Traumatic maxillofacial and skull base injury:

Is antibiotics prophylaxis indicated ?!

4FI Intern 陳晉瑋 / VS 韓吟宜

1. A Systematic Review of Prophylactic Antibiotics in the Surgical Treatment of Maxillofacial Fractures ~~J Oral Maxillofac Surg

64:1664-1668, 20062. Antibiotic prophylaxis for preventing meningitis in patients with

basilar skull fractures (Review) ~~The Cochrane Library 2007, Issue 2

Content

• First part: – Antibiotics prophylaxis for preventing infection in

maxillofacial fracture

• Second part: – Antibiotic prophylaxis for preventing meningitis in

basilar skull fracture

Epidemiology • Etiology

– Car accidents 73 (30.8%), motorcycle accidents 55 (23.2%),

altercations 23 (9.7%), sports 15 (6.3%)• Location

– 173 (72.9%) mandibular, – 57 (24.0%) zygomatico-orbital. – 33 (13.9%) maxillary

• Distribution of mandibular fractures– 32% condylar, 29.3% symphyseal-parasymphyseal, 20% angle, 12.5% body, 3.1% ramus, 1.9% dentoalveolar

• Distribution of maxillary fractures – Le Fort II 18 (54.6%), Le Fort I 8 (24.2%), Le Fort III 4 (12.1%), alveolar 3 (9.1%).

Zygomaticomaxillary complex (Tripod Fractures)

• Tripod fractures consist of fractures through:– Zygomatic arch (zygomaticotemporal)– Zygomaticofrontal– Zygomaticosphenoid – Zygomaticomaxillary

Comminuted

Le Fort Fractures

• Definition: – A separation of all or a portion

of the maxilla from the skull base

– Posterior maxillary sinus with the pterygoid plates of the sphenoid must be disrupted

• Type: – Type I transverse fracture– Type II pyramidal fracture– Type III complete crainofacial

fracture

Mandibular fracture type

• Unifocal fractures– condylar fractures (32%) and angle fractures (32%).

• Bifocal fracture(>95%) – angle and symphysis (32%)

• symptoms:– Facial swelling– Malocclusion – drooling– V3 numbness

Facial fracture management

• Seldom life-threatening unless in the airway• Consider spinal precautions• Control bleeding• Caution: NG tube replacement• High resolution CT

– Complex anatomy and fractures of the facial bones – Soft tissue complications

• Plain film facial series– Focal (nasal fracture)– CT is unavailable

Facial fracture management

• Treatment:– 173 mandibular fractures:

• 56.9% closed reduction, 39.8% open reduction, and 3.5% observation.

– 33 maxillary fractures:• 54.6% closed reduction, 40.9% open reduction,

and 4.5% observation

• Complications occurred in 17 (5.4%) patients and were mostly infections

Prophylactic antibiotics is necessary or not?

• Antibiotic prophylaxis has been considered a must in the surgical treatment of jaw fractures~ Oral and Maxillofacial Infections. Ed 4. Philadelphia, PA,

Saunders, 2002, p 359

• Evidence-based has been weak in a series of surgical disciplines from 1977 to 1986

• A higher infection rate in antibiotic treated situations– May give an advantage to opportunistic infection

• J Oral Maxillofac Surg 48:617, 1990

Factors influenced infection rate after facial fracture

• Before antibiotic prophylaxis, we should consider…

1. Type:– closed fracture (eg, mandibular condyle or ramus

fractures and maxillary Le Fort I–III fractures)– open fractures with direct communication to the oral

cavity and/or the skin surface

2. Treatment procedure used:– Open reduction or close reduction

Factors influenced infection rate after facial fracture

• Concerning the administration of antibiotics

1. Type• Streptococci(S. mutans and S. sanguis )• Lactobacilli(Gram negative, anaerobes)• staphylococci and corynebacteria• anaerobes, especially bacteroides

2. Dose

3. Duration

4. Route

A Systematic Review of Prophylactic Antibiotics

in the Surgical Treatment of Maxillofacial Fractures

J Oral Maxillofac Surg 64:1664-1668, 2006

The purpose of the review

• Answer the following questions:• 1) Does antibiotic prophylaxis decrease the

incidence of post-trauma infections in jaw

fracture treatment?• 2) Are there situations where an antibiotic

prophylaxis is not indicated?• 3) Which antibiotic is the drug of choice? In

what dose? And for how long?

Materials and methods

• Database MEDLINE and Cochrane

Zallen and Curry in 1975

• Prophylactic antibiotics in the treatment of compound mandibular fractures– RCT study (one test group and one control group)– 32 p’ts with Abx. Vs 30 p’ts without Abx.– 20/32 parenterally vs 10/32 orally– Infection rate 6% (Abx) vs 53%(non-Abx), p=0.0001

In 1983, Aderhold et al• Antibiotic treatment of 120 mandibular fractures All fractures had communication to the oral cavity

– 40 without Abx, 40 with Abx 48 hrs, 40 with Abx >48 hrs– Open and close reduction in 3 groups was comparable

– Short-term antibiotic prophylaxis was effective in reducing infection

– Long-term treatment did not significantly reduce the risk of infections as compared with the control group

In 1987, Chole and Yee• Prospective clinical trial of 101 patients with facial

fractures– 150 fractures(6 maxillary, 24 zygomatic, 120 mandibular)– Control vs IV cefazolin 1g 1 hour before surgery and 8

hours after– Maxillary, zygomatic, and subcondylar mandibular

fractures got no infected, irrespective of antibiotic prophylaxis given or not.

