C u r re n t Co n c e p t s i n

P ro p h y l a c t i c A n t i b i o t i c s i n
Oral and Maxillofacial S urgery
Chad Dammling, DDS, MDa,*, Shelly Abramowicz, DMD, MPHb,
Brian Kinard, DMD, MDa

KEYWORDS
 Antibiotic  Prophylaxis  Maxillofacial surgery

KEY POINTS
 Antibiotic prophylaxis use should be limited to established guidelines and standardized protocols to
avoid risk of antimicrobial resistance, toxicity, and excess cost.
 In addition to sterile surgical technique, proper perioperative administration and antibiotic selection
are imperative to prevent surgical site infections.
 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.
 Most dentoalveolar procedures do not require antibiotic prophylaxis, although special consider-
ations exist for infective endocarditis prevention and foreign body placement.
 Use of perioperative prophylactic antibiotics for other maxillofacial procedures depends on the sur-
gical classification and exposure to oral or pharyngeal mucosa.

INTRODUCTION Antimicrobial prophylaxis is the use of antibi-

otics in the perioperative period in order to prevent
When performing any surgical procedure, the pre- infection at the surgical site or at distant loca-
vention of infection at local and distant sites is al- tions.4 This can be directly contrasted with thera-
ways a concomitant goal.1 There are a variety of peutic antibiotics which treat and eradicate active
factors that influence the rate of surgical site and infections often for an extended period of time.5
distant infections that must be taken into consider- Surgical wounds can be classified as class I-IV
ation. Foreign bodies (eg, dental implants, recon- based upon their degree of contamination and
structive hardware) have the potential to increase involvement of respiratory, alimentary, gastroin-
infection rates.1 Patient-related risk factors include testinal, or urinary tract lining (Table 1). For each
the age of the patient, immune status, medical of these classifications, specific guidelines and
comorbidities (eg, diabetes), tobacco use, and recommendations exist for antimicrobial prophy-
nutritional status. Surgical factors are wound laxis prior to surgery.
closure, contamination level, duration of opera- Class I surgery (clean surgery) occurs when
tion, and tissue quality.2 Further, there are critical there are no breaks in the respiratory, gastrointes-
steps during all operations that decrease the likeli- tinal, or urinary tract barriers and there is no preop-
hood of infection, such as adequate irrigation, erative inflammation at the surgical site.1
clean incisions, removal of debris, hemostasis, Examples of these surgeries include extraoral
oralmaxsurgery.theclinics.com

and properly placed mucoperiosteal flaps.3 lymph node excisions and parotidectomies. Class
I surgery has an infection rate of approximately 2%

a
Department of Oral and Maxillofacial Surgery, School of Dentistry, University of Alabama at Birmingham,
1919 7th Avenue South, Room 406, Birmingham, AL 35233, USA; b Division of Oral and Maxillofacial Surgery,
Department of Surgery, Emory University School of Medicine, Oral and Maxillofacial Surgery, Children’s Health-
care of Atlanta, 1365 Clifton Road, Building B, Suite 2300, Atlanta, GA 30322, USA
* Corresponding author.
E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am 34 (2022) 157–167

https://doi.org/10.1016/j.coms.2021.08.015
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158 Dammling et al

Table 1
Surgical classification system

Classification Criteria and Examples Risk of Infection (%)

Clean Parotidectomy, lymph node excision <2
Elective: nonemergent, nontraumatic. No acute
inflammation. No break in respiratory,
gastrointestinal, biliary, or genitourinary tracts
Clean-contaminated Cleft lip or palate surgery. Orthognathic surgery. Cyst <10
enucleation
Urgent or emergency care that is otherwise clean, or
elective opening of respiratory, gastrointestinal,
biliary, or genitourinary tract with minimal spillage
Contaminated Mandibular fractures Approximately 20
Nonpurulent inflammation. Gross spillage from
gastrointestinal or genitourinary tract. Penetrating
trauma <4 h old. Chronic open wounds
Dirty Odontogenic abscess Approximately 40
Purulent inflammation with preoperative perforation
of respiratory, gastrointestinal, or genitourinary
tract. Penetrating trauma >4 h old
Adapted from Halpern LR, Adams DR. The Dentoalveolar Surgical Patient: Perioperative Principles Based on Contempo-
rary Controversies. Oral Maxillofac Surg Clin North Am. 2020;32(4):495-510.

