Antimicrobial prophylaxis for major head and neck surgery in cancer patients: sulbactam-ampicillin versus clindamycin-amikacin

Evidence-Based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-Site Infections in Plastic and Reconstructive Surgery

BACKGROUND

After nearly a decade of new data, the Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons was updated for prophylactic systemic antibiotics to prevent surgical-site infections (SSI). Pharmacotherapeutic concepts using antimicrobial stewardship were applied for clinical interpretation and management to optimize patient outcomes and minimize resistance.

METHODS

PRISMA, Cochrane, and GRADE certainty of evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched for randomized controlled trials (RCTs). The authors included patients who had plastic and reconstructive surgery and were treated with prophylactic systemic antibiotics administered perioperatively (preoperatively, intraoperatively, or postoperatively). Comparisons were made between active interventions and nonactive interventions (placebo) at different prespecified durations to determine the development of an SSI. Meta-analyses were performed.

RESULTS

The authors included 138 RCTs that met eligibility criteria. RCTs consisted of 18 breast, 10 cosmetic, 21 hand/peripheral nerve, 61 pediatric/craniofacial, and 41 reconstructive studies. The authors examined bacterial data extracted from studies for patients who did or did not take prophylactic systemic antibiotics for prevention of SSI. Clinical recommendations were provided using level I evidence.

CONCLUSIONS

Surgeons have long been overprescribing systemic antibiotic prophylaxis in plastic and reconstructive surgery. Evidence supports antibiotic prophylaxis to prevent SSI for specific indications and durations. Prolonged antibiotic use has not been linked to reductions in SSIs, and misuse may increase the bacterial diversity of infections. Greater efforts should focus on transitioning from practice-based to pharmacotherapeutic evidence-based medicine.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Assessment of the In Vitro Cytotoxic Profile of Two Broad-Spectrum Antibiotics-Tetracycline and Ampicillin-On Pharyngeal Carcinoma Cells

Background and Objectives: In spite of the fact that antibiotics are considered to be the cornerstone of modern medicine, their use in the treatment of cancer remains controversial. In the present study, the main objective was to examine the effects of two antibiotics—tetracycline and ampicillin—on the viability, morphology, migration, and organization and structure of the nuclei and the actin fiber network of pharyngeal carcinoma cells—Detroit-562. Materials and Methods: In order to determine the viability of the cells, the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) method was applied after the cells were stimulated with five concentrations of tetracycline and ampicillin (10, 25, 50, 75, and 100 μM) for 72 h. A scratch assay was used to assess the migration ability of the cells. For the visualization of the nuclei and actin fibers, 4,6-diamidino-2-phenylindole (Dapi) and Rhodamine-Phalloidin were used. Results: There are different effects of tetracycline and ampicillin. Thus, tetracycline: (i) exhibited a concentration-dependent cytotoxic effect, decreasing cell viability to approximately 46%; (ii) inhibits cellular migration up to 16% compared to 60% for control cells; and (iii) induces changes in cell morphology as well as apoptotic changes in the nucleus and F-actin fibers. In contrast, in the case of ampicillin, an increase in viability up to 113% was observed at 10 μM, while a decrease in viability up to approximately 94% was observed at the highest concentration tested (100 μM). Conclusions: The results indicated a different effect regarding the impact on pharyngeal carcinoma cells. Thus, tetracycline has a concentration-dependent cytotoxic effect, while in the case of ampicillin a slight stimulation of cell viability was observed.

Antimicrobial Prophylaxis in Neonates and Children Undergoing Dental, Maxillo-Facial or Ear-Nose-Throat (ENT) Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs) represent a potential complication in surgical procedures, mainly because clean/contaminated surgery involves organs that are normally colonized by bacteria. Dental, maxillo-facial and ear-nose-throat (ENT) surgeries are among those that carry a risk of SSIs because the mouth and the first respiratory tracts are normally colonized by a bacterial flora. The aim of this consensus document was to provide clinicians with recommendations on surgical antimicrobial prophylaxis in neonates (<28 days of chronological age) and pediatric patients (within the age range of 29 days−18 years) undergoing dental, maxillo-facial or ENT surgical procedures. These included: (1) dental surgery; (2) maxilla-facial surgery following trauma with fracture; (3) temporo-mandibular surgery; (4) cleft palate and cleft lip repair; (5) ear surgery; (6) endoscopic paranasal cavity surgery and septoplasty; (7) clean head and neck surgery; (8) clean/contaminated head and neck surgery and (9) tonsillectomy and adenoidectomy. Due to the lack of pediatric data for the majority of dental, maxillo-facial and ENT surgeries and the fact that the recommendations for adults are currently used, there is a need for ad hoc studies to be rapidly planned for the most deficient areas. This seems even more urgent for interventions such as those involving the first airways since the different composition of the respiratory microbiota in children compared to adults implies the possibility that surgical antibiotic prophylaxis schemes that are ideal for adults may not be equally effective in children.

