Limited Antibiotic Dosing During the Operative Management of Mandible Fractures Is NOT Associated with an Increased Risk for Surgical Site Infections

Purpose: The purpose of this study is to answer the research question: Among patients undergoing transoral operative treatment of isolated, open mandible fractures, do those who receive only intraoperative antibiotics when compared to those receiving intraoperative antibiotics and other antibiotics dosing combinations, e.g.  preoperative or postoperative antibiotics, have an increased risk of surgical site infections (SSIs).

We hypothesize that there is no difference in the frequency of SSIs between patients receiving intraoperative antibiotics and those receiving intraoperative plus additional preoperative or postoperative antibiotics.  The aims of this study are to estimate and compare: 1) the frequencies of SSIs and 2) adverse antibiotic effects (AAEs) between patients who receive only intraoperative antibiotics and those who receive intraoperative antibiotics plus additional preoperative or postoperative antibiotics while undergoing operative treatment of open mandible fractures.

Methods:

Study design/Sample:

To answer the research question, the investigators designed and implemented a retrospective cohort study that enrolled a sample derived from the patients who presented to Harborview Medical Center (HMC) between June 30th, 2009 and July 31st, 2014 with open mandibular fractures. Inclusion criteria were subjects age 18 years or older with isolated open mandibular fractures treated operatively via transoral approaches.  Subjects were excluded if they presented with any other fractures, complex mandibular fractures (e.g. requiring transcervical approach), gunshot wounds, pre-existing concomitant mandibular fractures, fracture site infections present, closed mandibular fractures, immunocompromised (e.g. HIV+, any immunosuppressive medication), or if they received antibiotics for any other indication.

Study variables:

The primary predictor variable was antibiotic exposure.  The experimental (intraoperative) group received antibiotics administered within 1 hour before surgical incision , with possible intraoperative re-dosing consistent with the Joint Commission’s Surgical Care Improvement Project (SCIP) criterion for prophylactic surgical antibiotics¹.    The control group subjects received antibiotics per the experimental group plus additional preoperative and/or postoperative antibiotics.   

The primary outcome variable was the presence or absence of SSIs (e.g. the presence of pus, osteomyelitis, or wound dehiscence requiring more intervention than local wound care). The secondary outcome variable was the presence or absence of an AAE. Uni-, bivariate, and multiple logistic regression statistics were used and statistical significance was set at p<0.05.

Results: The sample was composed of 510 subjects with a mean age of 29 ± 11.4 years. 86% were males. The experimental group had 58 (11%) subjects. The control group had 452 (89%) subjects.  The SSI frequencies in the experimental and control groups were 9% and 17% respectively. OR 0.45 (95% CI 0.17-1.15) P=0.13.  In the multivariable logistic regression model, only tobacco use was associated with an increased risk for SSI; OR = 2.7 (95% CI 1.5-5.2), p=0.0015***.

There were 5 (1%) AAEs reported. All AAEs were isolated to the control group.  

Conclusion: Limiting antibiotic exposure to only intraoperative antibiotics among patients undergoing transoral operative treatment of isolated open mandible fractures is not associated with an increased risk of SSIs. These results support the assertion that intraoperative antibiotics alone suffice in the management of open mandible fractures.

Disclosure:  This study was supported in part by the University of Washington Department of OMS Research and Education Fund

References:

1. Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections. JAMA.2010;303(24):2479-2485. doi:10.1001/jama.2010.841.