Antibiotics in Head and Neck Surgery • Classification of wounds • Commonly used antibiotics •...
Transcript of Antibiotics in Head and Neck Surgery • Classification of wounds • Commonly used antibiotics •...
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Antibiotics in Head and NeckSurgery
Department of OtolaryngologyUTMB
Resident Physician:Karen L. Stierman, M.D.Faculty Physician: Ronald W. Deskin, M.D.
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Introduction
• Classification of wounds• Commonly used antibiotics• Indications for perioperative antibiotics in
head and neck surgery
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Wound Infections
• Largest group of postooperative infectiouscomplications of surgery
• Second most frequent type of nocosomialinfection
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Considerations for the use ofantibiotic therapy
• Risk of developing wound infection– classification of wound– host and local factors
• Cost of therapy– 1992 cost of treating a wound infection $36,000
• Side effects and development of resistance
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Resistance to Antibiotic Therapy
• Virtually all bacterial pathogens have theability to acquire resistance to antibiotictherapy
• This problem is more common innocosomial pathogens such as VRE andMRSA
• More recently, community acquiredpathogens have developed resistant strains
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Resistant Strept. Pnuemoniae
• Resistance to penicillin is found in 30 to70% of isolates depending on the hospital
• Some strains are also found to be resistantto one of the following: cephalosporins,Bactrim, chloramphenicol,or a macrolide
• Children are more likely than adults to beinfected with strains resistant tochloramphenicol, erythromycin or Bactrim
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Classification of Wounds
• Clean• Clean contaminated• Contaminated• Dirty
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Clean wounds
• Associated with an elective case• No break in aseptic technique• No associated inflammation• Infection rate of 1% to 5%
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Clean Contaminated Wounds
• Oropharyngeal, respiratory, alimentary orGU tract is entered under controlledconditions
• Most head and neck surgeries fall under thiscategory
• Infection rate is 8% to 11% in general,although major head and neck cases have arate of 28 -87%.
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Contaminated Wounds
• Result after:– Spillage from the GI tract– Major break in sterile technique– With acute nonpurulent inflammation
• Includes fresh traumatic wounds• Infection rate of 15%-17%
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Dirty Wounds
• Organisms causing post-operative infectionare present prior to operation
• Wounds associated with old trauma, anabscess, or a perforated viscus.
• Infection rate greater than 27%
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Timing
• Antibiotics are most effective when givenbefore bacteria enters the blood stream ortissue.
• Studies have shown antibiotics have lesseffect if given after 3 hours frominnoculation.
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Route
• Parenteral administration is the traditionalroute
• IM injections achieve the highest sustainedlevel.
• It is recommended in contaminated cases toadminister IV and IM loading dosesfollowed by a continuous IV or intermittentIM injections.
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Commonly Used Antibiotics
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Penicillins
• Act by causing abnormal cell walldevelopment in actively dividing bacterialcells.
• Groups are as follows:– Natural penicillins, penicillinase resistant
penicillins, aminopenicillins, antipsuedomonalpenicillins, and extended spectrum penicillins.
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Natural Penicillins
• Drug of choice for St. pyogens and St.pneumoniae, and Clostridia perfringens
• 30% of isolates of St. pneumoniae arepenicillin resistant.
• Oral form in PenV, IM form is PenG
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Synthetic Penicillins
• Include nafcillin, oxacillin, and methicillin,cloxacillin and dicloxacillin.
• Used when S.aureus is suspected as thesedrugs are resistant to B-lactamase
• Side effects include interstitial nephritis,leukopenia, and reversible hepaticdysfunction.
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Aminopenicillins
• Include ampicillin and amoxicillin• Not effective in presence of B-lactamase• Antibiotics of choice for Enterococcus sp.• Active against some gram - rods (E. coli
and P.mirabilis)
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Antipsuedomonal Penicillins
• Include carbenicillin and ticarcillin.• Similar gram negative activity as
aminopenicillins• Poor activity against Klebsiella sp.• Side effects: sodium loading and platelet
dysfunction• Synergistic with aminoglycosides against
Psuedomonas.
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Extended Spectrum Penicillins
• Include mezlocillin and piperacillin• Similar to antipsuedomonal penicillins but
more active against Klebsiella sp. andStreptococcus.
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Cephalosporins
• Divided into first, second, and thirdgeneration classes
• Inhibit bacterial cell wall synthesis
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First Generation Cephalosporins
• Cephalothin, cephapirin, cephradine, andcefazolin
• Active against Strept.sp and Staph sp.• Limited gram negative activity• Side effect: allergic reactions, drug
eruptions, phlebitis, and diarrhea.
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Second GenerationCephalosporins
• Cefoxitin, cefotetan, cefuroxime• Increased gram negative coverage• Cefoxitin and cefotetan are more active
against anaerobes
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Third Generation Cephalosporins
• Cefotaxime, ceftizoxime, ceftriaxone,ceftazidime
• Less active against Gram positiveorganisms
• More active against the Enterobacteriaceaeand other Gram negative organisms
• Side effects include hypersensitivityreaction, hematological disturbances, GIand renal complaints.
