J Oral Maxillofac 4934~942.
Surg
1991
Survey of Antibiotic Prophylaxis for Intraoral Orthogna thic Surgery CAPT JAMES M. HEIT, DDS, USAF, DC,* COL VINCENT W. FARHOOD, DDS, USAF, DC,t AND MAJ RICHARD C. EDWARDS, DDS, USAF, DC+ A survey was sent to 114 oral and maxillofacial surgery residency programs to determine the prophylactic use of antibiotics with intraoral orthognathic procedures. Seventy-four percent of the programs responded. Review of the data showed that all programs used antibiotic prophylaxis for intraoral orthognathic procedures, and that penicillin or a cephalosporin were the drugs most often used. However, there was no consistent protocol for the method or duration of drug administration. A discussion of rationale for antibiotic usage, concentration, and duration is presented.
ministration of the antibiotic probably does not alter drug concentration within the wound until revascularization occurs.3 Burke demonstrated the phenomenon when he noted that organisms inoculated in wounds are maximally susceptible to antibiotics when the drug is present in the tissue before the bacteria are introduced. He further noted that initiation of antibiotic therapy 3 hours or longer after contamination has no observable effect on lesion size.4*5 The need for prophylactic antibiotic coverage for intraoral orthognathic surgery has been questioned by the results of specific studies,6m8 and the criteria for the use of prophylactic antibiotics appear to differ. Some authors favor prophylactic coverage for all intraoral orthognathic cases.‘,’ Another author reports that he reserves its use for those patients with a history of a well-established need for prophylaxis, ie, rheumatic fever, those with metabolic disease that may lower resistance to infection, and those who have an osteotomy that requires the use of sizable bone grafts.6 Other criteria cited include cases when fascial spaces are opened through an intraoral approach, if a potential exists for formation of large hematomas, if tissue trauma is excessive, when the duration of surgery is longer than 4 hours, or when intraoral and extraoral surgery is done simultaneously. lo The purpose of this survey of oral and maxillofacial surgery residency programs was to document the preferred regimen and criteria for antibiotic prophylaxis in intraoral orthognathic procedures and to
The role of antibiotics in intraoral orthognathic surgery remains controversial. Exposure of the surgically mobilized osseous segments to the contaminants of the oral cavity. nasal cavity, or maxillary sinuses for many practitioners is the criterion for use of prophylactic antibiotic coverage.’ However. correct patient selection and preparation, careful handling of tissues, and proper wound care can reduce the postoperative infection rate and the need for antibiotic coverage. The basic purpose of antibiotic prophylaxis is to provide an adequate drug level in the tissues before, during, and for the shortest possible time after the procedure.* The antibiotic concentration in the blood clot surrounding the wound will be determined by systemic blood titers at the time of clot formation. After the clot has stabilized, further ad-
Received from the Department of Oral and Maxillofacial Surgery, David Grant USAF Medical Center, Travis Air Force Base, CA. * Second-Year Resident. t Assistant Chairman. $ staff. The views expressed in this material are those of the authors and do not reflect the offkial policy or position of the US government, the Department of Defense, or the Department of the Air Force. Address correspondence and reprint requests to Capt Heit: USAF Medical Center/SGDO. Travis AFB. CA 945355300. This is a US government
work.
There are no restrictions
on
its use. 0278-2391/91/4904-0003$0.00/O
340
341
HEJT ET AL
correlate what has been reported with clinical practice.
in the literature
Materials and Methods A questionnaire was sent to the 114 oral and maxillofacial surgery residencies listed in the 1987-88 edition of the ASDA Guide to Oral and Maxillofacial Surgery Residencies. Eighty-four of those surveyed (74%) responded. Topics addressed in the questionnaire included percentage of intraoral orthognathic procedures incorporating antibiotic prophylaxis, criteria used for use of prophylactic antibiotics, antibiotic of choice, route of administration, and duration of use. Results All participants in the study responded that they use antibiotic prophylaxis 76% to 100% of the time. The criteria for deciding whether to use antibiotic prophylaxis during intraoral orthognathic procedures were reported as opening fascial spaces through the intraoral approach (43), use of bone grafts intraorally (34), formation of a large hematoma (34), excessive tissue trauma (13), duration of surgery greater than 4 hours (19), simultaneous intraoral and extraoral surgery (19), and use of rigid fixation ( 15). The antibiotics of choice were penicillin (64) and cephalosporin (20), some programs reporting more than one choice. The most common dosage for penicillin was 2 million U every 4 hours (two thirds of users). All respondents administered the antibiotics intraveneously. Some used a limited time regimen, and some carried their treatment for 2 weeks (intravenously [IV] and orally). Eight programs give antibiotics IV intraoperatively and in the recovery room only, while 13 give it for 24 hours postoperatively, 13 for 48 hours postoperatively, and 11 for 72 hours postoperatively. Many institutions give postoperative antibiotics IV followed by oral regimens. Five programs follow IV administration with 5 days of oral penicillin, 23 with 7 to 10 days of oral penicillin, and 7 give cephalosporin IV, followed by 5 to 7 days of cephalosporin orally. There were several interesting comments in response to the criteria for use of prophylactic antibiotics. Eight respondents considered antibiotic prophylaxis routine for all their orthognathic procedures, but did not specify their reasons. Two who responded considered it imperative for medicolegal reasons. One of the respondents said, “Patients who get infected tend to sue. Even though they (antibiotics) may not be necessary, failure to use antibiotics is not understood by the lay public.”