Antibiotic prophylaxis in head and neck cancer surgery: Systematic review and Bayesian network meta-analysis

Postoperative surgical site infections (SSI) are worrisome complications after head and neck cancer surgery. Due to the lack of direct comparisons, it is difficult to indicate the best antibiotic in the setting of SSI prophylaxis for patients with head and neck cancer. For this reason, we decided to conduct a Bayesian network meta-analysis of clinical studies evaluating various antibiotic classes for SSI prophylaxis; thus, we directly and indirectly compared all the available antibiotics in the setting of head and neck oncological surgery. We performed a systematic review and a network meta-analysis according to the PRISMA-NMA checklist. Regarding inclusion criteria, we included articles with retrospective or prospective design recruiting adult participants with head and neck neoplasm of any subsite that compared different antibiotics or that compared different antibiotic treatment duration with sample sizes of more than 10 patients. Overall, 310 citations were identified by the search on all databases. Of these, 250 were excluded based on title and abstract, leaving 60 publications for full text examination. Finally, 20 papers were included for data extraction and analysis. In total, 8627 patients were evaluated across the included studies. Results of the Bayesian network meta-analysis showed that when compared to clindamycin short course, the antibiotics effective in preventing SSI were ampicillin/sulbactam or other penicillin short course (OR: 0.37, 95%CrI: 0.19-0.72), cefazolin/metronidazole short course (OR: 0.26, 95%CrI: 0.06-0.93), cefazolin (OR: 0.36, 95%CrI: 0.17-0.79), ampicillin/sulbactam long course (OR: 0.20, 95%CrI: 0.04-0.91), cefazolin/metronidazole long course (OR: 0.27, 95%CrI: 0.09-0.64), cefoperazone (OR: 0.05, 95%CrI: 0.002-0.89), cefotaxime (OR: 0.04, 95%CrI: 0.002-0.85). There was no significant difference between clindamycin and no antibiotic (OR: 2.3, 95%CrI: 0.59-9.9). Clindamycin plus aminoglycoside seemed to give a slight protection from SSI compared to clindamycin alone (OR: 0.30, 95%CrI: 0.09-0.99) or no antibiotic (OR: 0.13, 95%CrI: 0.02-067). Antibiotic prophylaxis is important in preventing SSI in head and neck cancer setting. Current evidence suggests that penicillins and cephalosporins are the best choice. Moreover, long duration course does not give any advantage compared to short course prophylaxis. Finally, it is important to implement appropriate antibiotic prophylaxis in patients that are labeled as penicillin allergic, in this regard clindamycin seems to be ineffective and, for this reason, further research is needed to provide a better care for this subset of patients.

Perioperative Antibiotics in Clean-Contaminated Head and Neck Surgery: A Systematic Review and Meta-Analysis

Background

The optimal evidence-based prophylactic antibiotic regimen for surgical site infections following major head and neck surgery remains a matter of debate.

Methods

Medline, Cochrane, and Embase were searched for the current best evidence. Retrieved manuscripts were screened according to the PRISMA guidelines. Included studies dealt with patients over 18 years of age that underwent clean-contaminated head and neck surgery (P) and compared the effect of an intervention, perioperative administration of different antibiotic regimens for a variable duration (I), with control groups receiving placebo, another antibiotic regimen, or the same antibiotic for a different postoperative duration (C), on surgical site infection rate as primary outcome (O) (PICO model). A systematic review was performed, and a selected group of trials investigating a similar research question was subjected to a random-effects model meta-analysis.

Results

Thirty-nine studies were included in the systematic review. Compared with placebo, cefazolin, ampicillin–sulbactam, and amoxicillin–clavulanate were the most efficient agents. Benzylpenicillin and clindamycin were clearly less effective. Fifteen studies compared short- to long-term prophylaxis; treatment for more than 48 h did not further reduce wound infections. Meta-analysis of five clinical trials including 4336 patients, where clindamycin was compared with ampicillin–sulbactam, implied an increased infection rate for clindamycin-treated patients (OR = 2.73, 95% CI 1.50–4.97, p = 0.001).

Conclusion

In clean-contaminated head and neck surgery, cefazolin, amoxicillin–clavulanate, and ampicillin–sulbactam for 24–48 h after surgery were associated with the highest prevention rate of surgical site infection.

Perioperative Antibiotics in Clean-Contaminated Head and Neck Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

The optimal evidence-based prophylactic antibiotic regimen for surgical site infections following major head and neck surgery remains a matter of debate.