when prophylactic antibiotics are not given. In repeat intraoperative dosing may be necessary to
contrast, procedures that disrupt the mucosa or maintain adequate serum levels.9,10 The patient’s
respiratory epithelium (class II or clean- weight (especially in obese or pediatric patients)
contaminated surgery) have been reported to must be taken into consideration to achieve
have an infection risk rate of approximately 10% adequate steady-state levels.
to 15% when prophylactic antibiotics are not pro- Antibiotic prophylaxis use should be limited to
vided.1,3 All intraoral procedures are considered established guidelines and standardized indica-
class II and can cause a transient bacteremia tions to avoid risk of antimicrobial resistance,
requiring antimicrobial prophylaxis.6,7 When pro- toxicity, and excess cost.11 In the past several
phylactic antibiotics are given and combined with years, guidelines have greatly narrowed the indi-
good surgical technique, these rates can be cations for use because of increased risk to benefit
decreased to as low as 1%.2,3 ratios.12 These potential risks include life-
Salivary flora introduces a multitude of bacteria threatening anaphylaxis and specific antibiotic-
(ie, gram-positive aerobes and anaerobic bacteria) associated side effects, such as Clostridium diffi-
into the surgical site. Gram-negative aerobes are cile colitis and tendon injury associated with clin-
generally not part of the head and neck but often damycin and fluoroquinolones, respectively.11
colonize the oropharynx in patients with upper Judicious use of antibiotics is also critical to pre-
aerodigestive tract cancers or poor oral health.8 vent multiple drug-resistant strains of bacteria
When performing class III procedures (contami- that have already evolved because of excessive
nated surgery; eg, open mandibular fractures) or overprescribing and overuse.4 Even short-term
class IV procedures (dirty surgery; eg, odonto- use through prophylaxis with a single dose has
genic abscesses), therapeutic antibiotics may be been shown to select for resistant viridans
indicated in addition to preoperative prophylactic streptococci.13
therapy.4 According to the American Society of Health-
The overall goal of prophylactic antibiotic ther- System Pharmacists (ASHP) guidelines, the goals
apy is to provide adequate blood levels of an anti- of an antimicrobial agent for prophylaxis should
biotic during the procedure to reduce be to prevent surgical site infections, prevent sur-
contamination from transient bacteremia caused gical site infection morbidity and mortality, reduce
by physiologic flora.5 These optimal levels of pro- the duration and cost of health care, produce no
phylactic antibiotics should occur before incision, adverse effects, and have no adverse conse-
and therefore proper timing and dosage are quences to the flora of the hospital or of the pa-
crucial.9 For operations that last more than 2 hours, tient.9 Further, whichever agent is chosen should

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 Current Concepts in Prophylactic Antibiotics 159

