Elsevier

Oral Oncology

Volume 74, November 2017, Pages 181-187
Oral Oncology

Considerations for antibiotic prophylaxis in head and neck cancer surgery

https://doi.org/10.1016/j.oraloncology.2017.09.011Get rights and content

Highlights

  • Evidence for ideal antibiotic prophylaxis regimens is limited.

  • Short antibiotic prophylaxis durations are as effective as longer durations.

  • Prophylaxis should cover Gram-positive, anaerobic, and Gram-negative bacteria.

  • Extended-spectrum prophylaxis (MRSA, P. aeruginosa) is typically not warranted.

Abstract

Peri/post-operative antibiotic prophylaxis (POABP) has become standard practice for preventing surgical site infections (SSI) in head and neck cancer patients undergoing microvascular reconstruction, but few data exist on optimal POABP regimens. Current surgical prophylaxis guideline recommendations fail to account for the complexity of microvascular reconstruction relative to other head and neck procedures, specifically regarding wound classification and antibiotic duration. Selection of POABP spectrum is also controversial, and must balance the choice between too narrow, risking subsequent infection, or too broad, and possible unwanted effects (e.g. antibiotic resistance, Clostridium difficile-associated diarrhea). POABP regimens should retain activity against bacteria expected to colonize the upper respiratory/salivary tracts, which include Gram-positive organisms and facultative anaerobes. However, Gram-negative bacilli also contribute to SSI in this setting. POABP doses should be optimized in order to achieve therapeutic tissue concentrations at the surgical site. Antibiotics targeted towards methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa are not warranted for all patients. Prolonged POABP durations have shown no differences in SSI when compared to short POABP durations, but prolonged durations provide unnecessarily antibiotic exposure and risk for adverse effects. Given the lack of standardization behind antibiotic POABP in this setting and the potential for poor patient outcomes, this practice necessitates an additional focus of surgeons and antimicrobial stewardship programs. The purpose of this review is to provide an overview of POABP evidence and discuss pertinent clinical implications of appropriate use.

Introduction

The incidence of surgical site infections (SSI) in head and neck cancer patients undergoing microvascular free-tissue transfer remains high, despite routine peri/post-operative antibiotic prophylaxis (POABP) [1], [2]. While surgical excision and use of free flaps has become mainstay treatment in complex head and neck cancers, the technical components of surgery (e.g. tumor resection, neck dissection, flap harvest and revascularization) contribute to multiple wounds with diverse microbial flora at high risk for SSI [1], [3]. SSI in this setting add to significant patient morbidity and can include flap failure, fistula development, functional or cosmetic abnormalities, and death [4], [5]. SSI also contribute to elevated healthcare expenditure from prolonged patient hospitalizations, thus potentiating additional complications (e.g. post-operative pneumonia, deep-vein thrombosis) that can delay post-surgical chemo- or radiotherapy [6]. Discrepancies in optimal POABP regimens and wound classifications, in addition to difficult infectious risk assessment, are obstacles in the determination of appropriate antibiotic management and the long-term outcomes of head and neck cancer patients who receive free-tissue transfer.

Ketcham et al. were first to describe decreased SSI when using perioperative chloramphenicol in head and neck cancer patients after extensive surgical reconstruction [7]. Subsequent literature has supported POABP use in head and neck cancer surgery [8], [9], [10], [11], but few sufficiently describe best practices regarding spectrum and duration. The majority of published data are limited by comparisons of heterogeneous or obsolete antibiotic regimens, nonstandard wound or SSI endpoint definitions, and small patient samples. Furthermore, many studies were not designed to determine appropriate antibiotic spectrum or durations, or were performed without present-day advancements in surgical technique. These concerns ultimately make study results difficult to extrapolate to the general population. A summary of studies examining relevant antibiotic prophylaxis comparisons in head and neck cancer patients is described in Table 1.

Additional issues surround the potential for free-tissue wound misclassification and the subsequent impact on antibiotic prophylaxis trends. Surgical infection prophylaxis guideline recommendations fail to account for the complexity of wounds secondary to excising fungating tumors and free-tissue transfer relative to other head and neck surgeries [12], [13], [14], [15]. This may contribute to discordance in national antibiotic prophylaxis prescribing habits, irrespective of guideline recommendations [16]. Further, limited data are available regarding risk factors for SSI with multi-drug resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa. This proves difficult for clinicians to guide informed therapeutic decisions and prevent potential antibiotic overexposure, which can ultimately lead to antibiotic resistance and other severe antimicrobial-related adverse effects [17].

