Clin. Otolaryngol. 1990, 15, 363-366
Chest infection following head and neck surgery: a pilot study RANDALL P. MORTON, C A R Y G . MELLOW AND E. B . DORMAN Department of Otolaryngology, Head und Neck Surgery, Green Lane Hospital, Auckland, New Zealand
Accepted for publication 7 June 1989
MORTONR. P., MELLOWC. G. & DORMAN E. €3. (1990) Clin. Otolaryzgol. 15, 363-366 Chest infection following head and neck surgery: a pilot study
This paper reports the results of a pilot study which examined factors associated with chest infection following head and neck surgery. The overall rate of chest infection was 1 I %, but was 20% in those patients having a tracheotomy. No infection developed in patients with an intact airway. Other factors which emerged as possibly important were the duration of surgery and heavy regular alcohol intake. We recommend that prophylactic antibiotics be continued for at lease 48 h in patients requiring a tracheotomy as part of their head and neck surgery. This is against the trend of shorter antibiotic regimens recommended for prevention of wound infections. Keywords antibiotic prophylaxis head and neck surgery chest infection Clinical studies relating to major head and neck surgery and antibiotic prophylaxis have focused on wound This is understandable as the effects of wound infection can be considerable, causing major morbidity and a prolonged hospital stay. There are many different antibiotic regimens in use and most of them are reported to restrict wound sepsis in contaminated head and neck surgical procedures to about 20%. Generally, little consideration has been given to the incidence of chest infection after head and neck surgery but some reports 4,8-10 suggest a rate of 0-29% can be expected. The rate is even higher (44%) in patients receiving no prophylactic antibiotics.' Antibiotic regimens lasting for 3 or 4 days confer no added advantage over those
of 24 h or less when considering the rate of post-operative wound infections, but the short course does not seem to be as effective as a longer one in preventing postoperative chest infection." We conducted a pilot study of 2 antibiotic regimens to assess their relative efficacy and to determine which factors were the strongest predictors of post-operative chest infection. This paper reports our results and discusses the implications.
Methods Patients admitted to the Head and Neck Surgery Unit at Green Lane Hospital for major head and neck surgery were enrolled into a trial in which patients were randomly allocated to 2 different treatment regimens.
Correspondence: Randall P. Morton, Department of Otolaryngology, Head and Neck Surgery, Green Lane Hospital, Green Lane, Auckland 3, New Zealand.
363
364
R . P . MORTON
e t al
Table 1. Antibiotic regimen Group 1 Group 2
Augmentin (Cost = $20. I6 per day) Ampicillin Flucloxacillin Metronidazole (cost = NZ$34.84 per day)
Table 3. Operative procedures 1.2 g i.v. 8-hourly Augmentin ‘WUP
500 mg i.v. 6-hourly 500 mg i.v. 6-hourly 500 mg* 8-hourly
*Intraoperative 500 mg metronidazole i.v. Post-operative 500 mg metronidazole suppositories. Table 2. Criteria for chest infection Should include two of the following: (1) Temperature rise above 37.S”’. (2) Radiological evidence. ( 3 ) Increase in sputum with signs and symptoms of infectivity. (4) Positive culture of pathogens.
These compared Augmentin (amoxicillin with clavulanic acid) against triple therapy (ampicillin, flucloxacillin and metronidazole). The antibiotics were commenced intra-operatively and were given for 4 postoperative days in accordance with the regimen outlined in Table 1. Patients allergic to penicillin, those receiving antibiotic therapy for other reasons, and those who had a pre-existing wound or chest infection, were excluded from this study. Details of the operation were recorded and an accurate record of temperature, state of the wound, the chest and the urinary system, were kept post-operatively. Criteria for determining the presence of a chest infection are detailed in Table 2. Results Forty-five patients were entered in this study: the operations are summarized in Table 3. The average age of the patients was 56 years (range 17-83) and there was no significant difference between the 2 groups for sex, age, preoperative haemoglobin or albumen, smoking history, alcohol intake, presence of malignancy, formation of tracheostomy or duration of surgery.