be active against most pathogens at the surgical work, and exfoliation of deciduous teeth do not
site and administered for the shortest time frame require a prophylactic antibiotic.
possible.9 Cefazolin is the most frequently chosen Overall, the AHA found that the cumulative
regimen because it has proven efficacy against bacteremia risk from daily activity (eg, chewing,
skin flora, including Staphylococcus aureus and brushing of teeth) is higher than those caused by
coagulase-negative staphylococci. These guide- dental, genitourinary, or gastrointestinal proced-
lines for antimicrobial prophylaxis also correlate ures.11,15 For most patients, the risk of adverse
with recommendations by the Surgical Care events from antibiotic use exceeds the benefit of
Improvement Project (SCIP).14 Seven of these prophylactic therapy unless they have risk factors
guidelines apply directly to the perioperative for serious IE complications.11 As a result of the
period: (1) antibiotics provided 1 hour before inci- findings discussed earlier, the AHA promotes the
sion, (2) antibiotic coverage for the most probable maintenance of oral health and hygiene as more
contaminant, (3) antibiotics discontinued with important than prophylactic antibiotics in the pre-
24 hours after surgery, (4) euglycemia throughout vention of IE in most patients.17
surgery and through the first 2 postoperative If a preoperative antibiotic is indicated, a single
days, (5) hair clipped at the surgical site, (6) Foley dose 30 to 60 minutes before the procedure
catheters removed within the first 2 postoperative should be provided to cover for the transient
days, and (7) normothermia throughout the surgi- bacteremia caused by oral bacterial flora (Table 3).
cal procedure (Table 2). The establishment of If this dose is inadvertently missed preoperatively,
these protocols has further standardized perioper- the medication can be administered up to 2 hours
ative care and reduced the incidence of surgical following the procedure.15,18 Further, if a patient is
site infections since their introduction in 2006. already taking an antibiotic for another condition
This article discusses indications for antibiotic (eg, amoxicillin for sinusitis), it is recommended
prophylaxis use during oral and maxillofacial sur- that a medication from a different class be chosen
gery procedures. For most dentoalveolar proced- for prophylactic coverage.6 Alternatively, treat-
ures, prophylactic antibiotics are not indicated ment can be delayed for 10 days following the
unless foreign bodies are to be placed, such as completion of the antibiotic course to allow for
dental implants.4 Perioperative prophylactic anti- reestablishment of oral flora.18 Then the oral and
biotics for other maxillofacial procedures depend maxillofacial surgeon (OMS) may proceed with
on the surgical classification and exposure to routine IE prophylaxis.
oral or pharyngeal mucosa. When prophylactic an-
tibiotics are indicated, published guidelines and
Dentoalveolar Procedures and Prosthetic
dosages are further reviewed here.
Joints
Based on current evidence, prophylactic antibi-
Dentoalveolar Procedures and Cardiac
otics for dentoalveolar procedures are not indi-
Conditions
cated for patients with prosthetic joints.18,19 A
Infective endocarditis (IE) is a rare but lethal dis- panel of experts selected by the American Dental
ease.12 Despite advancements in the manage- Association (ADA) in 2014 evaluated current evi-
ment and treatment of IE, patients still have high dence of prosthetic joint infections (PJIs) and
morbidity and mortality.12,15 The most common found no relationship between infections and
organisms isolated in IE are S aureus, viridans dental procedures. Similar to antibiotic use for pre-
streptococci, and enterococci species. Other, vention of IE, the risk of adverse drug reactions,
although rarer, bacteria include Haemophilus spe- costs, and antibiotic resistance outweighed the
cies, Aggregatibacter species, Cardiobacterium benefit of prescribing antibiotics for PJI prophy-
hominis, Eikenella corrodens, and Kingella.17 laxis (Box 3).
The American Heart Association (AHA) pub- Of note, some patients have conditions causing
lished guidelines for IE in 1955 and most recently an immunocompromised state (eg, rheumatoid
in 2021.15,16 These guidelines have been thor- arthritis) and the OMS should discuss need for a
oughly studied and revised after analysis and risk prophylactic regimen with the orthopedic surgeon
stratification. Antibiotic premedication is indicated or primary care physician. If this occurs, it is most
for patients with risk factors for complications from appropriate to have the orthopedic surgeon or pri-
IE and for select dental procedures that pierce the mary care doctor prescribe the appropriate
oral mucosa or manipulate gingival tissue/periapi- therapy.18
cal region of teeth (Boxes 1 and 2). For this reason, Perioperative prophylactic antibiotics for
routine anesthetic injections (through healthy tis- temporomandibular joint (TMJ) replacement sur-
sue), radiographs, prosthodontic or orthodontic gery are discussed later in this article. For patients

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160 Dammling et al

Table 2 Box 1
Surgical Care Improvement Project criteria in AP for a dental procedure: underlying
the immediate postoperative period conditions for which AP is suggested