This focused review provides updated information regarding evidence-based POABP use in head and neck cancer microvascular reconstruction. This includes SSI microbiology, POABP selection, dosing, and duration considerations, and challenges presented in the context of antimicrobial stewardship.

Section snippets

Literature search strategy

The following Medical Subject Headings terms were used to identify literature associated with this topic: “antibiotic prophylaxis”, “head and neck neoplasms”, “head and neck cancer”, “cancer of head and neck”, “cancer of the head and neck”, “free tissue flaps”, “free flap, microsurgical”. Subsequent broad key terms were searched using the PubMed database: “antibiotic prophylaxis head neck cancer”, “antimicrobial prophylaxis head neck cancer surgery”, “antibiotic prophylaxis free flap”. Other

Epidemiology of surgical site infections

Surgical site infections are the most common complication after extensive surgical resection of the head and neck, and occur in 13–51% of cases [2], [19], [20], [21], [22], [23]. SSI are formally defined as infections of the incision, organ, or space that occur after a surgical procedure [12]. While risk factors for SSI have been previously described [2], [4], [19], [24], [25], [26], the amount of inter-patient variability and disease severity complicates the approach of reliably predicting

Surgical site infection reporting and wound classification

Reporting standardized metrics is necessary to longitudinally track outcomes, provide quality assurance, and continually improve patient care. A common surgical metric of morbidity is SSI [30], [31]. SSI surveillance reporting is required in United States acute care hospitals [12], [32], [33] and is performed in accordance with the American College of Surgeons National Surgical Quality Improvement Program reporting standards (ACS NSQIP) and the Centers for Disease Control and Prevention’s (CDC)

Microbiology of the head and neck

The microbiome of the head and neck involves Gram-positive and facultative anaerobic bacteria that normally colonize the aero-digestive tract [37]. While not typically considered colonizers of the head and neck in healthy persons, the flora of head and neck cancer patients can also contain Enterobacteriaceae and other Gram-negative organisms [38]. Clinicians must also account for the introduction of different microorganisms from harvested flap tissue that contribute to the diverse bacteria

Spectrum of activity

Utilizing antibiotic prophylaxis with a spectrum targeted towards the organisms most likely to cause infection can prevent unnecessary patient harm. As the availability of specific antimicrobials varies based on institutional formulary restrictions, a more pragmatic approach is to quantify POABP by meaningful spectrum of activity. While POABP coverage for common Streptococcus and Staphylococcus spp. should be universal due to colonization of these organisms on human skin, the need for

Duration of POABP

National POABP duration prescribing practices vary significantly [16], irrespective of current surgical prophylaxis guideline recommendations for peri-operative antibiotic prophylaxis only [12], [13], [14]. Given the great variation in duration prescribing practices, POABP durations can be conveniently dichotomized to short (e.g. 24 h to 3 days), or prolonged (e.g. 4 to greater than 7 days) [2], [36], [52], [60].

Johnson et al. performed a randomized trial of one or five days of cefoperazone POABP

Antimicrobial stewardship and infection control considerations

Strategies to prevent antimicrobial misuse, a key component of antimicrobial stewardship, include using an appropriate antimicrobial spectrum, dosage, and duration needed to prevent or treat infection. Unnecessary antimicrobial use has contributed to significant antimicrobial resistance and subsequently, extremely limited therapeutic options to treat these infections. Antimicrobial stewardship programs (ASPs) are multidisciplinary organizations that utilize evidence-based recommendations to

Conclusions

Important considerations for appropriate POABP should be taken to decrease the incidence of SSI while minimizing the risks associated with antibiotic exposure. While the existing data is limited, the majority of evidence suggests the need to be cognizant of antibiotic selection, dose, and duration to ultimately improve patient outcomes and prevent significant patient morbidity. Based on existing evidence, short durations (e.g. less than 3 days) of broad-spectrum antibiotics that cover

Acknowledgements

None.

Author contributions

MPV, SLD, AMW, JEM, TAG: Contributions to manuscript draft and critical review.

Disclosures

Competing interests: The authors declare no competing interests.

Sponsorship: None.

Funding source: None.

References (79)

  • J.L. Wagner et al.

