|Year : 2016 | Volume
| Issue : 1 | Page : 42-48
Changing trends in antibiotic prophylaxis in head and neck surgery: Is short-term prophylaxis feasible?
Naresh K Panda, Muhammed Shafi, Sourabha K Patro, Jaimanti Bakshi, Roshan Kumar Verma
Department of Otolaryngology, Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||23-May-2016|
Naresh K Panda
Department of Otolaryngology, Head and Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Background: The duration and dosage of prophylactic antibiotics vary substantially among surgeons. This study explored the outcome and efficiency of short-term antibiotic prophylaxis in head and neck procedures. Methods: One hundred and forty-three patients undergoing various head and neck surgical procedures were included. They were categorized into two groups, clean (Group C) and clean-contaminated (Group CC). They received short-term prophylaxis with intravenous (IV) antibiotics. Group C patients received single dose IV antibiotic at induction and Group CC received antibiotic for 3 days. The scoring methods such as American Society of Anesthesiologist (ASA) score, National Nosocomial Infections Surveillance (NNIS) score, and additional treatment, discharge, erythema, purulent discharge, separation of deep tissue, isolation of bacteria and stay (ASEPSIS) were used. Scoring methods were used to analyze the risk factors and complications up to a period of 4 weeks postoperatively. Results: There were 83 patients in Group C and 60 patients in Group CC. Parameters such as body weight, body mass index (BMI), biochemical and hematological parameters along with surgical details, and postoperative wound assessment were analyzed. A significant association of surgical site infection (SSI) with BMI, anemia, hypoalbuminemia, and tobacco usage was noted along with a high incidence of SSI in surgical procedures involving the larynx. There was no significant relationship with ASA score and NNIS score. Conclusion: Short-term antibiotic prophylaxis in clean and clean-contaminated cases is feasible and effective as long-term prophylaxis. Correction of anemia, hypoalbuminemia, weight reduction, and avoidance of tobacco can prevent SSIs.
Keywords: Antibiotic prophylaxis, clean and contaminated surgery, surgical site infection
|How to cite this article:|
Panda NK, Shafi M, Patro SK, Bakshi J, Verma RK. Changing trends in antibiotic prophylaxis in head and neck surgery: Is short-term prophylaxis feasible?. J Head Neck Physicians Surg 2016;4:42-8
|How to cite this URL:|
Panda NK, Shafi M, Patro SK, Bakshi J, Verma RK. Changing trends in antibiotic prophylaxis in head and neck surgery: Is short-term prophylaxis feasible?. J Head Neck Physicians Surg [serial online] 2016 [cited 2020 Jun 6];4:42-8. Available from: http://www.jhnps.org/text.asp?2016/4/1/42/182854
| Introduction|| |
Hospital infection remains a major health-care problem, and the actual number of cases might exceed than estimates because infection rates are generally under-recorded by most hospitals. There exist difficulties in establishing an efficient epidemiological surveillance system during hospitalization and after discharge.
Surgical site infection (SSI) is the most common postoperative complication and it is the second most frequent type of nosocomial infection, head and neck surgery being no exclusion. As many as 5% of the patients develop wound infections, resulting in the delay in adjuvant therapy, prolonged hospitalization, and increased costs., They might influence the patient's quality of life (QOL) and can even lead to death. Empirical therapy to prevent SSI is probably the most common reason for using perioperative antibiotics.,
Postoperative antibiotic prophylaxis is not necessary after clean (C) operations due to low rates of SSIs; however, clean-contaminated (CC) wounds are associated with higher SSI rates due to the exposure to the mucosal flora of upper aerodigestive tract.,, There exists uncertainty in the duration of antimicrobial prophylaxis, shown by the lack of common practice among surgeons. Indian National Treatment Guidelines of National Center for Disease Control (version 1), 2016, and SIGN guidelines for surgical antimicrobial prophylaxis (updated April 2014) for head and neck and ENT surgeries are also not clear evidenced enough for deciding on the behalf of a surgeon during routine day-to-day clinical practice. Head and Neck cancer patients have high risks of surgery and anesthesia due to medical comorbidities and debilitated physical state.
Additional treatment, discharge, erythema, purulent discharge, separation of deep tissue, isolation of bacteria and stay (ASEPSIS) score describe the severity of SSIs with total score ranging from satisfactory healing (0–20) to wound infection (40–70). The National Nosocomial Infections Surveillance (NNIS) index for surveillance allows the classification of surgical patients according to both intrinsic and extrinsic risk factors based on wound class, procedure duration, and the American Society of Anesthesiologists (ASA) score and NNIS have high correlation with SSIs rates and exhibit good predictive power.,
Despite antibiotic usage, SSIs can be as high as 41.8% in clean-contaminated surgeries., Prophylactic antibiotic therapy in head and neck surgery is accepted to have a key role in clean-contaminated or contaminated surgeries as evidenced by 80–100% incidence of SSIs in the absence of antibiotics.
