Antibiotics+in+Head+and+Neck+Surgery%0d%0a%0d%0aDepartment+of+Otolaryngology+UTMB+Resident+Physician%3aKaren+L.+Stierman%2c+M.D.+Faculty+Physician%3a+Ronald+W.+Deskin%2c+M.D.%0d%0a%0d%0a%0cIntroduction%0d%0a%e2%80%a2+Classification+of+wounds+%e2%80%a2+Commonly+used+antibiotics+%e2%80%a2+Indications+for+perioperative+antibiotics+in+head+and+neck+surgery%0d%0a%0d%0a%0cWound+Infections%0d%0a%e2%80%a2+Largest+group+of+postooperative+infectious+complications+of+surgery+%e2%80%a2+Second+most+frequent+type+of+nocosomial+infection%0d%0a%0d%0a%0cConsiderations+for+the+use+of+antibiotic+therapy%0d%0a%e2%80%a2+Risk+of+developing+wound+infection%0d%0a%e2%80%93+classification+of+wound+%e2%80%93+host+and+local+factors%0d%0a%0d%0a%e2%80%a2+Cost+of+therapy%0d%0a%e2%80%93+1992+cost+of+treating+a+wound+infection+%2436%2c000%0d%0a%0d%0a%e2%80%a2+Side+effects+and+development+of+resistance%0d%0a%0d%0a%0cResistance+to+Antibiotic+Therapy%0d%0a%e2%80%a2+Virtually+all+bacterial+pathogens+have+the+ability+to+acquire+resistance+to+antibiotic+therapy+%e2%80%a2+This+problem+is+more+common+in+nocosomial+pathogens+such+as+VRE+and+MRSA+%e2%80%a2+More+recently%2c+community+acquired+pathogens+have+developed+resistant+strains%0d%0a%0d%0a%0cResistant+Strept.+Pnuemoniae%0d%0a%e2%80%a2+Resistance+to+penicillin+is+found+in+30+to+70%25+of+isolates+depending+on+the+hospital+%e2%80%a2+Some+strains+are+also+found+to+be+resistant+to+one+of+the+following%3a+cephalosporins%2c+Bactrim%2c+chloramphenicol%2cor+a+macrolide+%e2%80%a2+Children+are+more+likely+than+adults+to+be+infected+with+strains+resistant+to+chloramphenicol%2c+erythromycin+or+Bactrim%0d%0a%0d%0a%0cClassification+of+Wounds%0d%0a%e2%80%a2+%e2%80%a2+%e2%80%a2+%e2%80%a2+Clean+Clean+contaminated+Contaminated+Dirty%0d%0a%0d%0a%0cClean+wounds%0d%0a%e2%80%a2+%e2%80%a2+%e2%80%a2+%e2%80%a2+Associated+with+an+elective+case+No+break+in+aseptic+technique+No+associated+inflammation+Infection+rate+of+1%25+to+5%25%0d%0a%0d%0a%0cClean+Contaminated+Wounds%0d%0a%e2%80%a2+Oropharyngeal%2c+respiratory%2c+alimentary+or+GU+tract+is+entered+under+controlled+conditions+%e2%80%a2+Most+head+and+neck+surgeries+fall+under+this+category+%e2%80%a2+Infection+rate+is+8%25+to+11%25+in+general%2c+although+major+head+and+neck+cases+have+a+rate+of+28+-87%25.%0d%0a%0d%0a%0cContaminated+Wounds%0d%0a%e2%80%a2+Result+after%3a%0d%0a%e2%80%93+Spillage+from+the+GI+tract+%e2%80%93+Major+break+in+sterile+technique+%e2%80%93+With+acute+nonpurulent+inflammation%0d%0a%0d%0a%e2%80%a2+Includes+fresh+traumatic+wounds+%e2%80%a2+Infection+rate+of+15%25-17%25%0d%0a%0d%0a%0cDirty+Wounds%0d%0a%e2%80%a2+Organisms+causing+post-operative+infection+are+present+prior+to+operation+%e2%80%a2+Wounds+associated+with+old+trauma%2c+an+abscess%2c+or+a+perforated+viscus.+%e2%80%a2+Infection+rate+greater+than+27%25%0d%0a%0d%0a%0cTiming%0d%0a%e2%80%a2+Antibiotics+are+most+effective+when+given+before+bacteria+enters+the+blood+stream+or+tissue.+%e2%80%a2+Studies+have+shown+antibiotics+have+less+effect+if+given+after+3+hours+from+innoculation.