prophylaxis & prevention of postoperative surgical wound infections in oral surgery

Prophylaxis & Prevention of Postoperative Surgical Wound Infections in Oral Surgery

Dr. Giuseppe Bruno PitassiDr. Giuseppe Bruno Pitassi

Medical DoctorMedical DoctorDental SurgeonDental SurgeonSpecialist Maxillofacial SurgerySpecialist Maxillofacial SurgeryPgPg/Dip. Clinical Periodontology/Dip. Clinical Periodontology

Pitassi GB 2016

“Il Cavadenti” (Oil painting on canavas)

Michelangelo da Caravaggio, 1637 Firenze, Galleria Palatina

Prophylaxis, from Greek Prophylaxis, from Greek προφυλάσσωπροφυλάσσω,, means in English, means in English,

defend or anticipate. defend or anticipate.

Prophylaxis is any medical Prophylaxis is any medical procedure or public health whose procedure or public health whose purpose is to prevent, rather than purpose is to prevent, rather than

cure or treat, diseases.cure or treat, diseases.

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Wound infection is a term that has Wound infection is a term that has caused a lot of confusion among caused a lot of confusion among surgeons anywhere. surgeons anywhere.

In order to remedy such problem the In order to remedy such problem the Centre for Disease Control (CDC) Centre for Disease Control (CDC) released some definitions and released some definitions and protocols in 1999 that nowadays have protocols in 1999 that nowadays have been taken worldwide.been taken worldwide.

Pitassi GB 2016

Pitassi GB 2016

CDC DefinitionCDC Definition

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As per the CDC classification there are As per the CDC classification there are three types of Surgical Site Infection (SSI):three types of Surgical Site Infection (SSI):

1. Superficial Incisional SSI 1. Superficial Incisional SSI 2. Deep Incisional SSI 2. Deep Incisional SSI 3. Organ/Space SSI3. Organ/Space SSI

These are the most These are the most frequent clinical frequent clinical manifestation seen manifestation seen in Oral Surgeryin Oral Surgery

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Surgical Site InfectionsSurgical Site Infections ((SSSSI)I)

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Cross-section of abdominal wall depicting CDC Cross-section of abdominal wall depicting CDC classifications of surgical site infectionclassifications of surgical site infection

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Superficial Incisional Surgical Site InfectionSuperficial Incisional Surgical Site Infection

To call an infection a superficial SSI it To call an infection a superficial SSI it should meet the following criteria:should meet the following criteria:

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Deep Incisional Site InfectionDeep Incisional Site InfectionInvolves fascia & muscles, usually, Involves fascia & muscles, usually, with infection and pus collection with infection and pus collection Drainage, control of any source of Drainage, control of any source of continuing infection & antibiotic continuing infection & antibiotic therapy are indicated. therapy are indicated.

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Organ Space Surgical Site InfectionOrgan Space Surgical Site InfectionThese infections usually occur in These infections usually occur in the organ previously operated. the organ previously operated. Postoperative peritonitis is one Postoperative peritonitis is one such infection. These are very such infection. These are very difficult problems to manage and difficult problems to manage and have got a very high mortality.have got a very high mortality.

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Rationale about Preoperative Rationale about Preoperative Antimicrobial Prophylaxis Antimicrobial Prophylaxis

((AMPAMP))

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Antimicrobial Prophylaxis Antimicrobial Prophylaxis (AMP)(AMP)Any surgical incision exposes sterile tissues to non sterile Any surgical incision exposes sterile tissues to non sterile environment, therefore invariably some contamination environment, therefore invariably some contamination occurs during all surgeries.occurs during all surgeries.

In some conditions linked to the bacterial load and the In some conditions linked to the bacterial load and the immunological defences of the host this contamination immunological defences of the host this contamination can can flare up till to became a frank infection.flare up till to became a frank infection.

The rationale about the prophylactic administration of The rationale about the prophylactic administration of antibiotic is based on the assumption that achievement of antibiotic is based on the assumption that achievement of a sufficient concentration of antimicrobial in the tissues a sufficient concentration of antimicrobial in the tissues prevent wound colonization by bacteria. prevent wound colonization by bacteria.

The scientific basis of antimicrobial prophylaxis against The scientific basis of antimicrobial prophylaxis against postoperative infections were described by: postoperative infections were described by:

Burke, Polk & Stone 1950Burke, Polk & Stone 1950.. Pitassi GB 2016

Principles of Antimicrobial ProphylaxisPrinciples of Antimicrobial Prophylaxis

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PreamblePreamble

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Surgical Antimicrobial Prophylaxis (AMP) refers Surgical Antimicrobial Prophylaxis (AMP) refers to a very brief course of an antibiotic to start just to a very brief course of an antibiotic to start just before a surgical procedure begins. before a surgical procedure begins.

