Antibiotic prophylaxis is the use of antibiotics in the perioperative period to prevent surgical site infections from local flora. Specific guidelines and criteria exist to prevent these infections while also practicing antimicrobial stewardship. Most dentoalveolar procedures do not require antibiotic prophylaxis. For nondentoalveolar procedures, the decision to provide antibiotic prophylaxis is based on involvement of the respiratory, oral, or pharyngeal mucosa. Special considerations exist for patients at high risk for infective endocarditis, patients with head and neck cancer, and temporomandibular joint replacement procedures. This article discusses indications for antibiotic prophylaxis during oral and maxillofacial surgical procedures.
Key points
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Antibiotic prophylaxis use should be limited to established guidelines and standardized protocols to avoid risk of antimicrobial resistance, toxicity, and excess cost.
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In addition to sterile surgical technique, proper perioperative administration and antibiotic selection are imperative to prevent surgical site infections.
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Surgical procedures are classified as class I to IV based on the presence of active infection and their involvement of the respiratory, alimentary, gastrointestinal, or urinary tract lining.
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Most dentoalveolar procedures do not require antibiotic prophylaxis, although special considerations exist for infective endocarditis prevention and foreign body placement.
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Use of perioperative prophylactic antibiotics for other maxillofacial procedures depends on the surgical classification and exposure to oral or pharyngeal mucosa.
Introduction
When performing any surgical procedure, the prevention of infection at local and distant sites is always a concomitant goal. There are a variety of factors that influence the rate of surgical site and distant infections that must be taken into consideration. Foreign bodies (eg, dental implants, reconstructive hardware) have the potential to increase infection rates. Patient-related risk factors include the age of the patient, immune status, medical comorbidities (eg, diabetes), tobacco use, and nutritional status. Surgical factors are wound closure, contamination level, duration of operation, and tissue quality. Further, there are critical steps during all operations that decrease the likelihood of infection, such as adequate irrigation, clean incisions, removal of debris, hemostasis, and properly placed mucoperiosteal flaps.
Antimicrobial prophylaxis is the use of antibiotics in the perioperative period in order to prevent infection at the surgical site or at distant locations.4 This can be directly contrasted with therapeutic antibiotics which treat and eradicate active infections often for an extended period of time.5 Surgical wounds can be classified as class I-IV based upon their degree of contamination and involvement of respiratory, alimentary, gastrointestinal, or urinary tract lining ( Table 1 ). For each of these classifications, specific guidelines and recommendations exist for antimicrobial prophylaxis prior to surgery.
| Classification | Criteria and Examples | Risk of Infection (%) |
|---|---|---|
| Clean | Parotidectomy, lymph node excision Elective: nonemergent, nontraumatic. No acute inflammation. No break in respiratory, gastrointestinal, biliary, or genitourinary tracts |
<2 |
| Clean-contaminated | Cleft lip or palate surgery. Orthognathic surgery. Cyst enucleation Urgent or emergency care that is otherwise clean, or elective opening of respiratory, gastrointestinal, biliary, or genitourinary tract with minimal spillage |
<10 |
| Contaminated | Mandibular fractures Nonpurulent inflammation. Gross spillage from gastrointestinal or genitourinary tract. Penetrating trauma <4 h old. Chronic open wounds |
Approximately 20 |
| Dirty | Odontogenic abscess Purulent inflammation with preoperative perforation of respiratory, gastrointestinal, or genitourinary tract. Penetrating trauma >4 h old |
Approximately 40 |
Class I surgery (clean surgery) occurs when there are no breaks in the respiratory, gastrointestinal, or urinary tract barriers and there is no preoperative inflammation at the surgical site. Examples of these surgeries include extraoral lymph node excisions and parotidectomies. Class I surgery has an infection rate of approximately 2% when prophylactic antibiotics are not given. In contrast, procedures that disrupt the mucosa or respiratory epithelium (class II or clean-contaminated surgery) have been reported to have an infection risk rate of approximately 10% to 15% when prophylactic antibiotics are not provided. , All intraoral procedures are considered class II and can cause a transient bacteremia requiring antimicrobial prophylaxis. , When prophylactic antibiotics are given and combined with good surgical technique, these rates can be decreased to as low as 1%. ,
Salivary flora introduces a multitude of bacteria (ie, gram-positive aerobes and anaerobic bacteria) into the surgical site. Gram-negative aerobes are generally not part of the head and neck but often colonize the oropharynx in patients with upper aerodigestive tract cancers or poor oral health.