Although malnutrition, diabetes, excessive tobacco and alcohol intake, chemotherapy, radiotherapy, tumor stage, and tracheotomy have been associated with increased risk of SSI, its validity has been questioned as well., There exists ambiguity regarding the length of postoperative antibiotic prophylaxis and methods to reduce postoperative SSI rates. This study addresses these to find out the various risk factors associated with SSIs and to decide the duration of antibiotic prophylaxis.
| Methods|| |
This prospective study included all 143 consecutive head and neck procedures performed from January 2012 to July 2013 on patients of 15–75 years of age in two groups based on their categorization into clean (C) and clean-contaminated (CC) group having 83 and 60 patients, respectively, done after obtaining permission from the Institutional Review Board and taking written informed consent from each of the patients. As the consecutive patients who present to our outpatient department were not selectively referred to our tertiary care institute, it was a time-bound study between the 18 months mentioned above and absence of feasibility of random division of cases into groups because of the obvious reason of clean and clean-contaminated types of procedures being a standard among all practitioners such as stating involvement of mucosal surfaces in surgical steps as clean-contaminated procedures, it was not practically feasible for us to calculate the sample size statistically and randomly allocate the patients to the groups.
Group C was defined as surgery violating the skin only and Group CC was defined as surgery violating the mucosa of the upper aerodigestive tract and exposing the surgical site to its colonizing flora. Group C patients received single dose of intravenous (IV) antibiotic (amoxicillin + clavulanic acid) therapy in the operating room within ½ h of induction of anesthesia and second dose if surgery was prolonged beyond >4 h. It was ensured that the antibiotic was given at least 20 min prior to the incision. Group CC patients received first dose of antibiotic (amoxicillin + clavulanic acid + metronidazole) IV in the operating room within ½ h of induction of anesthesia and second dose if surgery got prolonged beyond >4 h, and then continued IV therapy for 72 h. In all the cases, the negative suction drain was removed within 3 days unless the drain was >30 cc, in which case, the drain removal was delayed.
Patients at extremes of age diagnosed of having any other focus infective focus such as URTI and UTI without sufficient follow-up for 30 days were excluded.
Preoperative nutritional status was evaluated through body mass index (BMI) and albumin levels (malnourished if <3.2 g/dl). All patients were ranked as per the classification of the ASA. The NNIS risk index including three parameters preoperative ASA score, surgical duration, and wound class was noted. For both Group C and Group CC, 1 point was scored for each finding such as preoperative ASA assessment of 3, 4, or 5, duration of surgery longer than 75% of similar cases, and surgical wound classed as contaminated, dirty, or infected. The NNIS risk index score is modified by subtracting 1 point for endoscopic procedures, hence ranging from −1 to 3. An index of 0 is interpreted as low risk, 1 as intermediate, and 2 or 3 as having high risks of getting SSIs.
Follow-up was daily performed during their hospital stay and then once a week till 30 days after surgery.
Postoperatively, ASEPSIS scoring system  (additional treatment, serous discharge, erythema, purulent exudates, separation of deep tissue, isolation of bacteria and stay duration as in-patient) was used to evaluate wound status and to monitor and record the rate and severity of SSIs. ASEPSIS score ranges from 0 to 70: 0 to 10, satisfactory healing; 11 to 20, disturbances of healing: 21 to 30, minor wound infection; 31 to 40, moderate wound infection; and >40, severe wound infection. Scores of >20 were considered as SSI.
Incidence and various associated risk factors for SSI such as comorbid conditions, age, use of tobacco, and duration of surgery were evaluated. Patients' demographic details, preoperative biochemical and hematological parameters, disease and surgical details, duration of initial (surgical) hospital stay, duration of surgery, and type and timing of antibiotic prophylaxis were noted. Statistical analysis was done using Statistical Package for Social Sciences (version 15.0 for Windows, SPSS Inc., Chicago, IL, USA) and all tests were two-sided with a significance level of α = 0.05
| Results|| |
Of 83 patients in group C, 78 patients (93.98%) had a score of 0–20. The remaining 5 had SSI. 2/5 had minor wound infection (score 20–30), 2/5 had severe infection (score 30–40), and 1/5 had a score of more than 40 [Table 1].
|Table 1: The distribution of surgical site infection among the subjects of different additional treatment, discharge, erythema, purulent discharge, separation of deep tissue, isolation of bacteria and stay scores|
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In CC Group, 54/60 (90%) patients had a score of 0–20. Rest of the 6 patients (10%) had SSI. 1/6 had minor wound infection (score 20–30), 2/6 had moderate infection (score 30–40), and 3/6 had severe wound infection (score > 40) [Table 1]. The surveillance methodology using the NNIS scoring led to the categorization into three groups. In Group C, 77/83 (92.7%) patients had a score of 0, followed by 6/83 (7.3%) having a score 1. There was no correlation between NNIS and SSI in this study.
