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Antibiotics in Head and Neck SurgeryDepartment of OtolaryngologyUTMBResident Physician:Karen L.Stierman,M.D.Faculty Physician:Ronald W.Deskin,M.D.Antibiotics in Head and Neck S1IntroductionClassification of woundsCommonly used antibioticsIndications for perioperative antibiotics in head and neck surgery IntroductionClassification of 2Wound InfectionsLargest group of postooperative infectious complications of surgerySecond most frequent type of nocosomial infectionWound InfectionsLargest group 3Considerations for the use of antibiotic therapyRisk of developing wound infectionclassification of woundhost and local factorsCost of therapy1992 cost of treating a wound infection$36,000Side effects and development of resistanceConsiderations for the use of 4Resistance to Antibiotic TherapyVirtually all bacterial pathogens have the ability to acquire resistance to antibiotic therapyThis problem is more common in nocosomial pathogens such as VRE and MRSAMore recently,community acquired pathogens have developed resistant strainsResistance to Antibiotic Thera5Resistant Strept.PnuemoniaeResistance to penicillin is found in 30 to 70%of isolates depending on the hospitalSome strains are also found to be resistant to one of the following:cephalosporins,Bactrim,chloramphenicol,or a macrolideChildren are more likely than adults to be infected with strains resistant to chloramphenicol,erythromycin or BactrimResistant Strept.PnuemoniaeRe6Classification of WoundsCleanClean contaminatedContaminatedDirtyClassification of WoundsClean7Clean woundsAssociated with an elective caseNo break in aseptic technique No associated inflammationInfection rate of 1%to 5%Clean woundsAssociated with an8Clean Contaminated WoundsOropharyngeal,respiratory,alimentary or GU tract is entered under controlled conditionsMost head and neck surgeries fall under this categoryInfection rate is 8%to 11%in general,although major head and neck cases have a rate of 28-87%.Clean Contaminated WoundsOroph9Contaminated WoundsResult after:Spillage from the GI tractMajor break in sterile techniqueWith acute nonpurulent inflammationIncludes fresh traumatic woundsInfection rate of 15%-17%Contaminated WoundsResult afte10Dirty WoundsOrganisms causing post-operative infection are present prior to operationWounds associated with old trauma,an abscess,or a perforated viscus.Infection rate greater than 27%Dirty WoundsOrganisms causing 11Timing Antibiotics are most effective when given before bacteria enters the blood stream or tissue.Studies have shown antibiotics have less effect if given after 3 hours from innoculation.Timing Antibiotics are most ef12RouteParenteral administration is the traditional routeIM injections achieve the highest sustained level.It is recommended in contaminated cases to administer IV and IM loading doses followed by a continuous IV or intermittent IM injections.RouteParenteral administration13Commonly Used AntibioticsCommonly Used Antibiotics14PenicillinsAct by causing abnormal cell wall development in actively dividing bacterial cells.Groups are as follows:Natural penicillins,penicillinase resistant penicillins,aminopenicillins,antipsuedomonal penicillins,and extended spectrum penicillins.PenicillinsAct by causing abno15Natural PenicillinsDrug of choice for St.pyogens and St.pneumoniae,and Clostridia perfringens30%of isolates of St.pneumoniae are penicillin resistant.Oral form in PenV,IM form is PenGNatural PenicillinsDrug of cho16Synthetic PenicillinsInclude nafcillin,oxacillin,and methicillin,cloxacillin and dicloxacillin.Used when S.aureus is suspected as these drugs are resistant to B-lactamaseSide effects include interstitial nephritis,leukopenia,and reversible hepatic dysfunction.Synthetic PenicillinsInclude 17AminopenicillinsInclude ampicillin and amoxicillinNot effective in presence of B-lactamaseAntibiotics of choice for Enterococcus sp.Active against some gram-rods(E.coli and P.mirabilis)AminopenicillinsInclude ampici18Antipsuedomonal PenicillinsInclude carbenicillin and ticarcillin.Similar gram negative activity as aminopenicillinsPoor activity against Klebsiella sp.Side effects:sodium loading and platelet dysfunctionSynergistic with aminoglycosides against Psuedomonas.Antipsuedomonal PenicillinsInc19Extended Spectrum PenicillinsInclude mezlocillin and piperacillinSimilar to antipsuedomonal penicillins but more active against Klebsiella sp.and Streptococcus.Extended Spectrum PenicillinsI20CephalosporinsDivided into first,second,and third generation classesInhibit bacterial cell wall synthesisCephalosporinsDivided into fir21First Generation CephalosporinsCephalothin,cephapirin,cephradine,and cefazolinActive against Strept.sp and Staph sp.Limited gram negative activitySide effect:allergic reactions,drug eruptions,phlebitis,and diarrhea.First Generation Cephalosporin22Second Generation CephalosporinsCefoxitin,cefotetan,cefuroximeIncreased gram negative coverageCefoxitin and cefotetan are more active against anaerobesSecond Generation Cephalospori23Third Generation CephalosporinsCefotaxime,ceftizoxime,ceftriaxone,ceftazidimeLess active against Gram positive organismsMore active against the Enterobacteriaceae and other Gram negative organismsSide effects include hypersensitivity reaction,hematological disturbances,GI and renal complaints.Third Generation Cephalosporin24MacrolidesErythromycin,Pediazole(E-mycin and sulfisoxazole),Azithromycin and