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REVIEW ANALYSIS & EVALUATION
ARTICLE TITLE ANDBIBLIOGRAPHICINFORMATION
Effectiveness of postoperativeantibiotics in orthognathic surgery:a meta-analysis.
Danda AK, Ravi P.
J Oral Maxillofac Surg 2011;69:2650-6.
REVIEWERS
Lauren Harrell, MS, Vivek Shetty,DDS, Dr MedDent
PURPOSE/QUESTION
To determine whether extendingantibiotic coverage, beyond theperioperative period, is moreeffective in reducing the incidenceof infection following orthognathicsurgery
SOURCE OF FUNDING
Information not available
TYPE OF STUDY/DESIGN
Systematic review with meta-analysis of data
LEVEL OF EVIDENCE
Level 2: Limited-quality, patient-oriented evidence
STRENGTH OFRECOMMENDATION GRADE
Grade B: Inconsistent or limited-quality patient-oriented evidence
J Evid Base Dent Pract 2012;12:144-1451532-3382/$36.00� 2012 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.jebdp.2012.06.008
Extended Antibiotic Therapy may ReduceRisk of Infection Following OrthognathicSurgery
SUMMARY
Selection CriteriaThe authors examined 3 electronic databases (Ovid MEDLINE, PubMed,and Cochrane Register) for clinical trials involving antibiotic prophylaxisin orthognathic surgery. The authors found a total of 169 articles throughtheir search terms, yielding 32 full-text articles. Only 8 articles, with a com-bined sample of 532 subjects, met the quality criteria and were chosen forthe systematic review of antibiotic effectiveness.
Key Study FactorsThe strategy for identifying relevant studies included the following qualitycriteria: (1) patients who underwent orthognathic surgery within (2) a ran-domized clinical trial that included (3) a control group and involved (4)administration of short (perioperative) and extended-term (peri- and post-operative) antibiotics administered systematically to minimize postopera-tive infection.
Main Outcome MeasureThe main outcome of interest was the incidence of postoperative infectionfollowing orthognathic surgery. Diagnostic criteria for postoperative infec-tion was defined as ‘‘purulent or positive serosanguineous drainage fromthe surgical site, pain or tenderness, localized swelling and redness of thewound margin and surrounding tissue, an increase of body temperatureto higher than 38.5�C after more than 48 hours, and clinical diagnosis ofinfection.’’
Main ResultsOf 169 articles retrieved, 21 articles were included in the primary assess-ment, but only 8 articles met the quality criteria and were included inthe final review. The follow-up period ranged from 2 weeks to 3 months.A meta-analysis was conducted on the 8 studies and the odds ratio(OR) cal-culated. A combined odds ratio of 3.2 for the pooled studies suggested thatsubjects receiving extended-term antibiotics were 3.2 times less likely todevelop infection than those subjects receiving short-term antibiotics. Onaverage, 13.5 subjects would need to be treated with extended-term antibi-otics to prevent one additional infection (number needed to treat [NNT] =13.5). The authors found that the duration of the postoperative antibioticregimen did not improve the success rate. Also, studies with a better designquality (Category I trials) had greater effect sizes than those with lower de-sign quality (not blinded or controlled).
ConclusionsThe prophylactic administration of extended-term antibiotics appears tobe more effective at reducing the risk of postoperative infection thanshort-term antibiotics.
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
COMMENTARYANDANALYSIS
As transoral operations that breach mucosa and bone,orthognathic surgeries to correct jaw deformities are re-garded as contaminated procedures with a higher riskof postoperative infection. Antibiotics are routinely ad-ministered prophylactically to reduce the risk of postop-erative morbidity and the cost attributable to infections.However, the optimal duration of antibiotic coveragehas not been determined. The authors seek to resolvethe clinical ambivalence in the use of short-term (perio-perative only) or extended-term (both perioperativeand postoperative) antibiotics by conducting a meta-analysis of published studies. Based on their summaryfindings of surgical outcomes from 582 patients com-bined from 8 clinical studies that met the quality criteria,the authors conclude that extended antibiotic coverage ismore effective (OR, 3.2; 95% confidence interval [CI] =1.35 to 6.31) in decreasing the risk of postsurgical infec-tion. Also, the NNT was 13.5, indicating that, on average,13.5 subjects would need to be treated with extended-term antibiotics to prevent 1 additional infection.
