Discrepancies Between Clinical Prescribing Patterns Versus Literature

Recommendations for Antibiotic Usage in Facial Fractures

By JACQUELINE TUCKER, BS1, MADISON OXFORD, BA1 , JESSYKA G. LIGHTHALL, MD, FACS2

The first antibiotic, penicillin, was discovered in the 1920s. Throughout the next several decades antibiotic discovery was exponential. This led to an overall reduction in worldwide morbidity and mortality due to bacterial infections. However, the eventual overuse of these newly discovered antibiotics gave birth to antibiotic resistance. With increasing resistance, medication options for resistant infections became limited. To counter the increase in antibiotic resistance, antibiotic stewardship programs began to emerge at different hospitals and treatment centers. Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by physicians.1

1 The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA. 2 Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.

In addition to antibiotic resistance, there are other downsides to antibiotic administration, including side effects such as nausea and vomiting, and even potentially fatal diarrhea. An additional downside is financial. Antibiotics can also be expensive, increasing patients’ hospital bills. The advantages and disadvantages must be considered before administering antibiotics. Physicians should constantly ask themselves whether prescribing an antibiotic is necessary in the context of these downsides.

Antibiotics are often used in trauma patients, especially in patients with open fractures or those being repaired to avoid surgical site infections. Surgical site infections may necessitate additional surgeries, prolong hospitalizations, and be expensive as well as painful for patients.

Facial trauma is relatively common with more than 3 million facial injuries occurring per year in the United States.2 Facial fractures can be managed in a variety of ways, depending on their location. Various locations can include, but are not limited to, the midface, mandible, orbit, frontal sinus, or nasal area. Sometimes fractures are managed with closed reduction, which does not involve surgery, or with an open reduction, requiring surgery to reposition the fractured bones. In severe cases, more extensive reconstructive surgery may be required.

Facial fractures are a controversial topic when it comes to assessing appropriate antibiotic use, likely because of the complex nature and the variable presentation and management for facial fractures. In 2020, the Surgical Infection Society (SIS) Therapeutics and Guidelines Committee met to develop guidelines for antibiotic administration in the management of traumatic facial fractures. They recommended avoiding antibiotic usage in non-operative upper face, midface, and mandibular fractures.3

In a study comparing non-operative facial fracture management, patients who were treated with no antibiotics were compared to those treated with short term antibiotics. Neither group had any soft tissue infections after treatment.4 However, in a survey of otolaryngologists, plastic surgeons, and oral and maxillofacial surgeons, it was found that 66% prescribed prophylactic antibiotics for non-operative fractures. The most common fracture location that was prescribed antibiotics was dentate segment mandibles, followed by nasal bone fractures, and frontal sinus.5

When assessing operative management of facial fractures, several reports break down recommendations into preoperative, intraoperative, and postoperative antibiotic usage. The SIS also recommended avoiding preoperative and postoperative antibiotic prescriptions for mandibular or non-mandibular fractures.3

Contradictory to these recommendations, some previous articles show perioperative cefazolin can reduce the incidence of postoperative infections. In fact, one study demonstrated that in a cohort of patients with facial fractures, 42.2% of patients who did not receive antibiotics developed infections whereas only 8.9% of patients who did receive antibiotics had a postoperative infection.

Interestingly, 85% of surveyed physicians reported prescribing preoperative, intraoperative, or postoperative prophylactic antibiotics for surgically managed facial fractures.5 This demonstrates a large lack of consensus between recommendations and current practices of physicians. A research study investigating whether evidence-based recommendations aligned with evidence-based practice by assessing the literature and surveying physicians. In agreeance to what we have described here, they found prescriber practice differed markedly with literature recommendations.6

Knowing when and how to appropriately prescribe antibiotics is a vital skill in a physician’s toolbox. With so many contradictory recommendations and findings, it is difficult for physicians to determine the best course of action for individual patients. Additional research studies need to be conducted, and organizations should publish recommendations for their specialty or for specific surgeries. However, physicians must also take it upon themselves to stay up to date with current recommendations. The various presentations of facial fractures necessitate individualized management and recommendations, adding additional challenge for physicians. Further prospective clinical trials are necessary to determine the ideal recommendations.

References: 1. Centers for Disease Control and Prevention. Core Elements of Antibiotic Stewardship. Published April 7, 2021. Accessed March 28, 2022. https://www.cdc.gov 2. Gibson A, Boswell K. Facial Trauma: Challenges, Controversies, and Therapeutic Options. Trauma Reports. Published online April 2011. 3. Forrester JD, Wolff CJ, Choi J, Colling KP, Huston JM. Surgical Infection Society Guidelines for Antibiotic Use in Patients with Traumatic Facial Fractures. Surgical Infections. 2021;22(3):274-282. doi:10.1089/sur.2020.107 4. Malekpour M, Bridgham K, Neuhaus N, et al. Utility of Prophylactic Antibiotics in Nonoperative Facial Fractures. Journal of Craniofacial Surgery. 2016;27(7):1677-1680. doi:10.1097/ SCS.0000000000002724 5. Brooke SM, Goyal N, Michelotti BF, et al. A Multidisciplinary Evaluation of Prescribing Practices for Prophylactic Antibiotics in Operative and Nonoperative Facial Fractures. Journal of Craniofacial Surgery. 2015;26(8):2299-2303. doi:10.1097/SCS.0000000000001976 6. Mundinger GS, Borsuk DE, Okhah Z, et al. Antibiotics and Facial Fractures: Evidence-Based Recommendations Compared with Experience-Based Practice. Craniomaxillofacial Trauma & Reconstruction. 2015;8(1):64-78. doi:10.1055/s-0034-1378187