SCIP Measure Prosthetic cardiac valve or material

Designator Performance Measure Title Presence of cardiac prosthetic valve
INF-1 Prophylactic antibiotic Transcatheter implantation of prosthetic
received within 1 h before valves
incision
Cardiac valve repair with devices, including
INF-2 Prophylactic antibiotic annuloplasty, rings, or clips
selection for surgical patient
applicable to flora Left ventricular assist devices or implantable
heart
INF -3 Prophylactic antibiotics
discontinued within 24 h Previous, relapse, or recurrent IE
after surgery end time CHD
INF-4 Cardiac surgery patients with
controlled 6 AM and Unrepaired cyanotic congenital CHD,
postoperative blood glucose including palliative shunts and conduits.
INF-6 Surgery patients with Completely repaired congenital heart defect
appropriate hair removal with prosthetic material or device, whether
placed by surgery or by transcatheter during
INF-9 Urinary catheter removal on
the first 6 mo after the procedure
postoperative day 1 or
postoperative day 2 Repaired CHD with residual defects at the site
INF-10 Surgery patients with of or adjacent to the site of a prosthetic patch
perioperative temperature or prosthetic device
management Surgical or transcatheter pulmonary artery
valve or conduit placement such as Melody
INF, infection measure designators. valve and Contegra conduit
Adapted from Dua A, Desai SS, Seabrook GR, Brown KR,
Lewis BD, Rossi PJ, Edmiston CE, Lee CJ. The effect of Sur- Cardiac transplant recipients who develop car-
gical Care Improvement Project measures on national diac valvulopathy
trends on surgical site infections in open vascular proced-
ures. J Vasc Surg. 2014 Dec;60(6):1635–9. AP for a dental procedure not suggested
Implantable electronic devices such as a pace-
already with a TMJ prosthesis, it is recommended
maker or similar devices
that they are treated with prophylactic antibiotics
to cover for oral flora if they are to receive an infe- Septal defect closure devices when complete
rior alveolar nerve injection during the procedure. closure is achieved
During the administration of local anesthesia, the Peripheral vascular grafts and patches,
tip of the needle can potentially come in close con- including those used for hemodialysis
tact with or touch the condylar component fixation Coronary artery stents or other vascular stents
screws as they are positioned in the pterygoman- CNS ventriculoatrial shunts
dibular space.20
Vena cava filters

Dental Implants and Bone Grafting Pledgets

AP indicates antibiotic prophylaxis; CHD,
Infections around dental implants can be congenital heart disease; CNS, central nervous
extremely difficult to eradicate and often warrant system; and IE, infective endocarditis.
removal of the implant.21 Antibiotic prophylaxis
for dental implant procedures has been shown to From Wilson WR, Gewitz M, Lockhart PB, Bolger AF,
DeSimone DC, Kazi DS, Couper DJ, Beaton A, Kilmartin
be beneficial in reducing implant failure and post- C, Miro JM, Sable C, Jackson MA, Baddour LM; Amer-
operative infection rates.21,22 A Cochrane Review ican Heart Association Young Hearts Rheumatic Fever,
summarized these findings and recommended 2 Endocarditis and Kawasaki Disease Committee of the
or 3 g of amoxicillin 1 hour preoperatively to signif- Council on Lifelong Congenital Heart Disease and
Heart Health in the Young; Council on Cardiovascular
icantly reduce the failure rate of implants caused
and Stroke Nursing; and the Council on Quality of
by infection. In a separate retrospective analysis, Care and Outcomes Research. Prevention of Viridans
no differences were noted between clindamycin, Group Streptococcal Infective Endocarditis: A Scienti-
amoxicillin, or cephalosporins when given preop- fic Statement From the American Heart Association.
eratively.4 For both autogenous and allogeneic Circulation. 2021 May 18;143(20):e963-e978.

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 Current Concepts in Prophylactic Antibiotics 161

Box 2 bone grafting, a meta-analysis by Khouly and col-

Dental procedures requiring endocarditis leagues23 found that there are insufficient data to
prophylaxis support the use of prophylactic antibiotics for
bone grafting when performed without implant
All dental procedures that involve manipula- placement. An additional review by Klinge and col-
tion of gingival tissue or the periapical region leagues24 found a similar lack of evidence in the
of teeth or perforation of the oral mucosa. literature. There still remains a need for an
The following do not need prophylaxis: routine adequate randomized controlled trial to evaluate
anesthetic injections through noninfected tis- prophylaxis when bone grafts are placed indepen-
sue, dental radiographs, placement of remov- dent of dental implants.
able prosthodontic or orthodontic appliances, Postoperatively, antibiotics have not been
adjustment of orthodontic appliances, place-
shown to be beneficial to prevent infections of
ment of orthodontic brackets, shedding of de-
ciduous teeth, and bleeding from trauma to dental implants. Because of increased risk of
the lips or oral mucosa. adverse events and antibiotic resistance, postop-
erative antibiotics are not indicated following
Adapted from Wilson W, Taubert KA, Gewitz M, Lock- placement of dental implants.25 Despite this lack
hart PB, Baddour LM, Levison M, Bolger A, Cabell CH,
Takahashi M, Baltimore RS, Newburger JW, Strom BL,
of evidence or standardized guidelines, many den-
Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, tists empirically provide a postoperative course of
Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Du- therapy ranging from 1 to 5 days.23 The Misch In-
rack DT; American Heart Association. Prevention of ternational Institute recommends both prophylac-
infective endocarditis: guidelines from the American
tic and postoperative antibiotic therapy based on
Heart Association: a guideline from the American
Heart Association Rheumatic Fever, Endocarditis and the patient’s health status and the procedural
Kawasaki Disease Committee, Council on Cardiovascu- intervention (Table 4).26 Although there are no
lar Disease in the Young, and the Council on Clinical long-term randomized controls validating these
Cardiology, Council on Cardiovascular Surgery and protocols, their guidelines have been successfully
Anesthesia, and the Quality of Care and Outcomes
Research Interdisciplinary Working Group. J Am Dent
implemented by the many doctors that have
Assoc. 2008 Jan;139 Suppl:3S-24S. completed training through their institutions.23,26

