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Antibiotics and Facial Fractures: Evidence-Based Recommendations Compared to Experience-Based Practice
Gerhard S. Mundinger, M.D, Michael R. Christy, M.D., Daniel E. Borsuk, M.D., C.M., M.B.A., Zachary Okhah, B.S., Branko Bojovic, M.D., Amir H. Dorafshar, M.B.Ch.B., Eduardo D. Rodriguez, M.D., D.D.S..
Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA.
PURPOSE:Controversy regarding the role of antibiotics in the surgical management of craniofacial trauma abounds in both the literature and individual physician practices. The purpose of this study was to compare an evidence-based systematic review of the literature regarding antibiotic prophylaxis in operative craniofacial trauma to expert-based clinical practice.
METHODS:A systematic review of the literature was performed in November 2012 using Medline, Embase, Pubmed and Cochrane databases to identify all published studies evaluating the use of antibiotics in craniofacial trauma including the upper, middle and lower thirds of the craniofacial skeleton. Search terms included “frontal sinus”, “nasal bone”, “zygoma”, "orbit”, “mandible”, “fracture”, “antibiotics”, “prophylaxis,” and “facial fracture” alone and in combination. Each identified study was independently evaluated by three reviewers for inclusion or exclusion based on study design, study population, and indications for antibiotics. Expert opinions were garnered during the Advanced Orbital Surgery Symposium, held May 3-5th, 2012 in Baltimore, Maryland, in the form of surveys evaluating senior-surgeon clinical antibiotic prescribing practices by facial third.
RESULTS: Literature review identified 433 studies relating to antibiotic prophylaxis and facial fracture management. 47 studies were ultimately included following author review. Penicillins, cephalosporins, and clindamycin were the most commonly prescribed antibiotics. Studies supported the use of intraoperative antibiotics in all facial thirds. Literature review found no evidence supporting the use of post-operative antibiotics in routine upper and mid-face fractures. Support for pre-operative and post-operative antibiotic use in mandible fractures was mixed, with suggestion of benefit in open mandible fractures in some studies. Survey respondents (n= 17) cumulatively reported their antibiotic prescribing practices over 286 practice years and 24,012 facial fracture cases. With regard to expert practice, cefazolin was most commonly prescribed in all situations. Percentages of prescribers administering pre, intra, and post-operative antibiotics, respectively, by facial third were as follows: upper face 47.1%, 94.1%, 70.6%; mid-face 47.1%, 100%, 70.6%; mandible 68.8%, 94.1%, 64.7%. For those prescribing post-operative antibiotics, average duration for upper face, mid-face, and mandible fractures was 3.7, 4.0, and 4.6 days, respectively (range 1-7 days in each facial third). There were no significant differences between prescribing practices by facial third.
CONCLUSION:The available literature addressing antibiotic use in facial fracture management lacks adequate study design, data analysis, and resolution in facial fracture reporting to draw meaningful conclusions. Although the literature does not support pre and post-operative antibiotic use in upper and mid-face fractures, experts in the field report frequent antibiotic use at these time-points in all facial thirds. The higher reported rates of preoperative antibiotic use and longer average duration of post-operative antibiotic administration for mandible fractures may be warranted, especially for open fractures, and should be directly investigated.
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