The Incidence of Post Operative Infection Following Orthognathic Surgery Using Three Standard Perioperative Antimicrobial Protocols
All surgical procedures violate the epidermis or mucosa. Both are important barriers to prevent infection. Despite attempts to disinfect these surfaces, microbes are still present and may cause post-operative infections (POI). The oral cavity contains more bacteria than most other areas of the body which increases the risk of POI. Orthognathic surgical procedures are clean-contaminated and involve incising through non sterile oral mucosa. The purpose of the present study is to evaluate the effectiveness of three standard peri-operative antimicrobial regimes for preventing POI.
A retrospective review was conducted on patients undergoing orthognathic surgery between October 2005 and December 2010 at the Department of OMFS in Halifax, Nova Scotia, Canada. Data was gathered regarding the incidence of POI for both single and multiple jaw surgeries. The three antimicrobial courses used were: 1. One or two grams of cefazolin administered 30 min prior to incision followed by three post-operative doses every 8 hours, 2. Clindamycin 600mg IV 30 min pre-operatively and three post-operative doses every 8 hours, 3. Penicillin G 2 million units 30 min pre-operatively followed by four post-operative doses every 6 hours. All surgical sites were prepped with a 10% betadine solution prior to surgery and patients were discharged home with two weeks of chlorhexidine mouth rinse. Results were analyzed using chi-squared test for statistical significance.
1517 cases were preformed during the specified dates. A total of 135 POI were documented (8.9%). 313 patients had a bilateral sagittal split osteotomy (BSSO) only. The infection rate for this subset was 7.0%. 180 patients underwent a Lefort I osteotomy only and the incidence of infection was found to be 5.6%. 22 patients had a functional genioplasty (FG) only with POI rate of 9%. 102 patients had BSS0 and FG with POI rate of 14.7%. 44 patients had Lefort I and FG with POI rate of 4.55%. 573 patients had Lefort I and BSSO with POI rate of 9.6%. 282 patients had Lefort I, BSSO and FG with POI rate of 10.3%. The POI rate between BSSO, Lefort or FG only was not statistically significant. The combined incidence of POI for single jaw procedures was 6.6%. The combined incidence of POI for multiple jaw procedures was 10.9%. This was statistically significant p>0.05. 1030 patients received cefazolin peri-operatively. The incidence of POI in this group was 7.1%. 298 patients received penicillin G peri-operatively, with a POI incidence of 13.8% in this group. 189 patients received clindamycin peri-operatively with a POI incidence of 11.6% in this group. A significant difference (p < 0.05) was found between the cefazolin and penicillin G subset and between the cefazolin and clindamycin subset. There was no significant difference between the penicillin G and clindamycin groups.
The use of peri-operative antibiotic prophylaxis has been extensively studied and the benefits are clear. There has been debate concerning the recommended length of post-operative antibiotics following orthognathic surgery1. Not surprisingly, the rate of POI was higher for multi-jaw procedures. An increased POI rate was found in patients receiving penicillin G compared to cefazolin. Cefazolin is more resistant to beta lactamases and has broader spectrum of activity2. During orthognathic surgery cross contamination can occur from the skin, maxillary sinus and the nasal cavity. The microbes found in these locations may be more susceptible to cephalosporins. The findings suggest the incidence of POI is significant and a prospective study will be conducted to compare the efficacy of different peri-operative antimicrobial protocols.
References:
1. Danda AK, Ravi P. Effectiveness of Postoperative Antibiotics in Orthognathic Surgery: A Meta-Analysis
2. Katzung BG. Basic and Clinical Pharmacology. 8th edition Lange/McGraw-Hill; 2001