Table 3
Antibiotic regimens for a dental procedure regimen: single dose 30 to 60 minutes before procedure

Situation Agent Adults Children

Oral Amoxicillin 2g 50 mg/kg
Unable to take Ampicillin OR 2 g IM or IV 50 mg/kg IM or IV
oral medication Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV
Allergic to penicillin or Cephalexina OR 2g 50 mg/kg
ampicillin—oral Azithromycin or 500 mg 15 mg/kg
clarithromycin OR
Doxycydine 100 mg <45 kg, 2.2 mg/kg
>45 kg, 100 mg
Allergic to penicillin Cefazolin or ceftriaxoneb 1 g IM or IV 50 mg/kg IM or IV
or ampicillin
and unable to take
oral medication

Clindamycin is no longer recommended for antibiotic prophylaxis for a dental procedure.

IM indicates intramuscular; and IV, intravenous.
a
Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosing.
b
Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticarial with peni-
cillin or ampicillin.
From Wilson WR, Gewitz M, Lockhart PB, Bolger AF, DeSimone DC, Kazi DS, Couper DJ, Beaton A, Kilmartin C, Miro JM,
Sable C, Jackson MA, Baddour LM; American Heart Association Young Hearts Rheumatic Fever, Endocarditis and Kawasaki
Disease Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Car-
diovascular and Stroke Nursing; and the Council on Quality of Care and Outcomes Research. Prevention of Viridans Group
Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association. Circulation. 2021 May
18;143(20):e963-e978.