    Surgical prophylaxis with gram-negative activity for reduction of surgical site infections after microvascular reconstruction for head and neck cancer

    Head Neck

    (2016)
  • N. Penel et al.

    Prognostic significance of wound infections following major head and neck cancer surgery: an open non-comparative prospective study

    Support Care Cancer

    (2004)
  • M.J. Mazurek et al.

    Contamination of the surgical field in head and neck oncologic surgery

    Head Neck

    (2014)
  • A.S. Ketcham et al.

    The role of prophylactic antibiotic therapy in control of staphylococcal infections following cancer surgery

    Surg Gynecol Obstet

    (1962)
  • P. Dor et al.

    Prophylactic antibiotics in oral, pharyngeal and laryngeal surgery for cancer: (a double-blind study)

    Laryngoscope

    (1973)
  • R. Saginur et al.

    Antibiotic prophylaxis in head and neck cancer surgery

    J Otolaryngol

    (1988)
  • M. Piccart et al.

    Antimicrobial prophylaxis of infections in head and neck cancer surgery

    Scand J Infect Dis Suppl

    (1983)
  • V. Velanovich

    Choice of treatment for stage I floor-of-mouth cancer

    Arch Otolaryngol Head Neck Surg

    (1990)
  • S.I. Berríos-Torres et al.

    Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017

    JAMA Surg

    (2017)
  • World Health Organization. Global guidelines for the prevention of surgical site infection; 2016. Available at:...
  • D.W. Bratzler et al.

    Clinical practice guidelines for antimicrobial prophylaxis in surgery

    Am J Health-Syst Pharm

    (2013)
  • J.C. Dort et al.

    Optimal perioperative care in major head and neck cancer surgery with free flap reconstruction: a consensus review and recommendations from the enhanced recovery after surgery society

    JAMA Otolaryngol Head Neck Surg

    (2017)
  • Reiffel AJ, Kamdar MR, Kadouch DJ, Rohde CH, Spector JA. Perioperative antibiotics in the setting of microvascular free...
  • Antibiotic use in the United States. Centers for Disease Control and Prevention; 2017. Available at:...
  • T.S. Carey et al.

    A critical guide to case series reports

    Spine

    (2003)
  • B.B. Yarlagadda et al.

    Head and neck free flap surgical site infections in the era of the Surgical Care Improvement Project

    Head Neck

    (2016)
  • M.L. Durand et al.

    The time course and microbiology of surgical site infections after head and neck free flap surgery

    Laryngoscope

    (2015)
  • C.H. Yang et al.

    Surgical site infections among high-risk patients in clean-contaminated head and neck reconstructive surgery: concordance with preoperative oral flora

    Ann Plast Surg

    (2013)
  • A. Sepher et al.

    Antibiotics in head and neck surgery in the setting of malnutrition, tracheotomy, and diabetes

    Laryngoscope

    (2009)
  • S.Y. Park et al.

    Risk factors and etiology of surgical site infection after radical neck dissection in patients with head and neck cancer

    Kor J Intern Med

    (2016)
  • A. Robson et al.

    Pre-treatment clinical assessment in head and neck cancer: United Kingdom National Multidisciplinary Guidelines

    J Laryngol Otol

    (2016)
  • P.K. Waltz et al.

    Surgical site infections and associated operative characteristics

    Surg Infect (Larchmt)

    (2017)
  • M.E. van Kasteren et al.

    Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor

    Clin Infect Dis

    (2007)
  • American College of Surgeons National Surgical Quality Improvement Program. Data Variables and Definitions; 2016....
  • Surgical site infection (SSI) event. National Healthcare Safety Network, Centers for Disease Control and Prevention;...
  • National action plan to prevent health care–associated infections: road map to elimination. US Department of Health and...
  • Centers for Medicare and Medicaid Services (CMS) et al.

    Hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system changes and FY2011 rates; provider agreements and supplier approvals; and hospital conditions of participation for rehabilitation and respiratory care services; Medicaid program: accreditation for providers of inpatient psychiatric services. Final rules and interim final rule with comment period

    Fed Regist

    (2010)
  • S.A. Liu et al.

    Preliminary report of associated factors in wound infection after major head and neck neoplasm operations – does the duration of prophylactic antibiotic matter?

    J Laryngol Otol

    (2008)
  • D.W. Grant et al.

    Catastrophic outcomes in free tissue transfer: a six-year review of the NSQIP database

    Plast Surg Int

    (2014)
  • Cited by (0)

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