Prophylactic antibiotics in head and neck free flap surgery: A novel protocol put to the test

OBJECTIVE

Recent evidence supports the use of ampicillin-sulbactam as a favored choice for antibiotic prophylaxis following head and neck free flap reconstructive surgery. However, there is a paucity of evidence guiding the optimal duration of antibiotic prophylaxis. The aim of this study is to compare the infection rates of short courses of ampicillin-sulbactam versus extended courses of various antibiotics in head and neck free flap reconstructive surgery.

METHODS

This is a retrospective cohort study conducted from 2012 to 2017 at a tertiary academic center on 266 consecutive patients undergoing head and neck surgery with free flap reconstruction. The primary outcome measure was the rate of any infection within 30 days of surgery.

RESULTS

There were 149 patients who received antibiotic prophylaxis for an extended duration of at least seven days. 117 patients received a short course of antibiotics defined as 24 h for non-radiated patients and 72 h for radiated patients. Postoperative infections occurred in 45.9% of patients, of which 92.6% occurred at surgical sites. There was no significant difference in terms of postoperative infection rate between patients receiving an extended duration of antibiotics versus a short duration (p = 0.80). This held true for subgroups of surgical site infections (p = 0.38) and distant infections (p = 0.59 for pneumonia and p = 0.76 for UTI). Risk factors for infections were identified as hypothyroidism (p = 0.047) and clean contaminated wound classification (p = 0.0002).

CONCLUSION

Shorter duration of ampicillin-sulbactam prophylaxis in free flap reconstruction of head and neck defects does not negatively affect postoperative infection rates.

LEVEL OF EVIDENCE

Level 2b.

Discharge Delay in Head and Neck Free Flap Surgery: Risk Factors and Strategies to Minimize Hospital Days

Objective

Length of stay (LOS) includes time medically necessary in the hospital and time waiting for discharge (DC) afterward. This DC delay is determined in head and neck free flap patients. Reasons for and factors leading to DC delay, as well as associated adverse outcomes, are elucidated.

Methods

Retrospective chart review was performed for all head and neck free flap surgeries from 2012 to 2017. Data including demographics, comorbidities, and perioperative factors were collected. Regression analyses were performed to identify factors associated with DC delay.

Results

In total, 264 patients were included. Mean total LOS was 13.1 days. DC delay occurred in 65% of patients with a mean of 4.8 days. Factors associated with DC delay on univariate analysis included Medicaid/self-pay insurance, DC to a facility, and not having children ( P < .05). Multivariate analysis showed prolonged medically necessary LOS and surgery on a Monday/Friday ( P < .05) were associated with DC delay. Top reasons for DC delay included case management shortages, rejection by facility, and awaiting supplies. Eleven percent experienced complications during the DC delay.

Discussion

DC delay can add days and complications to the LOS. Prevention begins preoperatively with DC planning involving the patient’s closest family. Understanding limitations of the patient’s insurance may help plan DC destination. Optimizing hospital resources when available should be a focus.

Implications for Practice

Head and neck free flap patients require a team of teams unified in optimizing quality of care. DC delay is a novel quality metric reflecting the team’s overall performance. Through strategic DC planning and capitalizing on available resources, DC delay can be minimized.

Antibiotics, steroids, and combination therapy in chronic rhinosinusitis without nasal polyps in adults

Despite a lack of robust data regarding their efficacy, oral antibiotics and steroids remain two of the most common treatments for chronic rhinosinusitis without nasal polyps (CRSsNP). We sought to objectively compare the efficacy of antibiotics and steroids, independently and in combination, for the initial treatment of CRSsNP. To that end, we conducted a retrospective chart review of 100 patients-51 men and 49 women, age 20 to 85 years (mean: 50)-who were treated for CRSsNP from January 2010 through January 2015. Of this group, 17 patients were treated with an antibiotic only, 28 with a steroid only, and 55 with both agents. All patients underwent computed tomography (CT) before and after treatment, and we compared the three groups' pre- and post-treatment Lund-Mackay CT scores, symptom scores, and rates of surgery. The average time between the pre- and post-treatment visits was 4.4 weeks. The mean Lund-Mackay CT score for the entire study population was significantly lower after treatment than at baseline (6.3 vs. 9.1; p < 0.001); however, there were no significant differences among the three groups in either pre- or post-treatment scores. Symptom scores were significantly better in the combination therapy group than in the two monotherapy groups (p < 0.001). In all, 40 of the 100 patients underwent surgery; the difference in surgery rates among the three groups was not statistically significant (p = 0.884). Surgery was performed on 9 of the 52 (17.3%) patients who either were followed for at least 1 year or who had had surgery within the first year postoperatively; again, there were no significant differences among the three groups (p = 0.578). We conclude that although the Lund-Mackay CT scores decreased significantly in the antibiotic, steroid, and combination therapy groups, no one regimen was superior to any other for treating CRSsNP in our study.

A survey of neural tube defect pregnancies in north-west England

The preliminary results are reported of the first eighteen months of a three year survey of NTD affected pregnancies in the North Western Region of England. The results are consistent with a general decline in the incidence of NTD. Prenatal screening has been available for 10 years but babies continue to be born with NTD. Supportive services are often lacking for parents having had an affected pregnancy and methods of imparting advice regarding recurrence risks have been shown to be variable and not always efficient.