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162 Dammling et al

Box 3 Infection rates for clean procedures are

Management of patients with prosthetic joints extremely low, even without antibiotic prophylaxis,
undergoing dental procedures and are estimated at less than 2%. Systemic anti-
biotics have not been proved effective in reducing
Clinical recommendations: surgical site infections and generally a single dose
In general, for patients with prosthetic joint to cover for skin flora is indicated.9 If placement of
implants, prophylactic antibiotics are not rec- a prosthetic material such as hardware or an
ommended before dental procedures to pre- implant is planned, a similar perioperative dose
vent PJI. of a cephalosporin or clindamycin is indicated.9
For patients with a history of complications Routine sterile preparation and draping remain
associated with their joint replacement sur- recommended for all procedures.
gery who are undergoing dental procedures Compared with class I procedures, the current
that include gingival manipulation or literature recommends prophylactic antibiotics
mucosal incision, prophylactic antibiotics for any incisions through oral, nasal, or pharyngeal
should only be considered after consultation mucosa.9 This recommendation includes
with the patient and orthopedic surgeon. To coverage for S aureus, oropharyngeal anaerobes,
assess a patient’s medical status, a complete
and enteric gram-negative bacilli with cefazolin
health history is always recommended when
making final decisions regarding the need plus metronidazole, ampicillin/sulbactam, clinda-
for antibiotic prophylaxis. mycin, or cefuroxime plus metronidazole.11 It has
been shown that a short course of antimicrobial
Clinical reasoning for the recommendation: therapy (<24 hours) has improved outcomes
 There is evidence that dental procedures are compared with an extended course (>72 hours)
not associated with prosthetic joint implant for both oral surgery and ear, nose, and throat pro-
infections. cedures. The administration of antibiotics for more
 There is evidence that antibiotics provided than 72 hours was associated with more adverse
before oral care do not prevent prosthetic effects than the short-term dose even in just the
joint implant infections. perioperative period.27,28
 There are potential harms of antibiotics,
including risk for anaphylaxis, antibiotic resis- Head and neck oncology
tance, and opportunistic infections such as C Head and neck oncologic procedures are at an
difficile. increased risk of infection because of the pres-
 The benefits of antibiotic prophylaxis may ence of multiple wound locations, including the
not exceed the harms for most patients. primary tumor site, neck dissection, free flap donor
 The individual patient’s circumstances and sites, and tracheostomy. The diverse flora present
preference should be considered when within these locations and exposure to the oral
deciding whether to prescribe prophylactic cavity contribute to persistently high rates of infec-
antibiotics before dental procedures. tion despite perioperative and postoperative anti-
biotic therapy29 (Table 5). Free flap
Adapted from Sollecito TP, Abt E, Lockhart PB, et al.
The use of prophylactic antibiotics prior to Dental pro-
reconstruction increases the risk of surgical site
cedures in patients with prosthetic joints: Evidence- infection by 2.2 to 2.8 times and tracheotomy in-
based clinical practice guideline for dental creases infection risk 3-fold.8 A total laryngectomy
practitioners-a report of the American Dental Associa- caries the highest risk of postoperative surgical
tion Council on Scientific Affairs. J Am Dent Assoc.
site infection out of all head and neck procedures.
2015;146(1):11-16.e8.
Surgical site infections in these patient popula-
tions are increasingly problematic because of po-
Other Maxillofacial Procedures tential delays in adjuvant therapy and prolonged
tracheostomy status.29 For these reasons, the
Aside from the dentoalveolar procedures dis- modifiable risk factors discussed earlier are imper-
cussed earlier, other maxillofacial procedures ative to address preoperatively, including malnutri-
often require antibiotic prophylaxis based on their tion and tobacco use. Proper assessment of
involvement of respiratory or alimentary tracts (ie, nutritional status is critical given that many of these
oral, nasal, pharyngeal mucosa). Examples of disorders can severely limit adequate oral intake.
clean procedures include thyroidectomy, extraoral Surgical site infections in head and neck onco-
lymph node excisions, and blepharoplasties, logic procedures are estimated at 24% to 87% if
whereas clean-contaminated surgeries include prophylactic antibiotics are not provided.9 For pa-
orthognathic procedures, rhinoplasty, and cleft tients treated with perioperative prophylactic anti-
palate repair.9 biotics, infection rates are decreased to 5.8% to

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 Table 4
Misch International Implant Institute prophylaxis protocol
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Type Patient Selection Procedure Antibiotic Antimicrobial

Type 1 ASA 1 or 2  Simple extraction of unin- None Chlorhexidine 14.8 mL (0.5 oz)
fected teeth BID for 2 wk
 Single-tooth implant
 Second-stage surgery
 Limited soft tissue reflection
surgery
Type 2 ASA 1 or 2  Multiple simple extractions Amoxicillin 1 g 1 h before Chlorhexidine 14.8 mL (0.5 oz)
 Traumatic extractions surgery and 500 mg 6 h later BID for 2 wk
 Multiple implants/limited
reflection
 Socket grafting
 Immediate implants/no
disorder
Type 3 ASA 1 or 2  Membrane bone grafting Amoxicillin 1 g 1 h before Chlorhexidine 14.8 mL (0.5 oz)
(allograft, xenograft, or surgery and 500 mg TID for BID for 2 wk
alloplast) 3d

Current Concepts in Prophylactic Antibiotics

 Multiple implants/extensive
reflection
 Multiple immediate
implants
Type 4 ASA>2  Full-arch implants Amoxicillin 1 g 1 h before Chlorhexidine 14.8 mL (0.5 oz)
 Long-duration surgery  Sinus lift surgery and 500 mg TID for BID for 2 wk
 Less experienced surgeon  Autogenous bone graft 5d
 Immunocompromised
 Active periodontal disease
Type 4 Sinus Sinus augmentation patients  Sinus patients Augmentin 875/125 mg BID Chlorhexidine 14.8 mL (0.5 oz)
starting 1 d before and 5 d BID for 2 wk
after

Abbreviation: ASA, American Society of Anesthesiologists; BID, twice a day; TID, 3 times a day.
Adapted from Resnik RR, Misch C. Prophylactic antibiotic regimens in oral implantology: Rationale and protocol. Implant Dent. 2008;17(2):142-150.