Laryngectomy/ pharyngectomy + RND* 9 Composite resection 1 (‘Commando’) Craniofacial resection 1 Nasopharyngeal resection 1 RND* 3 Parotidectomy 1 Thyroidectom y 1 Cricopharyngeal 2 Myotomy Tracheoplasty 1 Frontoethmoidectomy 2 Maxillectomy 1
Triple fherapj group
9
~
*Radical Neck Dissection
Five patients (1 1Yo) developed chest infections: 3 from the Augmentin group and 2 from the triple therapy group. These differences were not significant. Thirty-five patients (78%) were regular smokers at the time of surgery: 4 smokers (11%) and 1 non-smoker (10%) developed a chest infection, indicating no difference between the 2 groups. Patients with a history of heavy alcohol intake had a 15% (3 of 20) rate of chest infection whereas non-drinkers and light drinkers had a rate of only 8% (2 of 25). The numbers were small, however, so the difference was not statistically significant. Twenty-five patients had tracheostomies or laryngectomy stomas created during the course of their operation. Five (20%) developed chest infections whereas none of the other 20 patients developed a chest infection. This was statistically significant (P < 0.05: chi-square analysis). The mean duration of surgery was 3.7 h. Seventeen patients (38%) had operations lasting longer than 3.7h. Five (29%) of these developed chest infections. None of the 28 patients with an operation taking less than 3.7 h developed a chest infection. This difference was statistically significant (P < 0.05). Culture of infected sputum produced Staphylococcus aureus, Escherichia coli,
Chest infection following head and neck surgery Pseudornonus, Huemophilus injuenzae, Enterobacter, and Klebsiella ( x 2). Discussion There was no difference in the rate of chest infection between the 2 antibiotic regimens. Although the numbers in our study were small, we feel there were sufficient reasons to support a single antibiotic regimen rather than the triple therapy. The single therapy was not only easier to administer, but cheaper. (The cost of the triple therapy is 25% greater than that of Augmentin alone.) Only patients who had a prolonged anaesthetic (more than 3.7 h) together with formation of a tracheostomy or laryngectomy stoma during the course of their operation, developed a chest infection. Which of these 2 factors (time or tracheostomy) is the more important is uncertain, but it is likely to be the tracheal surgery ( 2 of the longer operations did not have a tracheostomy, and neither of them developed a chest infection). All our patients had diligent, early, postoperative chest physiotherapy and, if a tracheostomy or stoma was in place, regular tracheal suction toilet. Generally, a tracheostomy was retained for at least 5 days post-operatively. Unlike abdominal surgery, where there is splinting of the diaphragm, our patients were able to breathe deeply, However, a tracheostomy tube impairs a patient's ability to cough strongly and also tends to promote aspiration from the pharynx. These factors are likely to have precipitated, or contributed to the development of a chest infection. Age did not emerge as a factor in our service, but a study of head and neck cancer surgery in a geriatric population' yielded a post-operative chest infection rate of 20% which is twice our rate. No statement was made regarding antibiotic prophylaxis or how many required tracheostomy in the other study, so direct comparison may not be valid.