In Group CC, 23/60 (38.3%) had a score of 0 followed by 37/60 (61.6%) with a score of 1. All the SSI cases 6/60 (10%) had a score of 0 in 1 patient and score of 1 in 5 patients. There was no statistically significant difference [Table 2].
|Table 2: The distribution of surgical site infection among the subjects who had different National Nosocomial Infections Surveillance score and its statistical significance|
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Preoperative American Society of Anesthesiologist scoring and surgical site infection
In Group C, majority of the patients belonged to ASA 1, i.e. 68/83 (81.9%). Only 15/83 (18.1%) had an ASA score of 2. There was no statistical correlation between preoperative ASA score and SSI.
In Group CC, 40/60 (66.7%) belonged to ASA 1. 20/60 (33.3%) patients had ASA score of 2. No significant difference was found between ASA score and SSI [Table 3].
|Table 3: The distribution of surgical site infection among the subjects who had different American Society of Anesthesiologist scores and their statistical significance|
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Surgical site infection data
SSI was diagnosed on the basis of ASEPSIS. The overall incidence of clinically diagnosed SSI in our series was 11/143 (7.69%). Group C had an incidence of 6.02% (5/83) [Figure 1] whereas Group CC had 10% (6/60) incidence of SSI.
|Figure 1: (a) Surgical site infection on the 5th postoperative day following excision of a benign neck lesion (b) well-granulating wound on the 10th postoperative day (same patient)|
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There was no correlation between SSI with age and sex of the patients.
Disease-specific surgical site infection
About 4/6 cases of SSI in Group CC belonged to laryngectomy [Table 4] and [Figure 2].
|Table 4: The distribution of infected cases of surgical site infection with different diagnosis among clean-contaminated patients|
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|Figure 2: (a) Patient with surgical site infection on the 10th postoperative day following total laryngectomy. Patient had severe infection (additional treatment, discharge, erythema, purulent discharge, separation of deep tissue, isolation of bacteria and stay score >40) due to the development of pharyngocutaneous fistula (b) picture of surgical wound of a noninfected patient following the same procedure (total laryngectomy) on the 7th postoperative day and at 3 weeks on follow-up|
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Patient variables and surgical site infection
BMI had a significant influence in the causation of SSI.
The mean BMI of patients having surgical site infection in Group C was 27.66 ± 2.58 and mean BMI of those having no evidence of SSI was 22.691 ± 2.78.
Similar observations were made in CC Group [Table 5].
|Table 5: The distribution and statistical significance of different patient variables among non-infected and surgical site infection cases|
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In addition, low albumin, low hemoglobin, tobacco use, and duration of surgery had a significant bearing on the development of SSI in patients.
| Discussion|| |
Prevention and control of postoperative SSIs have become the vital components of hospital infection control and quality management programs. Fonseca et al. showed a prolonged hospital stay, delay in adjuvant treatment, increased expenses, decreased QOL, and overall decreased survival rate in patients with SSI.
Our study has demonstrated that the ASEPSIS scoring permits detection of minor changes in surgical wounds and reduces subjectivity in symptom evaluation, thereby making it a useful and valuable classification system for research and education purposes.
Incidence of SSI in the head and neck cancer surgery not involving upper aerodigestive tract mucosa is low in our study (6.02% [n = 5/83]). These patients received a single dose of IV amoxicillin + clavulanic acid at the time of induction of anesthesia. Similar evidence can be seen in literature by Rosato et al. in their multicenter analysis comprising 14,934 thyroid surgeries, reporting lower incidence of SSI (0.3%) where 50% of the surgeons used antibiotic prophylaxis, 17% used antibiotic therapy, and 33% used neither prophylaxis nor therapy, though the antibiotic regimen was not mentioned that was used by the surgeons who operated in these 14,934 patients. In the present study, only one patient out of 51 thyroid surgeries (1.96%) [Figure 3] developed moderate infection according to ASEPSIS scoring system. Avenia et al. in their randomized control trial with 500 thyroid surgeries showed prophylactic antibiotic treatment to be beneficial in patients older than 80-year-old with concomitant metabolic, infective, or hematologic disease, patients those who are severely obese and receiving steroidal or immunosuppressive treatment, and in patients with cardiac valvulopathies.
