Meta-Analysis of Antibiotic Prophylaxis of Facial Fractures Managed by Open Reduction/Internal Fixation (ORIF)

Author(s):
Sebastian Schubl; Jacquelyn Phillips; Jeffry Nahmias; Linda Murphy; Marija Pejcinovska; Areg Grigorian; Viktor Gabriel; Catherine Kuza; Matthew Dolich; Philip Barie

Background:

Prolonged antibiotic prophylaxis (PAP) after operative facial fracture (FFx) repair persists despite accumulating evidence of lack of efficacy for prevention of surgical site infection (SSI). Three recently published randomized, controlled trials (RCTs) each terminated early due to demonstrated lack of efficacy PAP prompted a systematic review of the literature.

Hypothesis:

We hypothesized that PAP after operative FFx repair has no proven efficacy for the prevention of SSI.

Methods:

A systematic review of four databases: PubMed, CENTRAL, EMBase and Web of Science, from inception date through February 15, 2017 included RCTs, observational studies, and case studies. Two independent reviewers extracted fracture location, antibiotic use, SSI incidence, and time to surgery. Analysis was carried out for mandible, orbit and zygoma/LeFort independently. Comparisons for 24-72 hours and > 72 hours of PAP versus < 24 hours of post-operative prophylaxis were made. Odds ratios (OR) and 95% confidence intervals (95%CI) were estimated using the Mantel-Haenszel  approach of studies reporting direct comparisons.

Results:

We identified 192 manuscripts that underwent full text review, resulting in 26 studies that met inclusion criteria. Of these, 16 studies (2,316 patients) provided data for mandible, 4 studies (439 patients) for zygoma/LeFort, and 6 studies (377 patients) for orbital fractures. The incidence of SSI for each was 8.5% for mandible, 1.1% for zygoma/LeFort and 1.6% for orbital fractures.  Pooled analysis of each fracture type’s SSI rates showed no statistically significant association between the odds of developing a SSI with different prophylactic regimens. For mandible fractures treated with ORIF, the OR for developing a SSI for 24-72 hours of PAP relative to < 24 hours was 0.85 (95%CI (0.62-1.17)) whereas for > 72 hours of PAP the OR was 1.42 (95%CI (0.96-2.11). Removal of a single outlier non-RCT resulted in a statistically significant increase in SSI for > 72 hours of PAP vs <24 hours [OR = 1.63, 95%CI (1.08-2.46)]. Similarly, there was no improvement in SSI rate from PAP for zygoma/LeFort fractures [OR = 1.05 (95%CI (0.20-5.63)] when comparing > 72 hours to < 72 hours. The OR for orbital fractures could not be estimated.

Conclusions:

Our review underscores the lack of evidence that antibiotic prophylaxis post-operatively for any type of facial fracture managed by ORIF prevents or lowers SSI. PAP > 72 hours may paradoxically increase SSI after ORIF of mandible fractures. Given the low risk of SSI and the lack of efficacy demonstrated future placebo-controlled RCTs of adequate power are warranted.