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Peri-operative Antibiotics in the Setting of Oropharyngeal Reconstruction: Defining a Standard of Care?
Leslie E. Cohen, MD, Alyssa Reiffel, MD, Jill Ketner, PA, Tatiana Boyko, MD, Andrew Weinstein, MD, Jason Spector, MD FACS.
Weill Cornell, New York Presbyterian, NY, USA.
Recipient site infection following oropharyngeal reconstruction is a potentially disastrous complication that can jeopardize both the reconstruction and patient survival. Although studies suggest that peri-operative antibiotic administration reduces infection rates in these patients from 87% to 20%, there is no consensus among reconstructive surgeons regarding what constitutes the most appropriate antibiotic regimen, particularly regarding the duration of treatment, in the setting of reconstruction of the oropharynx. We reviewed our experience with peri-operative antibiotic administration in the setting of flap reconstruction of oral cavity defects.
A retrospective review was performed of all patients who underwent pedicled/local or free flap reconstruction of defects of the oropharynx following oncologic resection by a single surgeon at a single institution between 2007 and 2012.
Seventy nine patients were included: 50 underwent microvascular free flap reconstruction, while 29 underwent reconstruction with pedicled/local flaps. Patients received a combination of intravenous antibiotic agents designed to cover oral flora. Mean duration of intravenous peri-operative antibiotic administration was 5d (range, 1-12d). All patients received topical antibiotic prophylaxis (oral mouthwash). Complications included recipient site cellulitis (8.9%), mucocutaneous fistula (5.1%), dehiscence (2.5%), and hematoma formation (1.3%). Among those who developed complications, 20% received a short course of antibiotics (<5d), and 80% received 5 days or more. Wound infections were found to be associated with a preoperative history of chemoradiation, tobacco use, previous head and neck malignancy, low albumin and diabetes mellitus. Intraoperative variables linked with wound infections were length of surgery >12hrs, pedicled flap reconstruction and defects located at the mandible. Wound infections correlated with increased length of hospital stay and a delay in resuming PO intake.
Our data confirm that complex head and neck reconstruction is associated with significant post-operative morbidity. Despite the frequency with which complex oral cavity reconstructions are performed at our institution, no standardized regimen for peri-operative antibiotic administration exists as of yet. These data suggest that extended courses of peri-operative antibiotics do not confer additional benefits beyond short-course therapy. Although further study is warranted, these data may be used to justify limiting the duration of prophylactic antibiotics in order to minimize the incidence of antibiotic-related morbidities and reduce overall healthcare costs. Finally, these data may assist surgeons in recognizing which of their patients may be at higher risk for postoperative infection.
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