365 The presence of Gram-negative intestinal bacilli in the tracheal aspirate has been reported previously in patients with tracheostomies." It seems that the presence of a tracheostomy promotes colonization by Gram-negative bacteria, possibly from aspiration of pharyngeal secretions or from the stomach, via the naso-gastric tube. (Gram-negative bacilli generally become established in the pharynx in patients who are in hospital and debilitated, irrespective of their specific disease process.12) We expected smokers to carry a greater risk of chest infection but this did not emerge, possibly because most of our nonsmokers had in fact been chronic smokers at some stage. The trend of higher chest infections in heavy alcohol consumers was interesting, and deserves further study. While it is true that wound infections are probably related to contamination at the time of surgery, and that prophylactic antibiotics are not required for more than 24h, a chest infection may develop from retained secretions 2 or more days post-operatively." Johnston'' does not use antibiotics in patients having a tracheostomy, but he does not distinguish between those having tracheostomy alone, and those in whom the tracheostomy is performed in the course of a major head and neck resection. The prolonged anaesthetic and the debilitation for the first day or two post-operatively justifies the use of antibiotics for major surgery. We believe that it is appropriate to continue antibiotic therapy for at least 2 days post-operatively in patients having a tracheostomy as part of major head and neck surgery. This probably does not alter the incidence of post-operative wound infection but it will help avoid troublesome chest infection in the first few post-operative days.'" Long operations not requiring a tracheostomy probably need 24h or less antibiotic cover. The consequences of a chest infection are not as grave as those of wound infection (none of our patients developed pulmonary abscesses or significant pleural effusions)
366
R . P . MORTON
et al.
but may delay extubation and prolong hospital stay, and therefore deserve serious consideration. We need to examine in more detail the relation between tobacco consumption, alcohol consumption, operation time and tracheostomy, and post-operative chest infection. There is probably considerable confounding of these factors, and a larger study is now under way in our department.
References 1 SWIFTA.C. (1988) Wound sepsis, chemo/prophyClin. Otolarlaxis and maior head and neck surgery. . . yngol. 13, 81-83 2 BECKERG.D. & PARELLG.J. (1979) . , Cefazolin prophylaxis in head and neck cancer surgery. Ann. Otol. Rhinol. Laryngol. 88, 183-183 3 ROBBINS K.T., BYERSR.M., COLER., FAINSTEIN V., GUILLAMONDECUI O.M., SCHANTZS.P., WEBER H. (1988) Wound R.S., WOLF P. & GOEPFERT prophylaxis with metronidazole in head and neck surgery. Laryngoscope 98, 803-806 N., FEEW.E. & LEVINE P. 4 GOODER.L., ABRAMSON (1979) Effect of prophylactic antibiotics in radical head and neck surgery. Laryngoscope 89, 60 1-607
JOHNSON
J.T., MYERSE.N., Yu G.L.,WAGNERR.L.
& SICLERB.A. (1986) Cefazolin vs moxalactam? A
double blind randomized trial of cephalosporins in head and neck surgery. Arch. Otolaryngol. 112, 151-153 FEE,W.E., GLENNM., HANDENC. & HOPPM.L. (1984) One vs two days of prophylactic antibiotics in patients undergoing major head and neck surgery. Laryngoscope 94, 612-614 RAINEC.H., STELLP.M., CORKILL J.E., BARTZOKAS C.A. & GALLWAY A. (1984) Chemoprophylaxis in major head and neck surgery. J . R . Soc. Med. 77, 1006- 1009 TROTTJ.A., DAVIDD.J. & EDWARDSR.M. (1982) Experience with surgery for head and neck cancer in geriatric population. Aust. N . Z . J. Stwg. 52, 149-153 PICCART M., DORP. & KLASTERSKY J. (1988) Antimicrobial prophylaxis of infections in head and neck cancer surgery. Scand. J . Danfeet. Dis. SUPPI. 39, 92-96 P., MOISYN. & GUEDONC. (1988) Cefo10 GE-HANNO taxime in the prophylaxis of otorhinolaryngological cancer surgery. Long-term versus short-term administration, results of a multicentre study. Drugs 35, Suppl. 2, 111-1 15 11 JOHNSON J.T.(1987) Antibiotics in tracheostomy. In Antibiotic Therapy in Head and Neck Surgery. (ed. J. T. Johnson), pp. 93-102. Marcel Dekker, Inc., New York 12 JOHANSON W.E., PIERCEA.K. & SANFORDJ.P. (1969) Changing pharyngeal bacterial flora of hospitalized patients. N. Engl. J. Med. 281, 1137-1 140
