Peri-operative Antibiotics in the Setting of Oropharyngeal Reconstruction: Less is More.
Leslie E. Cohen, Md, Brendan M. Finnerty, MD, Alyssa J. Reiffel, MD, Andrew Weinstein, MD, Jill J. Ketner, PA, Tatiana Boyko, MD, Jason A. Spector, MD.
New York Presbyterian Cornell, New York, NY, USA.
Recipient site infection following oropharyngeal reconstruction is a potentially disastrous complication that can jeopardize both the reconstruction and patient survival. Although studies suggest that peri-operative antibiotic administration reduces infection rates in these patients from 87% to 20%, there is no consensus among reconstructive surgeons regarding what constitutes the most appropriate antibiotic regimen in the setting of reconstruction of the oropharynx. The duration of treatment is in particular dispute. We reviewed our experience with peri-operative antibiotic administration in the setting of flap reconstruction of oropharyngeal defects to assess for patterns of infection as a correlate of antibiotic duration.
A retrospective review was performed of all patients who underwent local, pedicled, or free flap reconstruction of defects of the oropharynx following oncologic resection by a single surgeon at a single institution between 2007 and 2013.
100 patients were included: 63 underwent microvascular free flap reconstruction, while 39 underwent reconstruction with pedicled or local flaps. Patients received a combination of intravenous antibiotic agents designed to cover oral flora. Mean duration of intravenous peri-operative antibiotic administration was 5.3 days (range, 1-22 days). All patients received topical antibiotic prophylaxis (oral mouthwash). There were 23 recipient site complications (23%) included cellulitis (9%), muco-cutaneous fistula (5%), abscess (5%), and wound dehiscence (4%). Duration of prophylactic antibiotic treatment, defined as less than 48 hours (short-course) or greater than 48 hours (long-course), was not a significant predictor of recipient site complication. Of the various antibiotic regimens, clindamycin prophylaxis was a significant risk factor for the development of a recipient site complication (OR 6.44; 95% CI, 1.64-25.37; p<0.008). There was no correlation between recipient site complications infections and a preoperative history of chemoradiation, tobacco or alcohol use, previous head and neck malignancy, albumin, hemoglobin, diabetes mellitus, and the presence of a tracheostomy. Increased duration of surgery was found to be a significant risk factor for the development of recipient site complications (OR 1.14; 95% CI 1.02-1.29; p=0.047). Duration of prophylactic antibiotic treatment, defined as <48 hours (“short-course”) or >48 hours (“long-course”), was not a significant predictor of recipient site complication. Recipient site complication was found to be a significant predictor of both increased length of hospital stay (p<0.001) and increased time to the resumption of enteral feeds (p<0.035).
Our data confirm that complex head and neck reconstruction is associated with significant post-operative morbidity. Despite the frequency with which complex oral cavity reconstructions are performed at our institution, no standardized regimen for peri-operative antibiotic administration exists as of yet. These data suggest that extended courses of peri-operative antibiotics do not confer additional benefits beyond short-course therapy. We recommend a limited postoperative 48 hour course of prophylactic antibiotics with sufficient aerobic and anaerobic coverage in order to minimize the incidence of antibiotic-related morbidities and reduce overall healthcare costs.
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