Antibiotic prophylaxis is commonly used to decrease the rate of infections in head and neck surgery. The aim of this paper is to present the available evidence regarding the application of antibiotic prophylaxis in surgical procedures of the head and neck region in healthy patients. A systemic literature review based on Medline and Embase databases was performed. All reviews and meta-analyses based on RCTs in English from 2000 to 2013 were included. Eight out of 532 studies fulfilled all requirements. Within those, only seven different operative procedures were analyzed. Evidence exists for the beneficial use of prophylactic antibiotics for tympanostomy, orthognathic surgery, and operative tooth extractions. Unfortunately, little high-level evidence exists regarding the use of prophylactic antibiotics in head and neck surgery. In numerous cases, no clear benefit of antibiotic prophylaxis has been shown, particularly considering their potential adverse side effects. Antibiotics are often given unnecessarily and are administered too late and for too long. Furthermore, little research has been performed on the large number of routine cases in the above-mentioned areas of specialization within the last few years, although questions arising with respect to the treatment of high-risk patients or of specific infections are discussed on a broad base.
With a focus on perioperative antibiotic regimes, the head and neck region attracts attention because bacterial colonization is omnipresent and the number of severe postoperative infections is comparatively low in the healthy patient. The latter is not surprising considering the superior immunologic structures and blood supply of the tissues in this region. Whereas postoperative surgical site infection (SSI) is rare in patients undergoing clean head and neck operations [
The regular questioning of the benefit of general prophylactic antibiosis is an important issue. Because of the anxiety with respect to postoperative complications, especially in elective surgery, many surgeons tend to prescribe antibiotics thereby neglecting the adverse side effects of this medication. Furthermore, such treatment might support the development of antibiotic-resistant colonies and might involve unnecessary expenditure for the individual or for the health care system. In return, a higher level of safety for the well-being of the patient and the outcome of the operation is expected [
Thus, the general question needs to be raised as to whether antibiotic prophylaxis is necessary in surgery. Bowater et al. have compiled three conclusions in a meta-analysis of randomized controlled trails (RCTs) demonstrating the challenge of this topic. First, the use of an antibiotic prophylaxis cannot be substantiated because of the variety of surgical procedures. Second, the risk of SSI is reduced by the administration of antibiotics, even if this has not been established by rigorous study. Third, the use of antibiotics should only be omitted if they are demonstrated to lack any value [
This paper gives a brief overview of the current evidence based recommendations regarding antibiotic prophylaxis for elective and emergency procedures in the noninfected operating field in the healthy patient. In addition, we point out those interventions in which antibiotic prophylaxis can be omitted with a clear conscience.
To highlight the current evidence for prophylactic antibiotics in head and neck and maxillofacial surgery, a comprehensive review of the literature was undertaken.