%0d%0a%0d%0a%0cRoute%0d%0a%e2%80%a2+Parenteral+administration+is+the+traditional+route+%e2%80%a2+IM+injections+achieve+the+highest+sustained+level.+%e2%80%a2+It+is+recommended+in+contaminated+cases+to+administer+IV+and+IM+loading+doses+followed+by+a+continuous+IV+or+intermittent+IM+injections.%0d%0a%0d%0a%0cCommonly+Used+Antibiotics%0d%0a%0d%0a%0cPenicillins%0d%0a%e2%80%a2+Act+by+causing+abnormal+cell+wall+development+in+actively+dividing+bacterial+cells.+%e2%80%a2+Groups+are+as+follows%3a%0d%0a%e2%80%93+Natural+penicillins%2c+penicillinase+resistant+penicillins%2c+aminopenicillins%2c+antipsuedomonal+penicillins%2c+and+extended+spectrum+penicillins.%0d%0a%0d%0a%0cNatural+Penicillins%0d%0a%e2%80%a2+Drug+of+choice+for+St.+pyogens+and+St.+pneumoniae%2c+and+Clostridia+perfringens+%e2%80%a2+30%25+of+isolates+of+St.+pneumoniae+are+penicillin+resistant.+%e2%80%a2+Oral+form+in+PenV%2c+IM+form+is+PenG%0d%0a%0d%0a%0cSynthetic+Penicillins%0d%0a%e2%80%a2+Include+nafcillin%2c+oxacillin%2c+and+methicillin%2c+cloxacillin+and+dicloxacillin.+%e2%80%a2+Used+when+S.aureus+is+suspected+as+these+drugs+are+resistant+to+B-lactamase+%e2%80%a2+Side+effects+include+interstitial+nephritis%2c+leukopenia%2c+and+reversible+hepatic+dysfunction.%0d%0a%0d%0a%0cAminopenicillins%0d%0a%e2%80%a2+%e2%80%a2+%e2%80%a2+%e2%80%a2+Include+ampicillin+and+amoxicillin+Not+effective+in+presence+of+B-lactamase+Antibiotics+of+choice+for+Enterococcus+sp.+Active+against+some+gram+-+rods+(E.+coli+and+P.mirabilis)%0d%0a%0d%0a%0cAntipsuedomonal+Penicillins%0d%0a%e2%80%a2+Include+carbenicillin+and+ticarcillin.+%e2%80%a2+Similar+gram+negative+activity+as+aminopenicillins+%e2%80%a2+Poor+activity+against+Klebsiella+sp.+%e2%80%a2+Side+effects%3a+sodium+loading+and+platelet+dysfunction+%e2%80%a2+Synergistic+with+aminoglycosides+against+Psuedomonas.%0d%0a%0d%0a%0cExtended+Spectrum+Penicillins%0d%0a%e2%80%a2+Include+mezlocillin+and+piperacillin+%e2%80%a2+Similar+to+antipsuedomonal+penicillins+but+more+active+against+Klebsiella+sp.+and+Streptococcus.%0d%0a%0d%0a%0cCephalosporins%0d%0a%e2%80%a2+Divided+into+first%2c+second%2c+and+third+generation+classes+%e2%80%a2+Inhibit+bacterial+cell+wall+synthesis%0d%0a%0d%0a%0cFirst+Generation+Cephalosporins%0d%0a%e2%80%a2+Cephalothin%2c+cephapirin%2c+cephradine%2c+and+cefazolin+%e2%80%a2+Active+against+Strept.sp+and+Staph+sp.+%e2%80%a2+Limited+gram+negative+activity+%e2%80%a2+Side+effect%3a+allergic+reactions%2c+drug+eruptions%2c+phlebitis%2c+and+diarrhea.%0d%0a%0d%0a%0cSecond+Generation+Cephalosporins%0d%0a%e2%80%a2+Cefoxitin%2c+cefotetan%2c+cefuroxime+%e2%80%a2+Increased+gram+negative+coverage+%e2%80%a2+Cefoxitin+and+cefotetan+are+more+active+against+anaerobes%0d%0a%0d%0a%0cThird+Generation+Cephalosporins%0d%0a%e2%80%a2+Cefotaxime%2c+ceftizoxime%2c+ceftriaxone%2c+ceftazidime+%e2%80%a2+Less+active+against+Gram+positive+organisms+%e2%80%a2+More+active+against+the+Enterobacteriaceae+and+other+Gram+negative+organisms+%e2%80%a2+Side+effects+include+hypersensitivity+reaction%2c+hematological+disturbances%2c+GI+and+renal+complaints.