– 37/79(14%) Abx vs 42/79 non-Abx(43%) in mandibular without condyle fracture, p=0.01

– Close reduction• Infections rate: Abx 23% vs no Abx 28%, p>0.05

– Open reduction• Infections rate: Abx 8% vs no Abx 62%, p<0.05

In 1988, Gerlach and Pape• Antibiotic treatment on infection rates in 200

mandibular fractures all treated with open reduction– Group 1 (n=50): 1-day Abx– Group 2 (n=50): 1-shot Abx– Group 3 (n=51): 3-day Abx course– Control (n=49): no Abx treatment

• 1-shot administration of Abx is sufficient to protect the patient from wound infection

Abubaker and Rollert in 2001

• Comparative, double-blind, placebo-controlled • 1-day prophylaxis versus a 5-day treatment with

penicillin. In a limited number of patients (n 30)• No benefit of a prolonged administration of

antibiotics

Heit et al in 1997

• Two different antibiotic regimens were compared in a prospective and nonrandomized clinical study– 90 patients with compound mandibular fractures– Group I: ceftriaxone (3rd cepha.) 1 g qd iv – Group II: penicillin G 2 million U q4h iv– Non-significant difference between the 2 regimens

Conclusion

• Indicated for prophylatic antibiotics – Mandibular fracture

without condyle– Open fracture– Open reduction treated

• Drug of choice– Penicillin G 2 million U q4h iv– Cefazolin 1g qd iv

• Duration– Short term (<48 hr), even “one shot”

Basilar Skull Fracture(BSF)

• Fracture involve the floor of the skull– cribiform plate, frontal bones, sphenoid bones,

temporal bone and occipital bones

• Clinical signs:– CSF leakage (otorrhea or rhinorrhea) – Hemotympanum (blood behind the eardrum) – Bruising behind the ears (postauricular ecchymoses) – Bruising around the eyes (periorbital ecchymoses) – Injury to cranial nerves

Background

• Incidence BSF– Nonpenetrating head trauma:

• 7~15.8% of all skull fractures• CSF leakage occurring in 2% to 20.8% of patients

• Special significance– Dura mater torn placing CNS in contact with bacteria from

the paranasal sinuses, nasopharynx or middle ear meningitis,

• Prophylactic antibiotics for preventing bacterial meningitis in patients with BSF is controversial– Choi 1996: prophylatic ABx had higher meningitis incidences– meta-analysis (Brodie 1997): significantly prevent meningitis

Antibiotic prophylaxis for basilar skull fractureMeta analysis

Villalobos et al. Cli infect Dis 1998; 27:364-369.

• 12 studies, 1241 patients• 58% received antibiotics• Antibiotics did not prevent meningitis

– RR 1.15(0.68-1.94) p=0.68

• CSF leakage subset– RR 1.34(0.75-2.41) p=0.36

Objectives of this review

• Primary hypothesis:– meningitis is lower when prophylactic antibiotics are

administered as soon as a diagnosis of BSF, with or without CSF leakage compared with no treatment

• Search strategy– The Cochrane Library Issue 3, 2005, MEDLINE (1966 to

September 2005), EMBASE (1974 to June 2005), and LILACS (1982 to September 2005)

• Selection criteria– Randomised controlled trials (RCTs)– Perform to meta-analysis

Frequency of meningitis 208 participants from the four RCTs for

meta-analysis

Frequency of meningitis

•Treatment: 10/109(9.2%)

•Control: 14/99(14.1%)

All cause mortality 208 participants from the four RCTs for

meta-analysis

All cause mortality

•Treatment: 5/109(4.6%)

•Control: 3/99(3.0%)

Meningitis-related mortality 208 participants from the four RCTs for

meta-analysis

Meningitis-related mortality

•Treatment: 1/109(0.9%)

•Control: 1/99(1.0%)

Treatment: 4/51

Control: 6/41

Treatment: 6/53

Control: 8/53

Main results

• No significant differences between antibiotic prophylaxis groups and control groups in:– frequency of meningitis– all-cause mortality– meningitis-related mortality– Subgroup

• CSF leakage• Non-CSF leakage

Conclusion

• Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with BSF

• Whether there is evidence of CSF leakage or not

• Until more research is completed, the effectiveness of antibiotics in patients with BSF cannot be determined

• Studies published to date are flawed by biases. Large, appropriately designed RCTs are needed.

What l learn• Antibiotics prophylaxis is not indicated in

– Maxillofacial fracture included zygomatic, maxillary and condyle of mandibule

– Basilar skull fracture with or without CSF leakage

• Antibiotics prophylaxis is indicated in– Mandibular fracture without condyle– Open reduction treated

• Drug of choice– Penicillin G 2 million U q4h iv– Cefazolin 1 g iv qd

• Duration– Short term (<48 hr), even “one shot”