For the study, an EMBASE (Elsevier Life Science Solutions) and MEDLINE (Pubmed) search was performed. The “Medical Subject Headings” terms were “prophylactic antibiotics” and “head and neck surgery” or “maxillofacial surgery.” We included all relevant studies in English from 2000 to 2013 (see Table
Inclusion criteria | Exclusion criteria |
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Pre-/peri-/postoperative administration of prophylactic antibiotics |
Case reports, technical notes, expert opinions, tutorials, nonsystematic reviews, and RCTs |
We excluded case reports, technical notes, animal or laboratory studies, expert opinions, tutorials, nonsystematic reviews, and neurosurgical case load. Furthermore, studies involving antibiotic prophylaxis in patients who underwent chemotherapy (CTx) or radiotherapy (RTx) or who had a clinical infection or in an immunocompromised (ICP) status were not taken into account (see Figure
See Table
Author | Year | Study design | Procedure | Sample size | SSI |
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ARR | NNT |
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Andreasen et al. [ |
2006 | Systematic review | Maxillofacial fractures | 4 Studies | ||||
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Lawler et al. [ |
2005 | Review | Dentoalveolar surgery | 4 studies | ||||
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Lodi et al. [ |
2012 | Interventional review | Third molars | 18 studies with 2456 participants | Compared with placebo, antibiotics probably reduce the risk of infection in patients undergoing third molar extraction(s) by approximately 70%. | SSI: |
SSI: 0.29 (95% CI 0.16 to 0.50) |
SSI: 12 |
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Abubaker and Rollert [ |
2001 | RCT | Mandible fractures | 30 patients (Group 1: 14, Group 2: 16). All patients received penicillin 2 M i.v. every 4 hours through the pre- and intraoperative period and for 12 hours postoperatively Group 1 then received 500 mg penicillin VK every 6 hours for 5 days, group 2 placebo for same duration and under the same schedule | Group 1: 2/14 (14.3%) |
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Esposito et al. [ |
2010 | Intervention review |
Dental implantation | 6 RCTs, |
The meta-analyses of the six trials showed a statistically significant higher number of participants experiencing implant failures in the group not receiving antibiotics |
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0.33 | 25 |
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Hochman et al. [ |
2006 | Meta-analysis | Tympanostomy | 9 RCTs, |
Topical prophylactic antibiotic drops for at least 48 h postoperatively |
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2 | |
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Dhiwakar et al. [ |
2012 | Cochrane review | Tonsillectomy | 10 RCT, antibiotics to reduce posttonsillectomy morbidity | Fever as secondary outcome |
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0.63, (95% CI 0.46 to 0.85) | |
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Saleh et al. [ |
2012 | Systematic review and meta-analysis | Endoscopic sinus surgery | Total of 4 RCT and meta-analyses with 3 RCT; |
0.76, 95% CI 0.64 to 0.09 |
In 2012, a Cochrane review was published concerning third molar extractions. In 18 double-blind placebo controlled trails, a placebo was compared with perioperative antibiotics in third molar removal in 2456 cases. Even though benefits could be identified with regard to the reduction of infections (
Bacterial contamination at the time of implant insertion is considered to be the origin of postoperative infection or even long-term implant loss. In a systematic review Esposito et al. demonstrated that the preoperative administration of 2 g amoxicillin prevented the failure of dental implants within the first three months in 1 of 33 cases. No statistically significant differences in postoperative infections and adverse events were observed. Four RCTs with a total of 1007 implant insertions in healthy patients were included in the review. No evidence was found for the use of postoperative antibiotics [
Up to the 1970s, some authors considered that antibiotics should not be used routinely in sagittal osteotomy/orthognathic surgery [
For the most common fracture in the maxillofacial area, namely, mandible fractures, many RCTs and retrospective case series have been published over the last few years. In a systematic review in 2011, Kyzas [
Andreasen et al. have reviewed four randomized studies concerning the potential benefit of antibiotic prophylaxis in maxillofacial fracture treatment [
He concludes that the administration of antibiotics results in a significant reduction in postinjury infections by threefold. Interestingly, no infection has been found in the zygoma, maxilla, or condylar region, irrespective of antibiotic prophylaxis.
Only one review matching the inclusion criteria was identified. Performing a Cochrane review based on 10 randomized controlled trails concerning the effect of prophylactic antibiotics for posttonsillectomy morbidity, Dhiwakar et al. described three primary outcomes, namely, pain, consumption of analgesia, and secondary hemorrhage, plus three secondary outcomes, namely, fever, time taken to resume normal diet and activities, and adverse events [
Saleh et al. evaluated the use of antibiotic prophylaxis in endoscopic sinus surgery. In a systematic literature search, 4 RCTs could be included, and a meta-analysis of three RCTs was conducted. No evidence for a statistically significant reduction in the incidence of infections after endoscopic sinus surgery was found (RR 0.76, 95% CI 0.64 to 0.09). The authors concluded that the current evidence did not support the routine use of prophylactic postoperative antibiotics in endoscopic sinus surgery [
In a meta-analysis by Hochman et al., the effect of topical antibiotics after tympanostomy was assessed. Nine studies with a total of 716 ears and 1344 patients were taken into account. The authors concluded that topical antibiotics were able to reduce the incidence of posttympanostomy otorhea as a sign of SSI by about 48% (OR 0.518; 95% CI 0.39–0.69;
In addition to the achievement of the expected operative result, the prevention of complications is the most important cofactor for surgical success. SSI is considered to be one of the most severe complications during surgical follow-up care. Our aim has been to find the best evidence for or against prophylactic antibiotics in common procedures in head and neck and maxillofacial surgery. However, only a few reviews or meta-analyses with a high level of evidence regarding the topics above have been identified in our systematic review.
