The Efficacy of Short-Term Vs. Long-Term Antibiotic Prophylaxis for Preventing Infections in Patients Undergoing Maxillomandibular Advancement for Obstructive Sleep Apnea

Statement of the Problem: A recent Cochrane review¹ concluded that long-term antibiotic prophylaxis (L-TAP) decreases the risk of a surgical site infection (SSI) compared to short-term antibiotic prophylaxis (S-TAP), in patients undergoing orthognathic surgery.  Maxillomandibular advancement (MMA) surgery is a special application of orthognathic surgery used to treat obstructive sleep apnea (OSA).  Currently, no data exist to define the most effective antibiotic regimen for preventing SSI in OSA patients treated by MMA; although this information is important as OSA patients may have more risk factors for SSI as they are generally older and have more medical comorbidities, than the typical orthognathic surgery patient who is generally young and healthy.  The purpose of this study was to determine if there is a difference in SSI between short-term and long-term antibiotic prophylaxis in patients undergoing MMA for treatment of OSA.

Materials and Methods: We performed a two-center retrospective cohort study consisting of 216 patients who underwent MMA for the treatment of OSA at either Vanderbilt University Medical Center (VUMC) between 1997 and 2007 (n=76) or Dalhousie University (DU) between 1997 and 2012 (n=140). The primary outcome measure was the rate of SSI.  A comprehensive systematic review of the medical records for each study patient was completed to identify SSI and the antibiotic regimen.  All patients had a minimum of six months of follow-up after MMA surgery. S-TAP was defined as antibiotic prophylaxis administered before and during surgery, and up to 24 hours after surgery. L-TAP was defined as antibiotic prophylaxis administered before and during surgery, and longer than 24 hours after surgery. The Centers for Disease Control and Prevention (CDC) criteria were used to define a SSI.²

Statistical Analysis: χ² test was used to test for group differences in rates of SSI and rates of fixation plate removal.  The Mann-Whitney test was used to test for group differences in demographic characteristics and surgical variables.  

Results: The study cohort consisted primarily of middle age (45.1 ± 10.2, range: 17-68 years), obese (BMI, 31.1 ± 6.1 kg/m²), males (75.5% males) with severe OSA (AHI, 47.2 ± 33).  All DU patients qualified for the S-TAP group (n=114), and all VUMC patients qualified for the L-TAP group (n=76). No statistically significant differences existed between the S-TAP and L-TAP groups for age, gender, and BMI.  The S-TAP group had significantly more SSI than the L-TAP group (L-TAP SSI rate, 10.7% vs. S-TAP SSI rate, 37.8%, p= <0.0001; Odds Ratio[OR]:5.2).  The vast majority of SSI were minor and were successfully treated by oral antibiotics (L-TAP, 87.5% vs S-TAP, 96.2%).  The mandible alone was the most frequent site of infection (L-TAP, 75% vs. S-TAP 72%).  There was a significantly greater risk of fixation plate removal in patients who experienced a SSI (SSI, 41% vs no SSI, 7.8%; p<0.0001; OR: 8.28), and most frequently mandibular plates were removed.  A significantly greater percentage of S-TAP group patients underwent plate removal, compared to patients in the L-TAP group (S-TAP, 21.7% vs. L-TAP, 9.3%, p=0.0225).

Conclusions: Long-term antibiotic prophylaxis, compared to short-term antibiotic prophylaxis, decreases the risk of surgical site infections and fixation plate removal in patients undergoing MMA for treatment of OSA.

References:

1. Brignardello-Petersen R, Carrasco-Labra A, Araya I, Yanine N, Cordova Jara L, Villanueva J. Antibiotic prophylaxis for preventing infectious complications in orthognathic surgery. Cochrane Database of Systematic Reviews 2015, Issue 1. Art. No.: CD010266. DOI: 10.1002/14651858.CD010266.pub2.

2. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, T, Emori G. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infection Control and Hospital Epidemiology 1992;13(10):606–8