|Figure 3: (a) The only one subject (1.96%) who had clinically evident surgical site infection (moderate infection, additional treatment, discharge, erythema, purulent discharge, separation of deep tissue, isolation of bacteria and stay score 30—40) among the 51 thyroid procedures (b) noninfected patients on the 7th and 4th week postoperatively following thyroid procedures|
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Among the Group CC, which received a 72 h of antibiotics in the form of IV amoxicillin + clavulanic acid + IV metronidazole 8 hourly, SSI rate was 10% (n = 6/60). Although major guidelines do not mention about 72 h long surgical prophylaxis of antimicrobials, we had planned to give 72 h of antibiotic therapy in view of the poor hygienic conditions prevailing in lower socioeconomic population, which comprised majority of our patients who present to us with head and neck malignancies for surgery where we open a mucosa-lined cavity. However, various studies by those such as Skitarelic et al., Johnson et al., Gehanno et al., and Girod el al. have reported higher incidences of SSIs in clean-contaminated procedures. The incidences including tracheoesophageal fistula are reported to be as high as 22–47%.
Majority of our patients with SSIs were following total laryngectomy (4/14) 28.57%, suggesting a high incidence of clinically evident SSI in postlaryngectomy cases similar to Cole et al., who stated that “hypopharyngeal location is significantly associated with poor surgical risk and subsequent SSI.” Other than postlaryngectomy cases, only two patients in Group CC had SSI. This indicates that with the exception of laryngectomy, 3-day therapy with antibiotic is efficacious even in clean-contaminated surgeries. Taghy et al. reported that prolonged and 2-day antimicrobial prophylaxis for clean-contaminated procedures was shown to be of similar efficacy.
Significant differences between BMIs of infected and noninfected cases were seen in both clean surgery (P = 0.01) and clean-contaminated surgery (P = 0.021) groups with the patients with SSI having a high BMI. Bamgbade  also reported that obese patients had higher ASA physical status scores and had higher incidence of SSI, than other patients (P = 0.001).
We found a significant association of low hemoglobin and SSI both in Group CC (P = 0.001) and in Group C (P = 0.0381). On the contrary, Pelczar et al. and Weber et al. found a high platelet count to be significantly related to SSIs. A definite cause could not be assigned.
This study has shown that tobacco usage (6/11 of SSI cases) and alcohol consumption (5/12 of SSI cases) played a role in the occurrence of SSI. In Group CC, a significant association between the SSI and duration of tobacco usage was seen. Those who consumed tobacco for more than 30 years had a high incidence of SSI (P = 0.008). Cole et al. noted a high incidence of infection and Jorgenson et al. demonstrated an increased frequency of pulmonary, circulatory, and infectious complications, which can lead to impaired wound healing with tobacco similar to our observations.
We also found preoperative hypoalbuminemia and low nutritional status to be a predictive factor for poor surgical outcomes in clean-contaminated cases. Gibbs et al. and various authors such as Matthew  and Lefebvre et al. had also reported similar results. However, the same correlation could not be demonstrated in clean surgical group.
Several factors related to the surgical procedure are associated with SSI. Cole et al., Weber et al., and Becker  found that duration of procedure was a risk factor. We also found correlation between SSI risk and length of procedure in the group of clean-contaminated surgeries (P = 0.029). On the contrary, this correlation was not observed in clean surgeries.
Woodfield et al. stated that both the ASA classification of physical status (P = 0.002) and the wound categories (P = 0.034) significantly predicted wound infection. The NNIS score, which we used to predict the risk index in our study did not show any significant difference in both clean (P = 0.520) and clean-contaminated surgeries (P = 0.250). This may be due to our exclusion of patients with severe comorbidities from our study.
The results of our study show that single-dose antibiotic prophylaxis did not lead to an increase in the rates of SSI. Single dose of antibiotic prophylaxis with amoxicillin + clavulanic acid for clean head and neck surgeries and amoxicillin + clavulanic acid along with metronidazole three times a day for 72 h for clean-contaminated surgeries have shown less incidence of SSI in head and neck cancer surgery. Fonseca et al. who stated that single-dose antibiotic prophylaxis did not lead to an increase in the rates of SSI and brought a monthly savings of $1980. Bantar et al. showed that short-term antibiotic prophylaxis was as efficient as long-term prophylaxis. Velasco et al. stated that antibiotic prophylaxis for more than 24 h is unnecessary and not beneficial. High compliance to one dose and 72 h antibiotic prophylaxis in clean and clean-contaminated surgeries, respectively, showed an appealing argument for decreasing antibiotic usage, and this was used by educational intervention encouraged by the hospital administrative measures that reduced access to extra costs. This is important in developing countries like ours.
Our study has shown that short-term antibiotic prophylaxis is possible and holds advantage in this era of restricted hospital budgets and increased bacterial resistance.
| Conclusion|| |
This study highlights the importance of avoidance of inappropriate use of antibiotics. A multicenter study in a larger cohort of patients is warranted to implement standard good practices for optimum surgical care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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