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Macrolides
• Erythromycin, Pediazole(E-mycin andsulfisoxazole), Azithromycin andClarithromycin
• Inhibits protein synthesis• Similar spectrum as PenG plus
Mycoplasma, Legionella, Actinomyces, andH. infl.
• Side effects include nausea, vomiting,diarrhea, and hepatitis.
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Other Antibiotics
• Clindamycin inhibits protein synthesis• Active against most Gram positive, and
anaerobic organisms.• Good penetration into bones and abscesses.• Side effects include psuedomembranous
colitis, mild nausea and diarrhea,leukopenia, and hepatotoxicity.
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Vancomycin
• Antibiotic of choice for MRSA• Associated with nephrotoxicity or
ototoxicity when given withaminoglycoside
• Associated with emergence of VRE• Great activity against Staph and
Enterococcus.
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Metronidazole
• Good for anaerobic organisms• Well absorbed into abscesses• Side effects include seizures, cerebellar
dysfunction, disulfiram reaction withETOH, psuedomembranous colitis
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Aminoglycosides
• Include gentamycin, tobramycin, andamikacin
• Good gram negative coverage includingPseudomonas
• Used in head and neck surgery againstmixed microbial abscesses and whenorganisms from GI tract are suspected.
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Sulfonamides
• Bactrim• Very active against Gram negative aerobic
organisms and some Gram positive such asStaph and Strept. species
• Should not be used in last month ofpregnancy
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Flouroquinolones
• Norfloxacin, Levofloxacin, Ciprofloxacin,and Ofloxacin.
• Good efficacy against gram negativeorganisms and some Staph species.
• Do not use in children or adolescents.
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Indications for AntimicrobialTreatment
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Otologic Surgery
• Postoperative use of ototopicalantimicrobial drops reduces the incidence ofotorrhea after tympanostomy tube insertion
• Studies show a reduction from 16.4% to 8%when Cortisporin drops are used from 1 to 5days postop
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Other Otologic Procedures
• No significant decrease in postoperativeinfection rates in those patients treated withperioperative antibiotics
• Wound infection is prevented moreeffectively by starting with a dry ear andobserving good surgical technique
• Neurotological procedures may requiresome antibiotic prophylaxis. More studiesneed to be carried out
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Tonsillar Surgery
• Antibiotics given 5-7 days post-operativelydecrease dysphagia, fever, pain, mouth odorand poor oral intake
• Ampicillin, amoxicillin in children• Augmentin in adults• Currently a 7 day course is recommended
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Odontogenic Infections
• Most commonly caused by oral flora• Have tendency to deepen causing neck
space abscess or cellulitus• After appropriate drainage, treatment is
recommended with IV penicillin or Cleocin.• Can be augmented with Cleocin mouthwash
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Neck Abscess
• Usual organisms are Staph, Strept, andanaerobes
• High incidence of B-lactamase resistantorganisms
• Antibiotic therapy with or without surgicaldrainage
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Facial Fractures
• Open mandible fractures have been shownto have a 30% decreased incidence ofinfection when perioperative treatment withclindamycin or penicillin is used
• Antibiotics covering the oral flora arerecommended in open mandible fracturesand any surgical procedures where thewound will be exposed to oral flora
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Lacerations and Soft TissueInjuries
• Soft tissue injuries of the head and neckincluding crush injuries, woundscontaminated by body secretions, pus orsoil, wounds with devitalized tissue andthose wounds seen three hours after injuryshould receive antibiotics
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Dog Bites
• 5% result in infection• Treatment is with Augmentin• Need to debride devitalized tissue
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Human Bites
• Staph, Stept, Eikenella, Bacteroides,Peptostrep
• Treatment is based on length of time frominnoculation
• Augmentin, Unasyn
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Nasal and Sinus Surgery
• Current recommendations are to give anti-staph coverage in patients with nasalpacking and to coat merocel packing withantibiotic ointment
• One study showed patients receiving lowdose Erythromycin after FESS reducedpost-surgical sinusitus complaints.
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Thyroid, Parotid andSubmandibular Surgery
• No efficacy in giving prophylactic therapyin these cases
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Cranial Base Surgery
• High risk for postoperative infections• More studies need to be done in this area• Current recommendation is a single broad
spectrum antibiotic for at least 48 hours
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Oncological Head and NeckSurgery
• High risk for infection if surgical sitecontaminated with aerodigestive secretions
• Depending on the study, infection rate isfrom 28 - 87% without antibiotics.
• This is reduced to 14% with antibiotictherapy in one study
• Major fistula is the most commoncomplication
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Oncological Head and NeckSurgery (cont’d)
• Antibiotics are recommended in major cleancontaminated head and neck oncologicalsurgery– Time course remains an issue. In most cases at
least a short course of 1 to 3 days is effective• Need for gram negative coverage
– One study showed a reduction of infection ratefrom 36 to 10 % with the addition of anaminoglycoside
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Summary
• Decision of whether to give antibiotics isbased on the individual case
• Need to consider cost, side effects anddevelopment of resistance, incidence ofinfection without antibiotics
• Antibiotics are never a substitute for goodsurgical technique