Discussion Evaluation of the data from this survey showed significant findings in several areas. Despite the evidence provided by several studies that questions the need for prophylactic antibiotic coverage, all the programs responded that they use prophylactic antibiotic coverage in 76% to 100% of their intraoral orthognathic cases. Contamination of fascial spaces by oral flora, and use of bone or other graft material were the principle criteria cited for providing antibiotic coverage. The true motivation for antibiotic usage is questionable, however, when comments indicate coverage is provided for medicolegal purposes. Penicillin was considered the drug of choice by the majority of programs responding. Several programs considered a cephalosporin as the prophylactic drug of choice, in spite of the fact that most studies show little or no therapeutic gain with cephalosporin and the difference in cost is considerable. “‘O The rationale for selecting specific antibiotics was not addressed by this survey, and none of the respondents specified their reason for choosing a cephalosporin. Intravenous administration was reported to be the preferred route of administration perioperatively. The greatest variations in the survey was in the dose of drug given, the interval, and the duration of coverage. The peak therapeutic concentration of an antibiotic at the site of infection should be three to four times the minimum inhibitory concentration (MIC). After rapid intravenous administration of penicillin, soft-tissue concentration reaches the peak level within 15 to 30 minutes and remains relatively stable for 2 hours. ” Penicillin G has a MIC for susceptible organisms of 0.1 p.glmL.” Administration of 600,000 U of penicillin G IV achieves a peak of 7 pg/mL, which is greater than three to four times the MIC for susceptible organisms. Therefore, for intraoral procedures, penicillin should be given parenterally in a dosage of 1 or 2 million U preoperatively and an additional dose every 1Y’zto 2 hours. The last antibiotic dose should be given in the recovery room.” The majority of responding programs continue antibiotic coverage beyond the immediate postoperative period despite evidence that prolonged postoperative coverage, especially oral medication, provides little or no therapeutic value, and may even be harmful to the patient.4-8*‘1 Summary A survey of oral and maxillofacial surgery residency programs was developed to document the
342 preferred regimen and criteria for antibiotic prophylaxis in intraoral orthognathic procedures. Considerable variance was encountered among programs. Little or no correlation between the literature and clinical practice in residency programs was apparent from evaluation of the data. References 1. Ruggles JE, Hann JR: Antibiotic prophylaxis in intraoral orthognathic surgery. J Oral Maxillofac Surg 42:797, 1984 2. Veterans Administration Ad Hoc Interdisciplinary Advisory Committee on Antimicrobial Drug Usage: Prophylaxis in surgery. JAMA 237:lOO3, 1977 3. Chodak GW, Plaut ME: Use of systemic antibiotics for prophylaxis in surgery: A critical review. Arch Surg 112:326, 1977
ANTIBIOTICS FOR INTRAORAL ORTHOGNATHIC
SURGERY
4. Burke JR: Preventive antibiotics in surgery. Postgrad Med 58:65, 1975 5. Burke JR: The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery 50:161, 1981 6. Yrastorza JA: Indications for antibiotics in orthognathic surgery. J Oral Surg 34514. 1976 7. Peterson LJ, Booth DF: Efftcacy of antibiotic prophylaxis in intraoral orthognathic surgery. J Oral Surg 34: 1088, 1976 8. Martis C, Karaabouta I: Infection after orthognathic surgery, with and without preventive antibiotics. Int J Oral Surg 13:490, 1984 9. Gallagher DM, Epker BN: Infection following intraoral surgical correction of dentofacial deformities. J Oral Surg 38: 117, 1980 10. Greenberg RN, James RB, Marier RL, et al: Microbiologic and antibiotic aspects of infection in the oral and maxillofacial region. J Oral Surg 37:873, 1979 11. Topazian, Goldberg: Oral and Maxillofacial Infections (ed 2). Philadelphia, PA, Saunders, 1987
Surg
1991
Survey of Antibiotic Prophylaxis for Intraoral Orthogna thic Surgery CAPT JAMES M. HEIT, DDS, USAF, DC,* COL VINCENT W. FARHOOD, DDS, USAF, DC,t AND MAJ RICHARD C. EDWARDS, DDS, USAF, DC+ A survey was sent to 114 oral and maxillofacial surgery residency programs to determine the prophylactic use of antibiotics with intraoral orthognathic procedures. Seventy-four percent of the programs responded. Review of the data showed that all programs used antibiotic prophylaxis for intraoral orthognathic procedures, and that penicillin or a cephalosporin were the drugs most often used. However, there was no consistent protocol for the method or duration of drug administration. A discussion of rationale for antibiotic usage, concentration, and duration is presented.
