2017-18 HSC Section 4 Green Book

Doerr

of choice? They identified 4 RCTs that met the search criteria. Collectively, the studies showed a 3-fold decrease in infection rates for mandibular fractures in the antibiotic-treated groups compared with the no-antibiotic control groups. The review identified a wide variety of antibiotics that seemed to have a uniform effect in reducing infections. The review further noted that the reduc- tion in infections was seen regardless of antibiotic duration. However, there was no benefit to giving postoperative antibiotics beyond 24 to 48 hours. Only 1 of the 4 studies actually looked at antibi- otics in facial fractures other than the mandible. This trial found no infections with repairs of maxil- lary, zygoma, or condyle fractures. The reviewers concluded that prophylactic antibiotics are benefi- cial in the treatment of mandible fractures but, because of a low risk of postoperative infection, prophylactic antibiotics were not indicated for other facial fracture sites. In 2011, Kyzas 2 published another comprehen- sive systematic review of antibiotics and mandible fractures with slightly different conclusions. Chal- lenging the notion that antibiotic use in mandible fractures was mandatory, and spurred by the weak literature previously highlighted, Kyzas sought to more clearly define the role for antibi- otics. This review included 9 randomized trials and 22 nonrandomized retrospective case series. He found the literature to be of poor quality with variable data that prohibited making any quantita- tive assessments. The reviewed studies had infec- tion rates ranging from 4.5% to 62% without antibiotics and from 1.9% to 29.4% with antibi- otics. He concluded that the support for prophy- lactic antibiotic use was limited and of weak quality. Based on his analysis, any recommenda- tion for routine antibiotic use was weak and not reliably supported by the literature. To determine the benefit of postoperative antibi- otics after mandible fracture repair, Miles and colleagues 3 conducted a prospective RCT. All subjects received preoperative and intraoperative antibiotics. Eighty-one subjects also received postoperative antibiotics and 100 had no postop- erative antibiotics. There were no differences in postoperative infection rates. There were infec- tions in 8 out of 81 subjects who received postop- erative antibiotics and 14 out of 100 who did not receive postoperative antibiotics. The investiga- tors were unable to show a benefit of using post- operative antibiotics for mandible fracture repair. A 2014 systematic review by Shridharani and colleagues 4 also looked at the potential benefit of antibiotics after mandible fracture repair. Their re- view found 73 potential articles with only 5 meeting defined criteria. They noted that, although several

Recognizing that facial fracture management has evolved over decades mostly devoid of any evidence-based research, and further recognizing the persistent challenges in conducting quality studies, it is easy to view evidenced-based facial fracture care as unattainable. However, some recent studies in facial fracture treatment have included higher level randomized trials as well as organized meta-analysis. As specialists, facial plastic surgeons must continue to adapt evidence-based approaches to both clinical prac- tice and research. Doing so validates what we are doing well and highlights areas needing improve- ment. Both the public and organized medicine de- mands this research and our specialty needs to provide it. This article reviews relevant issues in facial frac- ture management, emphasizing the evidence- based methodology. It highlights the few areas of facial trauma in which randomized studies and meta-analysis are available. It also points out the many other areas for which the evidenced-based literature is poor or altogether absent. Finally, the article examines the future of facial trauma care in which clinical registries and health databases may be better able to answer clinical questions too complex to be addressed by clinical trials. The role of antibiotics in facial fracture treatment remains unsettled and controversial. With injuries varying widely in fracture location, severity, and wound contamination, the clinical benefits of anti- biotics use is not easily determined. The literature on this topic is complex and at times conflicting. With the increasing rates of antibiotic resistance and calls for an evidence-based approach to patient care, clarifying the role for antibiotic use in facial trauma is important. The literature has tried to distinguish between antibiotic use in mandible fractures and antibiotics with other facial fractures, including those isolated mandibular condyle fractures. Surgeons agree on the need for antibiotics with infected wounds and most routinely administer antibiotics in the perioperative setting. The literature supporting preoperative antibiotic use is not clear-cut and the use of post- operative antibiotics is even more controversial. In 2006, Andreasen and colleagues 1 conducted a systematic review to identify the potential benefit of prophylactic antibiotics in the maxillofacial frac- tures. The reviewers sought to address 3 impor- tant questions: does antibiotic prophylaxis decrease infections in jaw fracture treatment, are there situations when antibiotic prophylaxis is not indicated, and which is the antibiotic prescription ANTIBIOTICS AND FACIAL FRACTURES

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