Prophylactic Use of Antibiotics in Otolaryngology & Head-Neck Surgery

Prophylactic Use of Antibiotics in Otolaryngology & Head-Neck Surgery

Dr. Muhammad Lipu SarwerMedical Officer

Medical Department

Beximco Pharma

Introduction

Surgical site infection (SSI) is one of the most common healthcare

associated infections resulting in an average additional hospital stay of

6.5 days per case.

In operations with a higher risk of infection (e.g. clean-contaminated

surgery), perioperative antibiotic prophylaxis has been shown to lower

the incidence of infection.

High antibiotic levels at the site of incision for the duration of the

operation, are essential for effective prophylaxis.

Risk of infection

• Age

• Nutritional status

• Diabetes

• Smoking

• Obesity

• Coexistent infections at a remote body site

• Colonization with microorganisms (e.g. Staph. aureus)

• Immunosuppression (inc. taking glucocorticoid steroids)

• Length of preoperative stay

• Coexistent severe disease

Patient

The risk of SSI depends on a number of factors; these can be related to the patient or the operation and some of them are modifiable

Risk of infection

Operation

• Duration of surgical scrub

• Preoperative shaving/ preoperative skin prep.

• Length of operation

• Appropriate antimicrobial prophylaxis

• Operating room ventilation

• Inadequate sterilization of instruments

• Foreign material in the surgical site

• Surgical drains

• Surgical technique inc. haemostasis,

• poor closure, tissue trauma

• Post-operative hypothermia

The risk is also related to the amount of contamination with microorganisms which is called “class” of the operation

Class Definition

Clean Operations in which no inflammation is encountered and the respiratory, alimentary or genitourinary tracts are not entered. There is no break in aseptic operating theatre technique.

Clean-contaminated Operations in which the respiratory, alimentary or genitourinary tracts are entered but without significant spillage.

Contaminated Operations where acute inflammation (without pus) is encountered, or where there is visible contamination of the wound. Examples include gross spillage from a hollow viscusduring the operation or compound/open injuries operated on within four hours

Dirty Operations in the presence of pus, where there is a previously perforated hollow viscus, or compound/open injuries more than four hours old.

Prophylactic antibiotics

• Prophylaxis with antibiotics has decreased the high incidence of

wound infection after head and neck operations that involve

incisions through oral or pharyngeal mucosa.

• Prophylactic administration of antibiotics can decrease

postoperative morbidity, shorten hospitalization, and reduce overall

costs attributable to infections.

• Additional doses during the procedure are advisable if surgery is

prolonged (i. e, >4 h), major blood loss occurs, or an antimicrobial

with a short half-life is used

The aim of prophylaxis

• The aim of prophylaxis is to augment host defense

mechanisms at the time of bacterial invasion.

• Prophylaxis is an attempt to attack organisms before

they have a chance to induce infection.

Antibiotic Prophylaxis

Timing for Administration

Additional Intra-operative doses

Post-operative antibiotic prophylaxis

Timing for Administration

Antibiotic prophylaxis administered too early or too late

increases the risk of SSI. Studies suggest that

antibiotics are most effective when given 30 minutes

before skin is incised.

Additional Intra-operative doses

High antibiotic levels, at the site of incision, for the duration of the operation, are essential for effective prophylaxis.

For operations lasting more than 4 hours re-dosing may be necessary.

Antibiotic Recommended re-dosinginterval/dose to give

Cefuroxime 4 hours, give 750mg IV

Clindamycin 4 hours give 300mg IV

Co-amoxiclav 4 hours, give 1.2g IV

Metronidazole 8 hours, give 500mg IV

Post-operative antibiotic prophylaxis

Studies have shown that giving additional antibiotic

prophylaxis after wound closure does not reduce infection

rates further. Post-operative antibiotics should only be

given to treat active/on-going infection unless specifically

recommended against the surgical procedure.