ministration of the antibiotic probably does not alter drug concentration within the wound until revascularization occurs.3 Burke demonstrated the phenomenon when he noted that organisms inoculated in wounds are maximally susceptible to antibiotics when the drug is present in the tissue before the bacteria are introduced. He further noted that initiation of antibiotic therapy 3 hours or longer after contamination has no observable effect on lesion size.4*5 The need for prophylactic antibiotic coverage for intraoral orthognathic surgery has been questioned by the results of specific studies,6m8 and the criteria for the use of prophylactic antibiotics appear to differ. Some authors favor prophylactic coverage for all intraoral orthognathic cases.‘,’ Another author reports that he reserves its use for those patients with a history of a well-established need for prophylaxis, ie, rheumatic fever, those with metabolic disease that may lower resistance to infection, and those who have an osteotomy that requires the use of sizable bone grafts.6 Other criteria cited include cases when fascial spaces are opened through an intraoral approach, if a potential exists for formation of large hematomas, if tissue trauma is excessive, when the duration of surgery is longer than 4 hours, or when intraoral and extraoral surgery is done simultaneously. lo The purpose of this survey of oral and maxillofacial surgery residency programs was to document the preferred regimen and criteria for antibiotic prophylaxis in intraoral orthognathic procedures and to
The role of antibiotics in intraoral orthognathic surgery remains controversial. Exposure of the surgically mobilized osseous segments to the contaminants of the oral cavity. nasal cavity, or maxillary sinuses for many practitioners is the criterion for use of prophylactic antibiotic coverage.’ However. correct patient selection and preparation, careful handling of tissues, and proper wound care can reduce the postoperative infection rate and the need for antibiotic coverage. The basic purpose of antibiotic prophylaxis is to provide an adequate drug level in the tissues before, during, and for the shortest possible time after the procedure.* The antibiotic concentration in the blood clot surrounding the wound will be determined by systemic blood titers at the time of clot formation. After the clot has stabilized, further ad-
Received from the Department of Oral and Maxillofacial Surgery, David Grant USAF Medical Center, Travis Air Force Base, CA. * Second-Year Resident. t Assistant Chairman. $ staff. The views expressed in this material are those of the authors and do not reflect the offkial policy or position of the US government, the Department of Defense, or the Department of the Air Force. Address correspondence and reprint requests to Capt Heit: USAF Medical Center/SGDO. Travis AFB. CA 945355300. This is a US government
work.
There are no restrictions
on
its use. 0278-2391/91/4904-0003$0.00/O
340
341
HEJT ET AL
correlate what has been reported with clinical practice.
in the literature
Materials and Methods A questionnaire was sent to the 114 oral and maxillofacial surgery residencies listed in the 1987-88 edition of the ASDA Guide to Oral and Maxillofacial Surgery Residencies. Eighty-four of those surveyed (74%) responded. Topics addressed in the questionnaire included percentage of intraoral orthognathic procedures incorporating antibiotic prophylaxis, criteria used for use of prophylactic antibiotics, antibiotic of choice, route of administration, and duration of use. Results All participants in the study responded that they use antibiotic prophylaxis 76% to 100% of the time. The criteria for deciding whether to use antibiotic prophylaxis during intraoral orthognathic procedures were reported as opening fascial spaces through the intraoral approach (43), use of bone grafts intraorally (34), formation of a large hematoma (34), excessive tissue trauma (13), duration of surgery greater than 4 hours (19), simultaneous intraoral and extraoral surgery (19), and use of rigid fixation ( 15). The antibiotics of choice were penicillin (64) and cephalosporin (20), some programs reporting more than one choice. The most common dosage for penicillin was 2 million U every 4 hours (two thirds of users). All respondents administered the antibiotics intraveneously. Some used a limited time regimen, and some carried their treatment for 2 weeks (intravenously [IV] and orally). Eight programs give antibiotics IV intraoperatively and in the recovery room only, while 13 give it for 24 hours postoperatively, 13 for 48 hours postoperatively, and 11 for 72 hours postoperatively. Many institutions give postoperative antibiotics IV followed by oral regimens. Five programs follow IV administration with 5 days of oral penicillin, 23 with 7 to 10 days of oral penicillin, and 7 give cephalosporin IV, followed by 5 to 7 days of cephalosporin orally. There were several interesting comments in response to the criteria for use of prophylactic antibiotics. Eight respondents considered antibiotic prophylaxis routine for all their orthognathic procedures, but did not specify their reasons. Two who responded considered it imperative for medicolegal reasons. One of the respondents said, “Patients who get infected tend to sue. Even though they (antibiotics) may not be necessary, failure to use antibiotics is not understood by the lay public.”