METHODS

Medline, Cochrane, and Embase were searched for the current best evidence. Retrieved manuscripts were screened according to the PRISMA guidelines. Included studies dealt with patients over 18 years of age that underwent clean-contaminated head and neck surgery (P) and compared the effect of an intervention, perioperative administration of different antibiotic regimens for a variable duration (I), with control groups receiving placebo, another antibiotic regimen, or the same antibiotic for a different postoperative duration (C), on surgical site infection rate as primary outcome (O) (PICO model). A systematic review was performed, and a selected group of trials investigating a similar research question was subjected to a random-effects model meta-analysis.

RESULTS

Thirty-nine studies were included in the systematic review. Compared with placebo, cefazolin, ampicillin-sulbactam, and amoxicillin-clavulanate were the most efficient agents. Benzylpenicillin and clindamycin were clearly less effective. Fifteen studies compared short- to long-term prophylaxis; treatment for more than 48 h did not further reduce wound infections. Meta-analysis of five clinical trials including 4336 patients, where clindamycin was compared with ampicillin-sulbactam, implied an increased infection rate for clindamycin-treated patients (OR = 2.73, 95% CI 1.50-4.97, p = 0.001).

CONCLUSION

In clean-contaminated head and neck surgery, cefazolin, amoxicillin-clavulanate, and ampicillin-sulbactam for 24-48 h after surgery were associated with the highest prevention rate of surgical site infection.

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.

Antibiotic Prophylaxis in Clean-Contaminated Head and Neck Surgery: A Systematic Review and Meta-analysis

Objective

To determine the optimal duration and type of antibiotic prophylaxis in patients undergoing clean-contaminated resection for head and neck cancer.

Data Sources

Search strategies were created by a medical librarian, implemented in multiple databases, and completed in June 2016.

Review Methods

The population of interest was adults ≥18 years undergoing clean-contaminated head and neck surgery, intervention was postoperative antibiotic prophylaxis, comparator was duration and types of antibiotics used, outcome was the wound infection rate, and the study design was randomized controlled trials (RCTs). Studies were excluded if not randomized, did not use systemic antibiotics, did not study wound infections, or included children. After excluding duplicates, the search strategy yielded 427 abstracts. After applying inclusion and exclusion criteria, 67 studies were screened, leaving 19 RCTs for review. PRISMA guidelines were followed. A random-effects model was used for meta-analysis.

Results

Meta-analysis of 340 patients in 4 RCTs showed that the pooled relative risk of wound infection was 0.98 (95% confidence interval [CI], 0.58-1.61; P = .718; I2 = 0.0%) in patients receiving 1 day vs 5 days of prophylaxis.

Conclusion

This study provides evidence that there is no difference in the risk of wound infection with 1 day vs 5 days of systemic antibiotic prophylaxis in clean-contaminated head and neck surgery, consistent with existing guidelines. Future large randomized trials are needed to more clearly define the appropriate choice of prophylaxis in penicillin-allergic patients.

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

BACKGROUND

The purpose of this study was to determine the incidence of and risk factors for surgical site infections in microvascular reconstruction for patients with head and neck cancer.

METHODS

One hundred seventeen patients with head and neck cancer undergoing microvascular reconstruction received postoperative surgical infection prophylaxis and were followed for 30 days. Surgical infection prophylaxis was categorized by empiric spectrum of activity. Risk factors for surgical site infection development and cumulative incidence of surgical site infections were characterized.

RESULTS

Thirty-seven patients developed surgical site infection (cumulative surgical site infection incidence of 31.6%). Risk factors identified in logistic regression include alcohol use (odds ratio [OR] = 2.704; 95% confidence interval [CI] = 1.029-7.106), increased surgical duration (OR = 1.403; 95% CI = 1.185-1.661), American Society of Anesthesiologists (ASA) class IV (OR = 3.075; 95% CI = 1.000-9.459), and lack of postoperative gram-negative coverage (OR = 15.139; 95% CI = 3.083-74.347).

CONCLUSION

Alcohol use, longer surgical duration, and lack of gram-negative postoperative prophylactic coverage are modifiable risk factors for surgical site infection development. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1454, 2016.

Surgical site infections among high-risk patients in clean-contaminated head and neck reconstructive surgery: concordance with preoperative oral flora

BACKGROUND

Salivary contamination of surgical wounds in clean-contaminated head and neck surgery with free flap reconstruction remains a major cause of infection and leads to significant morbidity. This study investigates the correlation between intraoral flora and surgical site infections (SSIs) among high-risk head and neck cancer patients undergoing resection and free flap reconstruction.

METHODS

One hundred twenty-nine patients were identified as being at high risk for infective complications based on cancer stage, tumor size, comorbid factors, and extent of reconstruction. All patients had intraoral swab cultures before surgery. Patients with culture-confirmed SSI after surgery were chosen for analysis, using the κ index and its 95% confidence interval for concordance analysis. All patients received clindamycin and gentamicin for antibiotic prophylaxis for 5 days. Antibiotic susceptibility testing of all isolates was obtained and analyzed.