Surgical antibiotic prophylaxis guidelines within Maxillofacial and ent for adult patients by NHS published in 2013

Procedure Standard AntibioticDose / Route

Mild Penicillin Allergy

Severe Penicillins /Cephalosporin Allergy

Alveolar bonegrafting(Intra-oral)

No prosthesis

Co-amoxiclav 1.2g IV at Induction

Cefuroxime 1500mg IV and Metronidazole 500mg IV atinduction

Clindamycin 600mg IV oninduction

Prosthesis forinternal fixation

Co-amoxiclav 1.2g IV atinduction + 2 furtherpost-op doses at 8 and16 hrs

Cefuroxime 1500mg IV andMetronidazole 500mg IV+ 2 further post-op doses at8 and 16 hrs

Clindamycin 600mg IV oninduction + 3 further post-opdoses at 6, 12 and 18 hrs

Head and Neck Surgery

Summary Table for Maxillofacial / ENT Antibiotic Prophylaxis Regimens in Patients

Procedure Standard AntibioticDose / Route

Mild Penicillin Allergy

Severe Penicillins /Cephalosporin Allergy

Openreduction andinternalfixation offractures(ORIF):

No prosthesis

Co-amoxiclav 1.2g IV atinduction

Cefuroxime 1500mg IV andMetronidazole 500mg IV atinduction

Clindamycin 600mg IV oninduction

Prosthesis forinternal fixation

Co-amoxiclav 1.2g IV atinduction + 2 furtherpost-op doses at 8 and16 hrs

Cefuroxime 1500mg IV andMetronidazole 500mg IV+ 2 further post-op doses at8 and 16 hrs

Clindamycin 600mg IV oninduction + 3 further post-opdoses at 6, 12 and 18 hrs

Head and Neck Surgery

Procedure Standard AntibioticDose / Route

Mild Penicillin Allergy

Severe Penicillins /Cephalosporin Allergy

Open fractures forconservative treatment

Co-amoxiclav 625mgPO TDS for 3 days

Cefradine 500mg QDS PO and Metronidazole 400mg TDS PO for 3 days

Clindamycin 450mg QDS PO for 3 days

Head and Neck Surgery

Procedure Standard AntibioticDose / Route

Mild Penicillin Allergy

Severe Penicillins /Cephalosporin Allergy

Major head and neck surgery (withmucosal breach)

Co-amoxiclav 1.2g IV atinduction

Cefuroxime 1500mg IV andMetronidazole 500mg IV atinduction

Clindamycin 600mg IV oninduction

Salivary glandsurgery

Co-amoxiclav 1.2g IV atinduction

Cefuroxime 1500mg IV andMetronidazole 500mg IV atinduction

Clindamycin 600mg IV oninduction

Head and Neck Surgery

Procedure Standard AntibioticDose / Route

Mild Penicillin Allergy

Severe Penicillins /Cephalosporin Allergy

Complex procedurese.g. ‘free’ cartilagereplacement

Co-amoxiclav 1.2g IV atinduction

Cefuroxime 1500mg IV andMetronidazole 500mg IV atinduction

Clindamycin 600mg IV oninduction

Closure of CSF leak with intranasalpathology / pack in position

Co-amoxiclav 1.2g IV atinduction.

Cefuroxime 1500mg IV andMetronidazole 500mg IV atinduction

Clindamycin 600mg IV oninduction

Nasal Surgery

Procedure Standard AntibioticDose / Route

Mild Penicillin Allergy

Severe Penicillins /Cephalosporin Allergy

Cochlear Implants Cefuroxime 1500mg IV+ 2 post-op doses at 8and 16 hrs.

Cefuroxime 1500mg IV+ 2 post-op doses at 8 and16 hrs.

Clindamycin 600mg IV oninduction + 3 further post-opdoses of oral clindamycin600mg at 6, 12 and 18 hrs

Ear Surgery

Antibiotics

Tab. Cefuroxime 250/500 mgInj. Cefuroxime 750 mg

Sus. Cefuroxime 125 mg/5 ml

Amoxicillin & Clavulanic acid (Co-amoxiclav)

Antibiotics

Clindamycin 150 mg and 300 mg capsules

Antibiotics

Metronidazole Tablet, Suspension, IV Infusion

Inj. Ceftriaxone 250/500 mg/1g/2g IM/IV

Beximco Pharma also offers---

Tab. Cefixime 200 mg

Thank Youwww.beximcopharma.com