ClarithromycinInhibits protein synthesisSimilar spectrum as PenG plus Mycoplasma,Legionella,Actinomyces,and H.infl.Side effects include nausea,vomiting,diarrhea,and hepatitis.MacrolidesErythromycin,Pediaz25Other AntibioticsClindamycin inhibits protein synthesisActive 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.Other AntibioticsClindamycin i26VancomycinAntibiotic of choice for MRSAAssociated with nephrotoxicity or ototoxicity when given with aminoglycosideAssociated with emergence of VREGreat activity against Staph and Enterococcus.VancomycinAntibiotic of choice27MetronidazoleGood for anaerobic organismsWell absorbed into abscessesSide effects include seizures,cerebellar dysfunction,disulfiram reaction with ETOH,psuedomembranous colitisMetronidazoleGood for anaerobi28AminoglycosidesInclude gentamycin,tobramycin,and amikacinGood gram negative coverage including PseudomonasUsed in head and neck surgery against mixed microbial abscesses and when organisms from GI tract are suspected.AminoglycosidesInclude gentamy29SulfonamidesBactrimVery active against Gram negative aerobic organisms and some Gram positive such as Staph and Strept.speciesShould not be used in last month of pregnancySulfonamidesBactrim30FlouroquinolonesNorfloxacin,Levofloxacin,Ciprofloxacin,and Ofloxacin.Good efficacy against gram negative organisms and some Staph species.Do not use in children or adolescents.FlouroquinolonesNorfloxacin,L31Indications for Antimicrobial TreatmentIndications for Antimicrobial 32Otologic SurgeryPostoperative use of ototopical antimicrobial drops reduces the incidence of otorrhea after tympanostomy tube insertionStudies show a reduction from 16.4%to 8%when Cortisporin drops are used from 1 to 5 days postopOtologic SurgeryPostoperative 33Other Otologic ProceduresNo significant decrease in postoperative infection rates in those patients treated with perioperative antibioticsWound infection is prevented more effectively by starting with a dry ear and observing good surgical techniqueNeurotological procedures may require some antibiotic prophylaxis.More studies need to be carried outOther Otologic ProceduresNo si34Tonsillar SurgeryAntibiotics given 5-7 days post-operatively decrease dysphagia,fever,pain,mouth odor and poor oral intake Ampicillin,amoxicillin in children Augmentin in adultsCurrently a 7 day course is recommendedTonsillar SurgeryAntibiotics g35Odontogenic InfectionsMost commonly caused by oral floraHave tendency to deepen causing neck space abscess or cellulitusAfter appropriate drainage,treatment is recommended with IV penicillin or Cleocin.Can be augmented with Cleocin mouthwashOdontogenic InfectionsMost com36Neck AbscessUsual organisms are Staph,Strept,and anaerobesHigh incidence of B-lactamase resistant organismsAntibiotic therapy with or without surgical drainageNeck AbscessUsual organisms ar37Facial FracturesOpen mandible fractures have been shown to have a 30%decreased incidence of infection when perioperative treatment with clindamycin or penicillin is usedAntibiotics covering the oral flora are recommended in open mandible fractures and any surgical procedures where the wound will be exposed to oral floraFacial FracturesOpen mandible 38Lacerations and Soft Tissue InjuriesSoft tissue injuries of the head and neck including crush injuries,wounds contaminated by body secretions,pus or soil,wounds with devitalized tissue and those wounds seen three hours after injury should receive antibioticsLacerations and Soft Tissue In39Dog Bites5%result in infectionTreatment is with AugmentinNeed to debride devitalized tissueDog Bites5%result in infectio40Human BitesStaph,Stept,Eikenella,Bacteroides,PeptostrepTreatment is based on length of time from innoculationAugmentin,UnasynHuman BitesStaph,Stept,Eiken41Nasal and Sinus SurgeryCurrent recommendations are to give anti-staph coverage in patients with nasal packing and to coat merocel packing with antibiotic ointmentOne study showed patients receiving low dose Erythromycin after FESS reduced post-surgical sinusitus complaints.Nasal and Sinus SurgeryCurrent42Thyroid,Parotid and Submandibular SurgeryNo efficacy in giving prophylactic therapy in these casesThyroid,Parotid and Submandib43Cranial Base SurgeryHigh risk for postoperative infectionsMore studies need to be done in this areaCurrent recommendation is a single broad spectrum antibiotic for at least 48 hoursCranial Base SurgeryHigh risk 44Oncological Head and Neck SurgeryHigh risk for infection if surgical site contaminated with aerodigestive secretionsDepending on the study,infection rate is from 28-87%without antibiotics.This is reduced to 14%with antibiotic therapy in one studyMajor fistula is the most common complicationOncological Head and Neck Surg45Oncological Head and Neck Surgery(contd)Antibiotics are recommended in major clean contaminated head and neck oncological surgeryTime course remains an issue.In most cases at least a short course of 1 to 3 days is effectiveNeed for gram negative coverage One study showed a reduction of infection rate from 36 to 10%with the addition of an aminoglycosideOncological Head and Neck Surg46SummaryDecision of whether to give antibiotics is based on the individual caseNeed to consider cost,side effects and development of resistance,incidence of infection without antibioticsAntibiotics are never a substitute for good surgical techniqueSummaryDecision of whether to 47
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