotic prophylaxis over 24 h for surgically treated fractures does not appear to be beneficial. Furthermore, there is no evidence for its use in conservatively treated fractures. These results should be interpreted with caution since all included studies had limitations.

Antibiotic prophylaxis for traumatic facial fractures

WHAT IS KNOWN AND OBJECTIVE

The purpose of this paper is to discuss the limitations of the evidence supporting the SIS recommendations for antibiotic prescribing in patients with traumatic facial fractures and to provide suggestions for clinical decision-making and further research in this area given the wide variation in prescribing practices.

COMMENT

The Surgical Infection Society (SIS) recently published guidelines on antibiotic use in patients with traumatic facial fractures. The guidelines recommend against the use of prophylactic antibiotics for all adult patients with mandibular or non-mandibular facial fractures undergoing non-operative or operative procedures. Despite the available evidence, surveys conducted in the United States and the United Kingdom prior to the publication of the SIS guidelines demonstrate substantial preoperative, intraoperative and postoperative prophylactic prescribing of antibiotics for patients with facial fractures undergoing surgery.

WHAT IS NEW AND CONCLUSION

With the exception of strong recommendations based on moderate-quality evidence to avoid prolonged postoperative antibiotic prophylaxis, the weak recommendations in the guidelines are a function of low-quality evidence. A logical choice for a narrow-spectrum antibiotic is cefazolin administered within 1 h of surgery and no longer than 24 h after surgery, since it is the gold standard of comparison based on clinical practice guidelines concerning antibiotic prophylaxis.

Use of antibiotics in traumatic mandibular fractures: a systematic review and meta-analysis

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.

Review of prophylactic prescribing of antibiotics during the management of fractured mandibles

OBJECTIVES

To provide evidence based guidance on the optimum prophylactic antibiotic prescribing regimens in the treatment of fractured mandibles to protect against surgical site infections.

MATERIAL AND METHODS

OVID and Pubmed databases were searched for articles published between 1946 and 2020. Inclusion criteria was for articles to be in English, involve adult patients aged 14 and over, and involve patients treated with oral or IV antibiotics preoperatively, perioperatively or postoperatively during treatment of open or closed fractures of the mandible. Exclusion criteria included infected fractures on presentation, immunocompromised patients, fractures resulting from gunshot and pathological fractures.

RESULTS

A number of retrospective and prospective, randomised, double blind placebo-controlled trials were identified as suitable for inclusion. The age range within these trials was 14-77 years old. The numbers of patients contained within each trial ranged from 30 to 642. The most commonly prescribed antibiotics were penicillin, administered orally or intravenously. Duration of administration ranged from hospital admission to five days postoperatively. Analysis of these studies failed to demonstrate a statistical difference on the number of surgical site infections and the duration of antibiotic course.

CONCLUSIONS

The available evidence reveals no statistical difference in infection rates whether antibiotics are prescribed pre, peri, or postoperatively. The duration of antibiotics therapy also appears not to be important. Current evidence does not support the recommendation of an optimum antibiotic prescribing regimen. Additional prospective studies looking at the duration and timing of antibiotics during the management of fractured mandibles are required to identify the optimum prescribing regimen.

Surgical Infection Society Guidelines for Antibiotic Use in Patients with Traumatic Facial Fractures

Background: Facial fractures are common in traumatic injury. Antibiotic administration practices for traumatic facial fractures differ widely. Methods: The Surgical Infection Society's (SIS's) Therapeutics and Guidelines Committee convened to develop guidelines for antibiotic administration in the management of traumatic facial fractures. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Pre-operative antibiotics were defined as those administered more than 1 hour before surgery. Peri-operative antibiotics were those administered within 1 hour of the start of surgery depending on the type of antibiotic and as late as ≤24 hours after surgery. Post-operative antibiotics were defined as those administered >24 hours after surgery. Prophylactic antibiotics were those administered for >24 hours without a documented infection. Evaluation of the published evidence was performed with the GRADE system. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: We recommend that in adult patients with non-operative upper face, midface, or mandibular fractures, prophylactic antibiotics not be prescribed and that in adult patients with operative, non-mandibular fractures, pre-operative antibiotics likewise not be prescribed. We recommend that in adult patients with operative, mandibular fractures, pre-operative antibiotics not be prescribed; and in adult patients with operative, non-mandibular facial fractures, post-operative (>24 hours) antibiotics again not be prescribed. We recommend that in adult patients with operative, mandibular facial fractures, post-operative antibiotics (> 24 hours) not be prescribed. Conclusions: This guideline summarizes the current SIS recommendations regarding antibiotic management of patients with traumatic facial fractures.

Antimicrobial regimens used in the treatment of mandibular fractures in UK maxillofacial units: changes over 12 years

In the case of most mandibular fractures, the prescription of antimicrobials for more than 24 hours postoperatively confers no clinical benefit. To establish the prescribing patterns for mandibular fractures in UK OMFS units, and to compare them with those used 12 years ago, we did a telephone and email survey of OMFS units in the UK. Antimicrobials were prescribed for more than 24 hours postoperatively by 76 units (65%) (considerably fewer than the 82 (87%) in 2005). The most commonly prescribed first-line antimicrobial was co-amoxiclav (75%). Although there has been some improvement since 2005, most units still prescribe antimicrobials for periods longer than 24 hours. National collaboration may improve their appropriate prescription.