The oral cavity is defined as a clean-contaminated site. Whereas many authors support antibiotic prophylaxis even for otherwise healthy patients, many other reviewers perceive no evidence for its use, for example, in teeth extractions, even though these are one of the most frequently performed operations in the head and neck region [
As implants have become increasingly important for replacing missing teeth, several studies deal with the effect of antibiotics on wound infection and early implant failure.
Even though prophylactic antibiotics given orally 1 h preoperatively significantly reduce early dental implant failure, no statistically significant differences in postoperative infections and adverse events have been observed [
For maxillofacial trauma, especially mandible fractures, many randomized and retrospective studies have been performed to evaluate the effect of antibiotic prophylaxis to minimize SSI. Unfortunately, important information is lacking concerning the type, duration, dosage, and route of administration of the applied antibiotic agent and the time between injury and definite treatment. For example, two clinical randomized studies have compared different antibiotic regimes with no control groups [
However, the wide spread use of antibiotics in the treatment of closed fractures of the central midface and the ascending ramus of the mandible is declining; in contrast to the recommendations given during previous decades, the tendency nowadays is to support the use of antibiotic prophylaxis in orthognathic surgery [
Because of the demand for a nearly perfect aesthetic outcome in the young cleft patient with little tolerance concerning infections that increase the risk of wound breakdown, palatal fistulas, poor speech or growth, and aesthetic results [
Unfortunately the interesting systematic literature review by Russell and Goldberg [
Even though tonsillectomy is one of the most routine procedures in head and neck surgery, we have found only one meta-analysis dealing with the effect of prophylactic antibiotics [
With regard to endoscopic sinus surgery, Saleh et al. [
The most significant advocate for the use of antibiotic prophylaxis in the field of head and neck surgery was found in the avoidance of posttympanostomy tube otorrhea. The meta-analysis by Hochman et al. [
Unfortunately, the current evidence extracted by this systematic review does not allow broad conclusions on the use of prophylactic antibiotics in clean or clean-contaminated head and neck surgery. Moreover, the topic of the prophylactic antibiotic regime in benign and malign tumor surgery in this region of specialization has not been challenged satisfactory. Furthermore, little research with strong evidence has been performed on the large number of routine cases in the above-mentioned regions of specialization within the last few years, whereas questions arising from the treatment of high-risk patients or of specific infections are merely discussed on a broad base. We should also emphasize that not all of the discussed recommendations are appropriate for patients at risk of developing severe infections because of immunodeficiency, radiation therapy, or chemotherapy or who are in need of endocarditis prophylaxis.
The fear of SSIs is the motivation for the use of antibiotics in noninfected sites in clean or clean-contaminated surroundings. In this systematic literature review, only seven procedures for head and neck surgery or maxillofacial surgery could be identified that had been reviewed on an adequate level of evidence. Evidence exists for the beneficial use of antibiotics in tympanostomy, orthognathic surgery, and operative tooth extractions. However, because of their adverse side effects, no recommendations are made for the use of antibiotics in the last-mentioned procedure. In conclusion, we have found a lack of RCT based reviews and meta-analyses dealing with the question of prophylactic antibiotics in head and neck and maxillofacial surgery.
The authors declare no conflict of interests regarding the publication of this paper.