When performing class III procedures (contaminated surgery; eg, open mandibular fractures) or class IV procedures (dirty surgery; eg, odontogenic abscesses), therapeutic antibiotics may be indicated in addition to preoperative prophylactic therapy.
The overall goal of prophylactic antibiotic therapy is to provide adequate blood levels of an antibiotic during the procedure to reduce contamination from transient bacteremia caused by physiologic flora. These optimal levels of prophylactic antibiotics should occur before incision, and therefore proper timing and dosage are crucial. For operations that last more than 2 hours, repeat intraoperative dosing may be necessary to maintain adequate serum levels. , The patient’s weight (especially in obese or pediatric patients) must be taken into consideration to achieve adequate steady-state levels.
Antibiotic prophylaxis use should be limited to established guidelines and standardized indications to avoid risk of antimicrobial resistance, toxicity, and excess cost. In the past several years, guidelines have greatly narrowed the indications for use because of increased risk to benefit ratios. These potential risks include life-threatening anaphylaxis and specific antibiotic-associated side effects, such as Clostridium difficile colitis and tendon injury associated with clindamycin and fluoroquinolones, respectively. Judicious use of antibiotics is also critical to prevent multiple drug-resistant strains of bacteria that have already evolved because of excessive overprescribing and overuse. Even short-term use through prophylaxis with a single dose has been shown to select for resistant viridans streptococci.
According to the American Society of Health-System Pharmacists (ASHP) guidelines, the goals of an antimicrobial agent for prophylaxis should be to prevent surgical site infections, prevent surgical site infection morbidity and mortality, reduce the duration and cost of health care, produce no adverse effects, and have no adverse consequences to the flora of the hospital or of the patient. Further, whichever agent is chosen should be active against most pathogens at the surgical site and administered for the shortest time frame possible. Cefazolin is the most frequently chosen regimen because it has proven efficacy against skin flora, including Staphylococcus aureus and coagulase-negative staphylococci. These guidelines for antimicrobial prophylaxis also correlate with recommendations by the Surgical Care Improvement Project (SCIP). Seven of these guidelines apply directly to the perioperative period: (1) antibiotics provided 1 hour before incision, (2) antibiotic coverage for the most probable contaminant, (3) antibiotics discontinued with 24 hours after surgery, (4) euglycemia throughout surgery and through the first 2 postoperative days, (5) hair clipped at the surgical site, (6) Foley catheters removed within the first 2 postoperative days, and (7) normothermia throughout the surgical procedure ( Table 2 ). The establishment of these protocols has further standardized perioperative care and reduced the incidence of surgical site infections since their introduction in 2006.
| SCIP Measure Designator | Performance Measure Title |
|---|---|
| INF-1 | Prophylactic antibiotic received within 1 h before incision |
| INF-2 | Prophylactic antibiotic selection for surgical patient applicable to flora |
| INF -3 | Prophylactic antibiotics discontinued within 24 h after surgery end time |
| INF-4 | Cardiac surgery patients with controlled 6 am and postoperative blood glucose |
| INF-6 | Surgery patients with appropriate hair removal |
| INF-9 | Urinary catheter removal on postoperative day 1 or postoperative day 2 |
| INF-10 | Surgery patients with perioperative temperature management |
This article discusses indications for antibiotic prophylaxis use during oral and maxillofacial surgery procedures. For most dentoalveolar procedures, prophylactic antibiotics are not indicated unless foreign bodies are to be placed, such as dental implants. Perioperative prophylactic antibiotics for other maxillofacial procedures depend on the surgical classification and exposure to oral or pharyngeal mucosa. When prophylactic antibiotics are indicated, published guidelines and dosages are further reviewed here.