%0d%0a%0d%0a%0cMacrolides%0d%0a%e2%80%a2+Erythromycin%2c+Pediazole(E-mycin+and+sulfisoxazole)%2c+Azithromycin+and+Clarithromycin+%e2%80%a2+Inhibits+protein+synthesis+%e2%80%a2+Similar+spectrum+as+PenG+plus+Mycoplasma%2c+Legionella%2c+Actinomyces%2c+and+H.+infl.+%e2%80%a2+Side+effects+include+nausea%2c+vomiting%2c+diarrhea%2c+and+hepatitis.%0d%0a%0d%0a%0cOther+Antibiotics%0d%0a%e2%80%a2+Clindamycin+inhibits+protein+synthesis+%e2%80%a2+Active+against+most+Gram+positive%2c+and+anaerobic+organisms.+%e2%80%a2+Good+penetration+into+bones+and+abscesses.+%e2%80%a2+Side+effects+include+psuedomembranous+colitis%2c+mild+nausea+and+diarrhea%2c+leukopenia%2c+and+hepatotoxicity.%0d%0a%0d%0a%0cVancomycin%0d%0a%e2%80%a2+Antibiotic+of+choice+for+MRSA+%e2%80%a2+Associated+with+nephrotoxicity+or+ototoxicity+when+given+with+aminoglycoside+%e2%80%a2+Associated+with+emergence+of+VRE+%e2%80%a2+Great+activity+against+Staph+and+Enterococcus.%0d%0a%0d%0a%0cMetronidazole%0d%0a%e2%80%a2+Good+for+anaerobic+organisms+%e2%80%a2+Well+absorbed+into+abscesses+%e2%80%a2+Side+effects+include+seizures%2c+cerebellar+dysfunction%2c+disulfiram+reaction+with+ETOH%2c+psuedomembranous+colitis%0d%0a%0d%0a%0cAminoglycosides%0d%0a%e2%80%a2+Include+gentamycin%2c+tobramycin%2c+and+amikacin+%e2%80%a2+Good+gram+negative+coverage+including+Pseudomonas+%e2%80%a2+Used+in+head+and+neck+surgery+against+mixed+microbial+abscesses+and+when+organisms+from+GI+tract+are+suspected.%0d%0a%0d%0a%0cSulfonamides%0d%0a%e2%80%a2+Bactrim+%e2%80%a2+Very+active+against+Gram+negative+aerobic+organisms+and+some+Gram+positive+such+as+Staph+and+Strept.+species+%e2%80%a2+Should+not+be+used+in+last+month+of+pregnancy%0d%0a%0d%0a%0cFlouroquinolones%0d%0a%e2%80%a2+Norfloxacin%2c+Levofloxacin%2c+Ciprofloxacin%2c+and+Ofloxacin.+%e2%80%a2+Good+efficacy+against+gram+negative+organisms+and+some+Staph+species.+%e2%80%a2+Do+not+use+in+children+or+adolescents.%0d%0a%0d%0a%0cIndications+for+Antimicrobial+Treatment%0d%0a%0d%0a%0cOtologic+Surgery%0d%0a%e2%80%a2+Postoperative+use+of+ototopical+antimicrobial+drops+reduces+the+incidence+of+otorrhea+after+tympanostomy+tube+insertion+%e2%80%a2+Studies+show+a+reduction+from+16.4%25+to+8%25+when+Cortisporin+drops+are+used+from+1+to+5+days+postop%0d%0a%0d%0a%0cOther+Otologic+Procedures%0d%0a%e2%80%a2+No+significant+decrease+in+postoperative+infection+rates+in+those+patients+treated+with+perioperative+antibiotics+%e2%80%a2+Wound+infection+is+prevented+more+effectively+by+starting+with+a+dry+ear+and+observing+good+surgical+technique+%e2%80%a2+Neurotological+procedures+may+require+some+antibiotic+prophylaxis.+More+studies+need+to+be+carried+out%0d%0a%0d%0a%0cTonsillar+Surgery%0d%0a%e2%80%a2+Antibiotics+given+5-7+days+post-operatively+decrease+dysphagia%2c+fever%2c+pain%2c+mouth+odor+and+poor+oral+intake+%e2%80%a2+Ampicillin%2c+amoxicillin+in+children+%e2%80%a2+Augmentin+in+adults+%e2%80%a2+Currently+a+7+day+course+is+recommended%0d%0a%0d%0a%0cOdontogenic+Infections%0d%0a%e2%80%a2+Most+commonly+caused+by+oral+flora+%e2%80%a2+Have+tendency+to+deepen+causing+neck+space+abscess+or+cellulitus+%e2%80%a2+After+appropriate+drainage%2c+treatment+is+recommended+with+IV+penicillin+or+Cleocin.