Chest infection following head and neck surgery: a pilot study RANDALL P. MORTON, C A R Y G . MELLOW AND E. B . DORMAN Department of Otolaryngology, Head und Neck Surgery, Green Lane Hospital, Auckland, New Zealand
Accepted for publication 7 June 1989
MORTONR. P., MELLOWC. G. & DORMAN E. €3. (1990) Clin. Otolaryzgol. 15, 363-366 Chest infection following head and neck surgery: a pilot study
This paper reports the results of a pilot study which examined factors associated with chest infection following head and neck surgery. The overall rate of chest infection was 1 I %, but was 20% in those patients having a tracheotomy. No infection developed in patients with an intact airway. Other factors which emerged as possibly important were the duration of surgery and heavy regular alcohol intake. We recommend that prophylactic antibiotics be continued for at lease 48 h in patients requiring a tracheotomy as part of their head and neck surgery. This is against the trend of shorter antibiotic regimens recommended for prevention of wound infections. Keywords antibiotic prophylaxis head and neck surgery chest infection Clinical studies relating to major head and neck surgery and antibiotic prophylaxis have focused on wound This is understandable as the effects of wound infection can be considerable, causing major morbidity and a prolonged hospital stay. There are many different antibiotic regimens in use and most of them are reported to restrict wound sepsis in contaminated head and neck surgical procedures to about 20%. Generally, little consideration has been given to the incidence of chest infection after head and neck surgery but some reports 4,8-10 suggest a rate of 0-29% can be expected. The rate is even higher (44%) in patients receiving no prophylactic antibiotics.' Antibiotic regimens lasting for 3 or 4 days confer no added advantage over those
of 24 h or less when considering the rate of post-operative wound infections, but the short course does not seem to be as effective as a longer one in preventing postoperative chest infection." We conducted a pilot study of 2 antibiotic regimens to assess their relative efficacy and to determine which factors were the strongest predictors of post-operative chest infection. This paper reports our results and discusses the implications.
Methods Patients admitted to the Head and Neck Surgery Unit at Green Lane Hospital for major head and neck surgery were enrolled into a trial in which patients were randomly allocated to 2 different treatment regimens.
Correspondence: Randall P. Morton, Department of Otolaryngology, Head and Neck Surgery, Green Lane Hospital, Green Lane, Auckland 3, New Zealand.
363
364
R . P . MORTON
e t al
Table 1. Antibiotic regimen Group 1 Group 2
Augmentin (Cost = $20. I6 per day) Ampicillin Flucloxacillin Metronidazole (cost = NZ$34.84 per day)
Table 3. Operative procedures 1.2 g i.v. 8-hourly Augmentin ‘WUP
500 mg i.v. 6-hourly 500 mg i.v. 6-hourly 500 mg* 8-hourly
*Intraoperative 500 mg metronidazole i.v. Post-operative 500 mg metronidazole suppositories. Table 2. Criteria for chest infection Should include two of the following: (1) Temperature rise above 37.S”’. (2) Radiological evidence. ( 3 ) Increase in sputum with signs and symptoms of infectivity. (4) Positive culture of pathogens.
These compared Augmentin (amoxicillin with clavulanic acid) against triple therapy (ampicillin, flucloxacillin and metronidazole). The antibiotics were commenced intra-operatively and were given for 4 postoperative days in accordance with the regimen outlined in Table 1. Patients allergic to penicillin, those receiving antibiotic therapy for other reasons, and those who had a pre-existing wound or chest infection, were excluded from this study. Details of the operation were recorded and an accurate record of temperature, state of the wound, the chest and the urinary system, were kept post-operatively. Criteria for determining the presence of a chest infection are detailed in Table 2. Results Forty-five patients were entered in this study: the operations are summarized in Table 3. The average age of the patients was 56 years (range 17-83) and there was no significant difference between the 2 groups for sex, age, preoperative haemoglobin or albumen, smoking history, alcohol intake, presence of malignancy, formation of tracheostomy or duration of surgery.