163
164 Dammling et al

Table 5
Despite this research, institutional protocols
Risk factors for infection complications in head following free flap reconstructive procedures
and neck surgery generally include 2 to 5 days of antibiotic coverage
because of the increased infectious risk discussed
Type of surgery Upper aerodigestive tract, earlier.
clean-contaminated
surgery, tracheostomy, Orthognathic surgery
and osteocutaneous flap For orthognathic surgery, there is a general lack of
reconstruction consensus for the preferred duration of prophylac-
Surgical factors Duration of surgery, tic antibiotic therapy.13 Without any antibiotic pro-
operative blood loss, flap phylaxis, the rate of infection can vary between
failure, operative 10% and 25% and, given the procedure is classi-
takebacks, and
fied as clean-contaminated, prophylactic antibi-
microsurgical revision
otics are always indicated immediately before
Medical factors ASA classification,
incision.22,32–34 Systematic reviews by Naimi-
advanced age, diabetes,
Akbar and colleagues13 and Oomens and col-
increased BMI
leagues32 found that there is a high amount of
Factors that Nutrition status,
bias in previous orthognathic studies that discuss
affect wound hypoalbuminemia,
healing hypothyroidism, the use of postoperative prophylactic antibiotic
smoking, tobacco use, regimens.22 There is no evidence regarding the
MRSA colonization effectiveness of a postoperative regimen and
Previous Previous radiation and both investigators conclude that a single preoper-
therapies previous surgery ative dose for bacterial coverage as discussed
Antibiotic Clindamycin earlier for clean-contaminated surgery is
selection sufficient.35

Abbreviations: BMI, body mass index; MRSA, methicillin- Temporomandibular joint replacement
resistant S aureus.
Surgical site infections following alloplastic joint
From Cannon RB, Houlton JJ, Mendez E, Futran ND.
Methods to reduce postoperative surgical site infections replacement can be a devastating complication
after head and neck oncology surgery. Lancet Oncol. and often require removal of the entire joint. The
2017;18(7):e405-e413. Reprinted with permission of Elsev- use of clean operating rooms, stringent protocols,
ier, Inc. and appropriate antibiotic therapy has decreased
orthopedic infection rates to approximately 1%
during primary joint replacements.9 When infec-
38%.9 Existing evidence recommends broad- tions occur, they present as early (within 3 months
spectrum antibiotics that cover gram-positive, of surgery), delayed (3–12 months), or late (after
gram-negative, and anaerobic bacteria with cefa- 12 months). A major contributing factor to the
zolin plus metronidazole, or ampicillin/sulbactam. development of late infections is bacterial forma-
For patients with a severe b-lactam allergy, the tion of a biofilm on the prosthesis, which also
combination of clindamycin and an aminoglyco- must be carefully monitored during TMJ
side (generally gentamycin), ciprofloxacin, or replacements.
aztreonam should be used.8,29 Clindamycin There is a significant amount of data from the or-
monotherapy should be avoided because there thopedic literature supporting the use of prophy-
are increased risks of surgical site infections lactic antibiotic therapy to cover for skin flora in
caused by the presence of increased gram- any joint replacement even though there is no
negative organisms and increased resistance in break in the respiratory or gastrointestinal epithe-
the head and neck.8,29,30 Clindamycin monother- lium.9 Further, for patients that are colonized with
apy was also found to increase the length of hos- methicillin-resistant S aureus (MRSA) preopera-
pital stay to 18 versus 11.4 days because of both tively or at hospitals with high rates of MRSA infec-
medical and surgical infections.31 It is recommen- tions, vancomycin is often given in addition to
ded that clinicians still consider the use of cefazo- cefazolin. Nasal mupirocin should also be adminis-
lin plus metronidazole if mild allergies are noted tered preoperatively to patients that are colonized
given low cross-reactivity rates between penicillin with MRSA.
and cephalosporins (w2%).8,29 TMJ replacement infections have been esti-
Postoperatively, no difference in efficacy has mated to occur 1.5% to 2.7% of the time.20 The
been reported in regimens of 24 hours of antibi- use of prophylactic antibiotics with correct timing
otics versus longer therapies for 7 days.9,29 and dose remains the most important factor in

