I. GENERAL CONSIDERATIONS

A. Wound Classifications

1. Clean: operation under aseptic conditions, no break in sterile technique, no evidence of infection or contamination of the wound, no transection of gastroenteric, tracheobronchial, upper aerodigestive, or genitourinary system

2. Clean-contaminated: same as above but wound in continuity with mucosal lined spaces containing bacteria

3. Contaminated: as a result of violence, association with gross spillage from hollow viscous, or complicated by a major break in technique

4. Dirty: continual drainage of rectal, tracheobronchial, or genitourinary discharge or actual drainage of purulent material

B. Indications for Perioperative Antibiotics in Head and Neck Surgery

1. Surgical cases that fall into any category except clean should have perioperative antibiotics.

2. There is evidence to suggest that neck dissections, without exposure to the upper aerodigestive tract, may have a lower rate of wound infection if perioperative antibiotics are employed, despite the fact that these are clean cases by the definitions outlined above.

3. If there is a reasonable probability of entering the upper aerodigestive tract during the course of a surgery that would otherwise be clean, it is prudent to use antibiotics perioperatively (eg, parapharyngeal tumor being approached transcervically).

4. Proximity to a contaminated area such as the oral commissure during excision of a cheek lesion or the nasal passage during excision of a nasal tip lesion warrants the use of perioperative antibiotics.

C. Contraindications

The infection rate for clean cases in the head and neck is extremely small (-1.0%). Clean cases performed in the head and neck region (apart from neck dissection) have never been demonstrated to have a lower infection rate if perioperative antibiotics are used.

D. Presurgical Pathogens Encountered in Head and Neck Cancer Patients

1. Skin flora: Staph, B-Hem Strep

2. Anaerobic organisms: Anaerobic Strep, Bacteroides, Fusobacterium (Anaerobic organisms are 10 times more common in the oral cavity than aerobic organisms.)

3. Aerobic gram-positive organisms: Strep, Staph

4. Aerobic gram-negative organisms: There is some controversy regarding the true pathogenetic role of these organisms. However, they clearly make up the flora that can be cultured from the upper aerodigestive tract in head and neck cancer patients.

5. The anaerobic bacterial load in the oral cavity may be considerably higher in patients with poor dentition and periodontal disease. For patients requiring edentulation, dental extraction at the time of surgery rather than after surgery has been advocated and demonstrated to result in a decreased postoperative infection rate.

E. Most Frequent Wound Isolates from Infected Head and Neck

Cancer Patient

1. Wound cultures are most frequently polymicrobial and rarely reflect pretreatment cultures

2. Anaerobic organisms

3. Aerobic gram-positive organisms

4. Aerobic gram-negative organisms

5. Fungi: Candida most frequently and almost uniformly represents colonization not true infection

F. Duration of Perioperative Antibiotic Use

1. Prophylactic perioperative antibiotics should be started prior to skin incision for maximal benefit.

2. There is no advantage to continuation of perioperative antibiotics beyond 24 to 48 hours postoperatively has ever been demonstrated.

The possible exception to this is metronidazole; because metronidazole may enter abscess spaces better than other antibiotics, its prolonged use has been associated with less severe postoperative infections in one study.

G. Prophylactic Antibiotic Regimens for Major Clean-Contaminated

Cases in the Head and Neck Patient

1. A variety of single and combination antibiotics have been evaluated and recommended for prophylaxis for major head and neck surgery involving the upper aerodigestive tract. The following regimens are the most commonly used in the United States and have documented efficacy in the literature. The particular regimen that is most effective for a given surgeon may depend on a number of factors including hospital environment, nature of patient population, etc. Surgeons may find that one or more of the following regimens is more effective than the others in their particular practice.

2. Clindamycin: 600 mg IV within 1 hour of surgery, 4 additional doses Q6H following surgery. The antibiotic may alternatively be given for a full 48 hours postoperatively, although there is no compelling evidence that the additional 24 hours confers any additional benefit.

3. Ampicillin/sulbactam: 1.5 grams IV within 1 hour of surgery and 8 additional doses at 6-hour intervals following surgery.

4. Cefazolin: 2.0 grams IV within 1 hour of surgery and 3 postoperative doses at 8-hour intervals. This regimen may be extended to a total of 48 hours postoperatively.

5. Cefazolin/metronidazole: cefazolin 1 gm IV 1 hour prior to surgery then 1 gram IV every 8 hours postoperatively for a total of 6 doses and metronidazole 900 mg IV 1 hour prior to surgery then 900 mg IV every 8 hours postoperatively for a total of 6 doses.

H. For minor, outpatient, clean-contaminated cases (tonsillectomy, palatopharyngoplasty, etc) the initial dose is administered as above. Subsequent postoperative doses of an orally administered, equivalent antibiotic are given for 5 days.

II. NURSING CONSIDERATIONS

A. General

These antibiotics will frequently need to be started in the preoperative holding area, or started “on call” to the operating room.

III. SUGGESTED READING

A. Doerr TD, Marunick MT. Timing of edentulation and extraction in the management of oral cavity and oropharyngeal malignancies. Head Neck. 1997;19:426-430.

B. Johnson JT, Kachman K, Wagner RL, Myers EN. Comparison of ampicillin/sulbactam versus clindamycin in the prevention of infection in patients undergoing head and neck surgery. Head Neck. 1997;19:367-371.

C. Johnson JT, Schuller DE, Silver F, et al. Antibiotic prophylaxis in high-risk head and neck surgery: one-day vs five-day therapy. Otolaryngol Head Neck Surg. 1986;95:554-557.

D. Johnson JT, Yu VL, Myers EN, et al. Cefazolin vs Moxalactam? A double-blind randomized trial of cephalosporins in head and neck surgery. Arch Head Neck Surg. 1986;112:151-153.

E. Righi M, Manfredi R, Farneti G, et al. Short-term versus long-term antimicrobial prophylaxis in oncologic head and neck surgery. Head Neck. 1996;18:399-404.

F. Robbins KT, Byers RM, Cole R, et al. Wound prophylaxis with metronidazole in head and neck surgical oncology. Laryngoscope. 1988;98:803-806.

G. Sawyer R, Cozzi L, Rosenthal DI, Maniglia AJ. Metronidazole in head and neck surgery--the effect of lengthened prophylaxis. Otolaryngol Head Neck Surg. 1990;103:1009-1011.

H. Weber RS, Raad I, Frankenthyaler R, et al. Ampicillin-sulbactam versus clindamycin in head and neck oncologic surgery the need for gram-negative coverage. Arch Otolaryngol Head Neck Surg. 1992;118:1159-1163.