Laryngectomy/ pharyngectomy + RND* 9 Composite resection 1 (‘Commando’) Craniofacial resection 1 Nasopharyngeal resection 1 RND* 3 Parotidectomy 1 Thyroidectom y 1 Cricopharyngeal 2 Myotomy Tracheoplasty 1 Frontoethmoidectomy 2 Maxillectomy 1
Triple fherapj group
9
~
*Radical Neck Dissection
Five patients (1 1Yo) developed chest infections: 3 from the Augmentin group and 2 from the triple therapy group. These differences were not significant. Thirty-five patients (78%) were regular smokers at the time of surgery: 4 smokers (11%) and 1 non-smoker (10%) developed a chest infection, indicating no difference between the 2 groups. Patients with a history of heavy alcohol intake had a 15% (3 of 20) rate of chest infection whereas non-drinkers and light drinkers had a rate of only 8% (2 of 25). The numbers were small, however, so the difference was not statistically significant. Twenty-five patients had tracheostomies or laryngectomy stomas created during the course of their operation. Five (20%) developed chest infections whereas none of the other 20 patients developed a chest infection. This was statistically significant (P < 0.05: chi-square analysis). The mean duration of surgery was 3.7 h. Seventeen patients (38%) had operations lasting longer than 3.7h. Five (29%) of these developed chest infections. None of the 28 patients with an operation taking less than 3.7 h developed a chest infection. This difference was statistically significant (P < 0.05). Culture of infected sputum produced Staphylococcus aureus, Escherichia coli,
Chest infection following head and neck surgery Pseudornonus, Huemophilus injuenzae, Enterobacter, and Klebsiella ( x 2). Discussion There was no difference in the rate of chest infection between the 2 antibiotic regimens. Although the numbers in our study were small, we feel there were sufficient reasons to support a single antibiotic regimen rather than the triple therapy. The single therapy was not only easier to administer, but cheaper. (The cost of the triple therapy is 25% greater than that of Augmentin alone.) Only patients who had a prolonged anaesthetic (more than 3.7 h) together with formation of a tracheostomy or laryngectomy stoma during the course of their operation, developed a chest infection. Which of these 2 factors (time or tracheostomy) is the more important is uncertain, but it is likely to be the tracheal surgery ( 2 of the longer operations did not have a tracheostomy, and neither of them developed a chest infection). All our patients had diligent, early, postoperative chest physiotherapy and, if a tracheostomy or stoma was in place, regular tracheal suction toilet. Generally, a tracheostomy was retained for at least 5 days post-operatively. Unlike abdominal surgery, where there is splinting of the diaphragm, our patients were able to breathe deeply, However, a tracheostomy tube impairs a patient's ability to cough strongly and also tends to promote aspiration from the pharynx. These factors are likely to have precipitated, or contributed to the development of a chest infection. Age did not emerge as a factor in our service, but a study of head and neck cancer surgery in a geriatric population' yielded a post-operative chest infection rate of 20% which is twice our rate. No statement was made regarding antibiotic prophylaxis or how many required tracheostomy in the other study, so direct comparison may not be valid.
