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The Use of Prophylactic Antibiotics in Mandibular Fracture Repair
Lauren C. Nigro, BA.
Robert Wood Johnson Medical School, UMDNJ, Camden, NJ, USA.

PURPOSE:
Antibiotic overuse is an important issue in healthcare. Many Pay for Performance programs include a quality measure that addresses this by financially penalizing hospitals that do not meet certain guidelines. For example, in the Surgical Care Improvement Project (SCIP), guidelines call for discontinuation of antibiotics within 24 hours. In some areas, there is strong pressure from hospital systems to control antibiotic use to conform to guidelines.
There is no standard protocol for the use of prophylactic antibiotics during repair of mandibular fractures. Studies of prophylactic antibiotic use are ambiguous and underpowered. The purpose of this study is to evaluate the use of antibiotics during mandibular fracture repair among practicing plastic and oral and maxillofacial surgeons and to define practical, clinical practice in this area. We hypothesize that antibiotics are frequently administered beyond 24 hours postoperatively, despite lack of data to support this, and do not meet SCIP guidelines.
METHODS:
A survey designed to assess the use of antibiotics in mandibular fracture repair was emailed to members of the American Society of Maxillofacial Surgeons and New Jersey Board Certified Oral and Maxillofacial Surgeons. Scenarios included a clearly closed fracture treated closed, a fracture with minimal soft tissue disruption treated closed or with internal fixation, a fracture with significant soft tissue disruption treated closed or with internal fixation, and a fracture through a third molar site. Responses were analyzed for trends and statistical significance.
RESULTS:
One hundred and twenty one of 820 (14.76%) surgeons responded to the survey. 75% of surgeons treated more than 10 fractures per year.
Most respondents preferred 24 hours or less of prophylaxis for fractures treated with intermaxillary fixation only. Respondents increasingly chose longer durations of antibiotic treatment for open fractures and fractures repaired with open reduction and internal fixation. In all scenarios, antibiotic usage outside of SCIP guidelines occurred, ranging from 10% in the case of subcondylar fractures treated with IMF, to over 80% in a comminuted angle fracture treated with ORIF.
A penicillin, followed by a first-generation cephalosporin, were the antibiotics of choice. Clindamycin was the preferred prophylactic agent for patients with a serious penicillin allergy. More than 80% of respondents would provide an additional oral antiseptic, such as Peridex. The majority of respondents would increase the duration and/or dose of their typical prophylactic regimen if particular patient-specific factors, such as immunocompromise, poor dentition/hygiene, or diabetes mellitus were present.
CONCLUSION:
Antibiotic usage in mandibular fracture treatment by experienced surgeons is frequently at odds with commonly accepted quality measure guidelines. Lack of strong evidence for or against this practice is lacking, however medicolegal concerns may influence the practitioner to follow common practice. As clinical decision making is increasingly influenced by outside sources, the pull between forces of guidelines and personal practice shows the need for better data.
Prophylactic antibiotic use by mandibular fracture type, location, and method of repair
No antibiotics< 24 hours antibiotics> 24 hours antibiotics
Fracture typeClosed
Open
Soft Open
p-value*
52.7%
4.1%
20.0%
<0.01
37.3%
26.7%
38.7%
0.02
10.0%
69.3%
40.5%
<.001
Fracture locationSubcondylar
Parasymphyseal
Angle
p-value
52.7%
6.1%
0.0%
<0.01
37.3%
30.0%
19.9%
0.03
10.0%
63.9%
80.1%
<0.01
Repair MethodORIF
IMF
p-value
0.2%
25.3%
<0.01**
24.2%
33.4%
<0.01
75.6%
41.3%
<0.01
All p-values derived from Pearson Chi Square tests unless indicated
* does not include soft open fracture
** Fisher exact


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