RESULTS

Thirty-seven patients experienced SSI, or an infection rate of 28.3%, occurring at a mean of 9.3 postoperative days. The overall concordance between oral flora and SSI was fair to moderate (κ index of 0.25), but detailed analysis shows a higher concordance for known and opportunistic pathogens, such as Pseudomonas aeruginosa and Enterococcus faecalis, compared to typical oral commensals. Antibiotic susceptibility tests show rapid and significant increases in resistance to clindamycin, indicating a need for a more effective alternative.

CONCLUSIONS

Predicting pathogens in SSI using preoperative oral swabs did not demonstrate a good concordance in general for patients undergoing clean-contaminated head and neck surgery, although concordance for certain pathogenic species seem to be higher than for typical intraoral commensals. The rapid development of resistance to clindamycin precludes its use as a prophylactic agent.

Preoperative topical antimicrobial decolonization in head and neck surgery

OBJECTIVES/HYPOTHESIS

Surgical site infections (SSIs) are an important cause of morbidity and mortality after head and neck surgery. Our primary objective was to determine the efficacy of preoperative topical antimicrobial decolonization before head and neck surgery.

STUDY DESIGN

Prospective, randomized controlled trial.

METHODS

This study was conducted among 84 patients presenting for head and neck surgery requiring admission to an academic medical center. Preoperative cultures were performed to identify Staphylococcus aureus carriers. Patients were randomized to preoperative topical antimicrobial decolonization with a 5-day regimen of chlorhexidine skin rinses and intranasal mupirocin coupled with standard perioperative systemic antimicrobial prophylaxis, versus standard prophylaxis alone. The main outcome was the incidence of SSIs.

RESULTS

Despite a trend suggesting a decrease in SSIs with perioperative topical antimicrobial decolonization (24% vs. 10%), there was no significant difference (odds ratio, 0.34; 95% confidence interval, 0.10-1.18; P = .079). Patients with a higher American Society of Anesthesiologists score (3 vs. 1; P = .02), with more operative blood loss (P = .05), and who required operative takeback (P = .04) had a higher rate of SSIs; there was a trend suggesting a higher rate of SSIs among patients undergoing clean-contaminated surgery compared to clean cases (P = .08) and among those having received prior radiation (P = .07) or chemotherapy (P = .06).

CONCLUSIONS

Preoperative antimicrobial decolonization did not significantly decrease the incidence of SSIs after head and neck surgery, but might be considered for high-risk groups despite the lack of conclusive evidence confirming efficacy. Risk factors for SSIs after head and neck surgery are identified for the first time in a prospective study.

Prognostic significance of wound infections following major head and neck cancer surgery: an open non-comparative prospective study

OBJECTIVE

We evaluated the incidence, risk factors and consequences of wound infection (WI) following major head and neck cancer surgery in an open non-comparative study.

PATIENTS AND METHODS

The study group, comprising 95 patients who underwent clean-contaminated procedures with opening of the upper aerodigestive tract for biopsy-proven squamous cell cancer, were studied over a 1-year period. Antibiotic prophylaxis was amoxicillin and clavulanic acid. More than 20 variables were prospectively recorded for each patient. The mean follow-up was 30 months.

MAIN RESULTS

The overall WI rate was 50.5% (48/95). Most pathogens isolated from samples were gram-negative rods. In univariate analysis, we found three risk factors for WI: alcohol consumption (P = 0.07), a hypopharyngeal location (P = 0.02) and laryngectomy stoma (P = 0.01). WI were associated with postoperative fever (P = l.5 x 10(-11)), postoperative antibiotic therapy (P = 1.5 x 10(-5)) and postoperative death (P = 0.043). Patients without WI had a median postoperative hospital stay of 15 days compared with 29 days for those with WI (P < 0.001). Healing of WI was achieved after a median time of 48 days. WI delayed postoperative radiation therapy in 21 out of 33 evaluable patients. But overall survival, and local and metastatic failures were similar with and without WI.

CONCLUSIONS

WI are associated with a heavy postoperative morbidity, but have no prognostic impact on cancer control.

Ureidopenicillins and beta-lactam/beta-lactamase inhibitor combinations

Although research and development of new penicillins have declined, penicillins continue to be essential antibiotics for the treatment and prophylaxis of infectious diseases. The most recent additions are the ureidopenicillins and beta-lactam/beta-lactamase inhibitor combinations. This article reviews the spectrum of activity, toxicity, pharmacokinetics, and clinical uses of the ureidopenicillins, and the beta-lactam/beta-lactamase inhibitor combination agents.