365 The presence of Gram-negative intestinal bacilli in the tracheal aspirate has been reported previously in patients with tracheostomies." It seems that the presence of a tracheostomy promotes colonization by Gram-negative bacteria, possibly from aspiration of pharyngeal secretions or from the stomach, via the naso-gastric tube. (Gram-negative bacilli generally become established in the pharynx in patients who are in hospital and debilitated, irrespective of their specific disease process.12) We expected smokers to carry a greater risk of chest infection but this did not emerge, possibly because most of our nonsmokers had in fact been chronic smokers at some stage. The trend of higher chest infections in heavy alcohol consumers was interesting, and deserves further study. While it is true that wound infections are probably related to contamination at the time of surgery, and that prophylactic antibiotics are not required for more than 24h, a chest infection may develop from retained secretions 2 or more days post-operatively." Johnston'' does not use antibiotics in patients having a tracheostomy, but he does not distinguish between those having tracheostomy alone, and those in whom the tracheostomy is performed in the course of a major head and neck resection. The prolonged anaesthetic and the debilitation for the first day or two post-operatively justifies the use of antibiotics for major surgery. We believe that it is appropriate to continue antibiotic therapy for at least 2 days post-operatively in patients having a tracheostomy as part of major head and neck surgery. This probably does not alter the incidence of post-operative wound infection but it will help avoid troublesome chest infection in the first few post-operative days.'" Long operations not requiring a tracheostomy probably need 24h or less antibiotic cover. The consequences of a chest infection are not as grave as those of wound infection (none of our patients developed pulmonary abscesses or significant pleural effusions)
366
R . P . MORTON
et al.
but may delay extubation and prolong hospital stay, and therefore deserve serious consideration. We need to examine in more detail the relation between tobacco consumption, alcohol consumption, operation time and tracheostomy, and post-operative chest infection. There is probably considerable confounding of these factors, and a larger study is now under way in our department.
References 1 SWIFTA.C. (1988) Wound sepsis, chemo/prophyClin. Otolarlaxis and maior head and neck surgery. . . yngol. 13, 81-83 2 BECKERG.D. & PARELLG.J. (1979) . , Cefazolin prophylaxis in head and neck cancer surgery. Ann. Otol. Rhinol. Laryngol. 88, 183-183 3 ROBBINS K.T., BYERSR.M., COLER., FAINSTEIN V., GUILLAMONDECUI O.M., SCHANTZS.P., WEBER H. (1988) Wound R.S., WOLF P. & GOEPFERT prophylaxis with metronidazole in head and neck surgery. Laryngoscope 98, 803-806 N., FEEW.E. & LEVINE P. 4 GOODER.L., ABRAMSON (1979) Effect of prophylactic antibiotics in radical head and neck surgery. Laryngoscope 89, 60 1-607
JOHNSON
J.T., MYERSE.N., Yu G.L.,WAGNERR.L.
& SICLERB.A. (1986) Cefazolin vs moxalactam? A
double blind randomized trial of cephalosporins in head and neck surgery. Arch. Otolaryngol. 112, 151-153 FEE,W.E., GLENNM., HANDENC. & HOPPM.L. (1984) One vs two days of prophylactic antibiotics in patients undergoing major head and neck surgery. Laryngoscope 94, 612-614 RAINEC.H., STELLP.M., CORKILL J.E., BARTZOKAS C.A. & GALLWAY A. (1984) Chemoprophylaxis in major head and neck surgery. J . R . Soc. Med. 77, 1006- 1009 TROTTJ.A., DAVIDD.J. & EDWARDSR.M. (1982) Experience with surgery for head and neck cancer in geriatric population. Aust. N . Z . J. Stwg. 52, 149-153 PICCART M., DORP. & KLASTERSKY J. (1988) Antimicrobial prophylaxis of infections in head and neck cancer surgery. Scand. J . Danfeet. Dis. SUPPI. 39, 92-96 P., MOISYN. & GUEDONC. (1988) Cefo10 GE-HANNO taxime in the prophylaxis of otorhinolaryngological cancer surgery. Long-term versus short-term administration, results of a multicentre study. Drugs 35, Suppl. 2, 111-1 15 11 JOHNSON J.T.(1987) Antibiotics in tracheostomy. In Antibiotic Therapy in Head and Neck Surgery. (ed. J. T. Johnson), pp. 93-102. Marcel Dekker, Inc., New York 12 JOHANSON W.E., PIERCEA.K. & SANFORDJ.P. (1969) Changing pharyngeal bacterial flora of hospitalized patients. N. Engl. J. Med. 281, 1137-1 140