Dentoalveolar Procedures and Cardiac Conditions
Infective endocarditis (IE) is a rare but lethal disease. Despite advancements in the management and treatment of IE, patients still have high morbidity and mortality. , The most common organisms isolated in IE are S aureus , viridans streptococci, and enterococci species. Other, although rarer, bacteria include Haemophilus species, Aggregatibacter species, Cardiobacterium hominis , Eikenella corrodens , and Kingella .
The American Heart Association (AHA) published guidelines for IE in 1955 and most recently in 2021. , These guidelines have been thoroughly studied and revised after analysis and risk stratification. Antibiotic premedication is indicated for patients with risk factors for complications from IE and for select dental procedures that pierce the oral mucosa or manipulate gingival tissue/periapical region of teeth ( Boxes 1 and 2 ). For this reason, routine anesthetic injections (through healthy tissue), radiographs, prosthodontic or orthodontic work, and exfoliation of deciduous teeth do not require a prophylactic antibiotic.
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Prosthetic cardiac valve or material
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Presence of cardiac prosthetic valve
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Transcatheter implantation of prosthetic valves
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Cardiac valve repair with devices, including annuloplasty, rings, or clips
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Left ventricular assist devices or implantable heart
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Previous, relapse, or recurrent IE
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CHD
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Unrepaired cyanotic congenital CHD, including palliative shunts and conduits.
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Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by transcatheter during the first 6 mo after the procedure
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Repaired CHD with residual defects at the site of or adjacent to the site of a prosthetic patch or prosthetic device
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Surgical or transcatheter pulmonary artery valve or conduit placement such as Melody valve and Contegra conduit
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Cardiac transplant recipients who develop cardiac valvulopathy
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AP for a dental procedure not suggested
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Implantable electronic devices such as a pacemaker or similar devices
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Septal defect closure devices when complete closure is achieved
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Peripheral vascular grafts and patches, including those used for hemodialysis
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Coronary artery stents or other vascular stents
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CNS ventriculoatrial shunts
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Vena cava filters
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Pledgets
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AP indicates antibiotic prophylaxis; CHD, congenital heart disease; CNS, central nervous system; and IE, infective endocarditis.
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All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.
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The following do not need prophylaxis: routine anesthetic injections through noninfected tissue, dental radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of deciduous teeth, and bleeding from trauma to the lips or oral mucosa.
Overall, the AHA found that the cumulative bacteremia risk from daily activity (eg, chewing, brushing of teeth) is higher than those caused by dental, genitourinary, or gastrointestinal procedures. , For most patients, the risk of adverse events from antibiotic use exceeds the benefit of prophylactic therapy unless they have risk factors for serious IE complications. As a result of the findings discussed earlier, the AHA promotes the maintenance of oral health and hygiene as more important than prophylactic antibiotics in the prevention of IE in most patients.
If a preoperative antibiotic is indicated, a single dose 30 to 60 minutes before the procedure should be provided to cover for the transient bacteremia caused by oral bacterial flora ( Table 3 ). If this dose is inadvertently missed preoperatively, the medication can be administered up to 2 hours following the procedure. , Further, if a patient is already taking an antibiotic for another condition (eg, amoxicillin for sinusitis), it is recommended that a medication from a different class be chosen for prophylactic coverage. Alternatively, treatment can be delayed for 10 days following the completion of the antibiotic course to allow for reestablishment of oral flora. Then the oral and maxillofacial surgeon (OMS) may proceed with routine IE prophylaxis.
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