Discussion Evaluation of the data from this survey showed significant findings in several areas. Despite the evidence provided by several studies that questions the need for prophylactic antibiotic coverage, all the programs responded that they use prophylactic antibiotic coverage in 76% to 100% of their intraoral orthognathic cases. Contamination of fascial spaces by oral flora, and use of bone or other graft material were the principle criteria cited for providing antibiotic coverage. The true motivation for antibiotic usage is questionable, however, when comments indicate coverage is provided for medicolegal purposes. Penicillin was considered the drug of choice by the majority of programs responding. Several programs considered a cephalosporin as the prophylactic drug of choice, in spite of the fact that most studies show little or no therapeutic gain with cephalosporin and the difference in cost is considerable. “‘O The rationale for selecting specific antibiotics was not addressed by this survey, and none of the respondents specified their reason for choosing a cephalosporin. Intravenous administration was reported to be the preferred route of administration perioperatively. The greatest variations in the survey was in the dose of drug given, the interval, and the duration of coverage. The peak therapeutic concentration of an antibiotic at the site of infection should be three to four times the minimum inhibitory concentration (MIC). After rapid intravenous administration of penicillin, soft-tissue concentration reaches the peak level within 15 to 30 minutes and remains relatively stable for 2 hours. ” Penicillin G has a MIC for susceptible organisms of 0.1 p.glmL.” Administration of 600,000 U of penicillin G IV achieves a peak of 7 pg/mL, which is greater than three to four times the MIC for susceptible organisms. Therefore, for intraoral procedures, penicillin should be given parenterally in a dosage of 1 or 2 million U preoperatively and an additional dose every 1Y’zto 2 hours. The last antibiotic dose should be given in the recovery room.” The majority of responding programs continue antibiotic coverage beyond the immediate postoperative period despite evidence that prolonged postoperative coverage, especially oral medication, provides little or no therapeutic value, and may even be harmful to the patient.4-8*‘1 Summary A survey of oral and maxillofacial surgery residency programs was developed to document the
342 preferred regimen and criteria for antibiotic prophylaxis in intraoral orthognathic procedures. Considerable variance was encountered among programs. Little or no correlation between the literature and clinical practice in residency programs was apparent from evaluation of the data. References 1. Ruggles JE, Hann JR: Antibiotic prophylaxis in intraoral orthognathic surgery. J Oral Maxillofac Surg 42:797, 1984 2. Veterans Administration Ad Hoc Interdisciplinary Advisory Committee on Antimicrobial Drug Usage: Prophylaxis in surgery. JAMA 237:lOO3, 1977 3. Chodak GW, Plaut ME: Use of systemic antibiotics for prophylaxis in surgery: A critical review. Arch Surg 112:326, 1977
ANTIBIOTICS FOR INTRAORAL ORTHOGNATHIC
SURGERY
4. Burke JR: Preventive antibiotics in surgery. Postgrad Med 58:65, 1975 5. Burke JR: The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery 50:161, 1981 6. Yrastorza JA: Indications for antibiotics in orthognathic surgery. J Oral Surg 34514. 1976 7. Peterson LJ, Booth DF: Efftcacy of antibiotic prophylaxis in intraoral orthognathic surgery. J Oral Surg 34: 1088, 1976 8. Martis C, Karaabouta I: Infection after orthognathic surgery, with and without preventive antibiotics. Int J Oral Surg 13:490, 1984 9. Gallagher DM, Epker BN: Infection following intraoral surgical correction of dentofacial deformities. J Oral Surg 38: 117, 1980 10. Greenberg RN, James RB, Marier RL, et al: Microbiologic and antibiotic aspects of infection in the oral and maxillofacial region. J Oral Surg 37:873, 1979 11. Topazian, Goldberg: Oral and Maxillofacial Infections (ed 2). Philadelphia, PA, Saunders, 1987