+%e2%80%a2+Can+be+augmented+with+Cleocin+mouthwash%0d%0a%0d%0a%0cNeck+Abscess%0d%0a%e2%80%a2+Usual+organisms+are+Staph%2c+Strept%2c+and+anaerobes+%e2%80%a2+High+incidence+of+B-lactamase+resistant+organisms+%e2%80%a2+Antibiotic+therapy+with+or+without+surgical+drainage%0d%0a%0d%0a%0cFacial+Fractures%0d%0a%e2%80%a2+Open+mandible+fractures+have+been+shown+to+have+a+30%25+decreased+incidence+of+infection+when+perioperative+treatment+with+clindamycin+or+penicillin+is+used+%e2%80%a2+Antibiotics+covering+the+oral+flora+are+recommended+in+open+mandible+fractures+and+any+surgical+procedures+where+the+wound+will+be+exposed+to+oral+flora%0d%0a%0d%0a%0cLacerations+and+Soft+Tissue+Injuries%0d%0a%e2%80%a2+Soft+tissue+injuries+of+the+head+and+neck+including+crush+injuries%2c+wounds+contaminated+by+body+secretions%2c+pus+or+soil%2c+wounds+with+devitalized+tissue+and+those+wounds+seen+three+hours+after+injury+should+receive+antibiotics%0d%0a%0d%0a%0cDog+Bites%0d%0a%e2%80%a2+5%25+result+in+infection+%e2%80%a2+Treatment+is+with+Augmentin+%e2%80%a2+Need+to+debride+devitalized+tissue%0d%0a%0d%0a%0cHuman+Bites%0d%0a%e2%80%a2+Staph%2c+Stept%2c+Eikenella%2c+Bacteroides%2c+Peptostrep+%e2%80%a2+Treatment+is+based+on+length+of+time+from+innoculation+%e2%80%a2+Augmentin%2c+Unasyn%0d%0a%0d%0a%0cNasal+and+Sinus+Surgery%0d%0a%e2%80%a2+Current+recommendations+are+to+give+antistaph+coverage+in+patients+with+nasal+packing+and+to+coat+merocel+packing+with+antibiotic+ointment+%e2%80%a2+One+study+showed+patients+receiving+low+dose+Erythromycin+after+FESS+reduced+post-surgical+sinusitus+complaints.%0d%0a%0d%0a%0cThyroid%2c+Parotid+and+Submandibular+Surgery%0d%0a%e2%80%a2+No+efficacy+in+giving+prophylactic+therapy+in+these+cases%0d%0a%0d%0a%0cCranial+Base+Surgery%0d%0a%e2%80%a2+High+risk+for+postoperative+infections+%e2%80%a2+More+studies+need+to+be+done+in+this+area+%e2%80%a2+Current+recommendation+is+a+single+broad+spectrum+antibiotic+for+at+least+48+hours%0d%0a%0d%0a%0cOncological+Head+and+Neck+Surgery%0d%0a%e2%80%a2+High+risk+for+infection+if+surgical+site+contaminated+with+aerodigestive+secretions+%e2%80%a2+Depending+on+the+study%2c+infection+rate+is+from+28+-+87%25+without+antibiotics.+%e2%80%a2+This+is+reduced+to+14%25+with+antibiotic+therapy+in+one+study+%e2%80%a2+Major+fistula+is+the+most+common+complication%0d%0a%0d%0a%0cOncological+Head+and+Neck+Surgery+(cont%e2%80%99d)%0d%0a%e2%80%a2+Antibiotics+are+recommended+in+major+clean+contaminated+head+and+neck+oncological+surgery%0d%0a%e2%80%93+Time+course+remains+an+issue.+In+most+cases+at+least+a+short+course+of+1+to+3+days+is+effective%0d%0a%0d%0a%e2%80%a2+Need+for+gram+negative+coverage%0d%0a%e2%80%93+One+study+showed+a+reduction+of+infection+rate+from+36+to+10+%25+with+the+addition+of+an+aminoglycoside%0d%0a%0d%0a%0cSummary%0d%0a%e2%80%a2+Decision+of+whether+to+give+antibiotics+is+based+on+the+individual+case+%e2%80%a2+Need+to+consider+cost%2c+side+effects+and+development+of+resistance%2c+incidence+of+infection+without+antibiotics+%e2%80%a2+Antibiotics+are+never+a+substitute+for+good+surgical+technique%0d%0a%0d%0a%0c