The authors synthesized data across the pooled studiesusing commercial meta-analysis software and a ‘‘randomeffects model.’’ To verify the validity of their approachand findings, we independently analyzed the authors’ da-taset with the alternate Cochran-Mantel-Haenszel test(SAS version 9.2). We determined a common OR of3.13 (95% CI = 1.48 to 6.63; P = .0017), which parallelsthe authors’ OR of 3.2. Also, the correspondingBreslow-Day test was not significant, indicating that theORs were homogeneous and, thus, could be combined.
An accurate estimation of infection risk was compli-cated by the methodological differences between the in-dividual studies as well as variations in the antibioticsused. The authors were rigorous in classifying the studydesigns and performing a stratified analysis based onthe quality of design; however, only 4 of the 8 studiesincluded in the meta-analysis could be classified as a cate-gory 1 trial (ie, randomized, double blinded, and placebocontrolled). The effect size and variation in treatment ef-fect were more pronounced in category I trials (OR, 4.97;95% CI = 1.81 to 13.65) than in category II trials (OR, 1.5;95% CI = 0.24 to 9.42) or category III trials (OR, 1.31;95% CI = 0.27 to 6.28). Studies that lacked a placebogroup failed to show a significant difference in infectionrates between short- and extended-term antibiotics. Addi-tionally, one of the studies classified as a category 1 trial(Bentley et al1) had a 60% infection rate (9/15) in theshort-term group and appeared to be the largest contrib-utor of significance in the meta-analysis. When this studyis excluded from the analysis, the Cochran-Mantel-
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Haenszel OR drops to 2.24 (95% CI = 0.98 to 5.1) andis not significant.
As the authors acknowledge, the data contained in thepublished tables did not contain details on subject-levelcharacteristics that could influence healing outcomes,such as gender, age, smoking status, oral hygiene, and du-ration of surgery. Additionally, there were variations inthe types of antibiotics used, the duration of use, as wellas the adjunctive use of chlorhexidine mouth rinses.Finally, a major weakness was the small number of qualityarticles available for systematic analysis; ultimately, thequality of a meta-analysis depends on the quality of arti-cles included (Walker et al2).
The routine administration of antibiotics is common tomany oral and maxillofacial surgeries; however, injudi-cious use of antibiotics increases costs, is associated withadverse effects, and promotes antibiotic resistance. A sys-tematic analysis, such as that attempted by the authors, al-lows us to reflect on the justification for prophylacticusage of antibiotics and to reason out the most appropri-ate guidelines for taking antibiotics. Certainly, prophylac-tic antibiotics may be justified in the presence of certainmedical conditions, such as diabetes mellitus and humanimmunodeficiency virus, which diminish host responseand increase the risk of infection. However, absent con-sideration of subject and operator-level characteristics(eg, smoker, duration of surgery, operator skill) in thestatistical model, clinicians contemplating the use of ex-tended antibiotics in orthognathic surgery should be cau-tious in uncritically applying the results of this study totheir individual patients.
REFERENCES
1. Bentley KC, Head TW, Aiello GA. Antibiotic prophylaxis in orthog-nathic surgery: a 1-day versus 5-day regimen. J Oral Maxillofac Surg1999;57:226.
2. Walker E, Hernandez AV, Kattan MW. Meta-analysis: its strengths andlimitations. Cleve Clin J Med 2008;75(6):431-9.
REVIEWERS
Lauren Harrell, MSResearch Associate, Section of Oral and Maxillofacial Surgery,23-009 UCLA School of Dentistry, 10833 Le Conte Avenue,Los Angeles, CA 90095-1668, Phone: [email protected] Shetty, DDS, Dr MedDentProfessor, Section of Oral and Maxillofacial Surgery, 23-009UCLA School of Dentistry, 10833 Le Conte Avenue,Los Angeles, CA 90095-1668, Phone: [email protected]
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