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 Current Concepts in Prophylactic Antibiotics 165

preventing PJI.20 Comparable with the orthopedic discontinued with 24 hours after surgery; 4)
literature, cephalosporins are used for prophylaxis euglycemia throughout surgery and through
(clindamycin if allergic) and vancomycin is indi- the first two post-operative days; 5) hair clip-
cated if the patient is a carrier for MRSA. It also ped at the surgical site; 6) foley catheters
has been recommended that TMJ prostheses are removed within the first two post-operative
soaked in a vancomycin solution before implanta- days; and 7) normothermia throughout the
tion into the patient. All TMJ replacement instru- surgical case.
mentation and devices should strictly be kept  Prophylactic antibiotics are generally not indi-
separate from contamination from the oral cav- cated for most routine dentoalveolar
ity.36 Following the procedure, a total of 7 to procedures.
10 days of continued oral antibiotic prophylaxis  Infective endocarditis (IE) prophylaxis is indi-
are recommended to prevent contamination by cated in patients with the presence of a car-
the parotid gland, ear canal, or oral cavity.20 diac valves, previous or recurrent infective
endocarditis, unrepaired congenital heart de-
SUMMARY fects or repaired defects with residual deficits,
and cardiac transplant recipients who
Aside from a few exceptions, most dentoalveolar develop cardiac valvulopathies.
procedures performed by OMSs do not require  IE prophylaxis is not indicated in patients with
antibiotic prophylaxis. If a patient meets criteria pacemakers, peripheral vascular grafts, stents,
for risk of IE, then premedication with the appro- CNS shunts, vena cava filters or cardiac
priate antibiotic coverage 30 to 60 minutes before pledgets.
the procedure should occur. For nondentoalveolar  Compared to the previous 2007 AHA guide-
head and neck procedures, the decision to pro- lines regarding antibiotic prophylaxis, clinda-
vide prophylactic antibiotics is based on the mycin is no longer recommended for patients
disturbance of the oral, nasal, or pharyngeal bar- that are penicillin allergic.
rier. If these areas are violated or involved in the  Class I surgery (clean surgery) occurs when
surgery, then the procedure is considered a there are no breaks in the respiratory, gastro-
clean-contaminated procedure (assuming no intestinal, or urinary tract barriers and there is
active infection is already present). The transient no preoperative inflammation at the surgical
bacteremia initiated by this involvement incurs a site. Generally, a single dose to cover for
10% risk of infection without treatment and pro- normal skin flora is indicated in addition to
phylactic antibiotics are indicated. In contrast, routine sterile prep and drape.
clean procedures do not require antibiotics unless  Class II procedures include any incision
a foreign body or implant is to be placed. As with through oral, nasal, or pharyngeal mucosa.
all procedures, clinical judgment and evaluation Prophylactic antibiotics are indicated for
of the patient’s medical status must be taken coverage of Staphylococcus aureus, oropha-
into consideration to stratify the risk of infection ryngeal anaerobes, and enteric gram-nega-
tive bacilli with cefazolin plus
and need for prophylactic and/or postoperative
metronidazole, ampicillin/sulbactam, clinda-
antibiotics. mycin, or cefuroxime plus metronidazole.

CLINICS CARE POINTS  When performing class III procedures

(contaminated surgery i.e. an open mandib-
ular fractures) or class IV procedures (dirty sur-
gery i.e. odontogenic abscesses), therapeutic
antibiotics may be indicated in addition to
 The goals of antimicrobial prophylaxis are to: preoperative prophylactic therapy.
prevent surgical site infections, prevent surgi-
 Head and neck oncologic procedures are at an
cal site infection morbidity and mortality;
increased risk of infection due to the presence
reduce the duration and cost of healthcare;
produce no adverse effects; and have no of diverse flora and multiple wound locations
including the primary tumor site, neck dissec-
adverse consequences to the flora of a hospi-
tion, free flap donor sites, and tracheostomy.
tal or of the patient.
 The Surgical Care Improvement Project (SCIP)
has laid out specific guidelines on how to
reduce surgical site infections. Seven of these
guidelines apply directly to the perioperative
period: 1) antibiotics provided one hour prior DISCLOSURE
to incision; 2) antibiotic coverage for the most
probable contaminant; 3) antibiotics The authors have nothing to disclose.

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166 Dammling et al

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