(AMP) (AMP) is not an attempt to sterilize tissues, but is not an attempt to sterilize tissues, but a complement used to reduce the microbial load a complement used to reduce the microbial load of intraoperative contamination to a level that of intraoperative contamination to a level that cannot overwhelm host defenses.cannot overwhelm host defenses.

Essentially AMP indications pertain to elective Essentially AMP indications pertain to elective operations in which tissue incision take place in operations in which tissue incision take place in the operating room or as well as in controlled the operating room or as well as in controlled contamination environment as the dental contamination environment as the dental surgery, and then there surgical wounds are surgery, and then there surgical wounds are closed.closed. Pitassi GB 2016

Four principles must be followed to maximize Four principles must be followed to maximize the benefits of AMP:the benefits of AMP:

The antibiotics to be used for prophylaxis The antibiotics to be used for prophylaxis against against

postoperative infections must:postoperative infections must:1)1) Be effective against pathogenic microorganism causing these Be effective against pathogenic microorganism causing these

infections.infections.

2) Use an antibiotic safe, with a broad spectrum that covers the most 2) Use an antibiotic safe, with a broad spectrum that covers the most probable intraoperative contaminants for the operationprobable intraoperative contaminants for the operation..

3) Administer the antibiotic in a manner to achieve a high level of drug in 3) Administer the antibiotic in a manner to achieve a high level of drug in both serum & tissues so that the bactericidal concentration of the both serum & tissues so that the bactericidal concentration of the drug is established in the tissues by the time of the incision and drug is established in the tissues by the time of the incision and permanent in them during the entire duration of the operation, until, at permanent in them during the entire duration of the operation, until, at most, a few hours after the incision is closed.most, a few hours after the incision is closed.

4) 4) Not have significant untoward side-effects. Not have significant untoward side-effects.

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The incidence of postoperative infections after oral and The incidence of postoperative infections after oral and dentoalveolar surgerydentoalveolar surgery is usually low is usually low . .

In healthy patient prophylactic administration of antibiotics is not In healthy patient prophylactic administration of antibiotics is not necessary. necessary.

The same The same must be appliedmust be applied to patients with metabolic diseases to patients with metabolic diseases that are controlled, as diabetic patients, that are controlled, as diabetic patients, having a good metabolic having a good metabolic balancebalance. .

On the other hand patients under antineoplastic chemotherapy On the other hand patients under antineoplastic chemotherapy must be treated prophylactically with antibiotics, if the surgical must be treated prophylactically with antibiotics, if the surgical procedure cannot be postponed till after cessation of the therapy.procedure cannot be postponed till after cessation of the therapy.

The same applies to patients affected by pharmaceutical The same applies to patients affected by pharmaceutical immunosuppression secondary to transplantation of solid immunosuppression secondary to transplantation of solid organs.organs.

Principles of Antimicrobial ProphylaxisPrinciples of Antimicrobial Prophylaxis

Pitassi GB 2016

Pitassi GB 2016

It must be emphasized that clean surgical It must be emphasized that clean surgical technique & prophylactic utilization of technique & prophylactic utilization of antibiotics in certain patients may antibiotics in certain patients may significantly reduce the incidence of significantly reduce the incidence of postoperative infections.postoperative infections.

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Methodology of prophylactic administrationMethodology of prophylactic administration

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Use full dose of chosen antibioticUse full dose of chosen antibiotic..

The antibiotic level in tissues during the The antibiotic level in tissues during the surgical procedure must be high.surgical procedure must be high.This occurs administering higher dose than This occurs administering higher dose than usual, 1 hour prior to starting the surgical usual, 1 hour prior to starting the surgical procedure, if the surgery implies local procedure, if the surgery implies local anesthesia or panesthesia or preferably at the onset of general referably at the onset of general anesthesia anesthesia if the procedure should be if the procedure should be performed under general anesthesia.performed under general anesthesia.


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Is also to be noted, Is also to be noted, once again, that in the case of surgical procedure to be once again, that in the case of surgical procedure to be carried out in anatomical areas not previously infected and then with the carried out in anatomical areas not previously infected and then with the only purpose of prevention of wound infection the administration of only purpose of prevention of wound infection the administration of antibiotics used for perioperative chemoprophylaxis:antibiotics used for perioperative chemoprophylaxis:

-Must not be started the day before the procedure or hours before the Must not be started the day before the procedure or hours before the operation, because we aim for peak drug levels at the site of intervention operation, because we aim for peak drug levels at the site of intervention when the procedure is underway, at the time that such effective tissue when the procedure is underway, at the time that such effective tissue concentration will be achieved, generally this will occur when tissue concentration will be achieved, generally this will occur when tissue dissection begins, whereupon the possibility of wound infection and the dissection begins, whereupon the possibility of wound infection and the risk of intraoperative contamination for bacterial penetration into deep risk of intraoperative contamination for bacterial penetration into deep tissues due to manipulation may increase;tissues due to manipulation may increase;

-Must be administrated for limited period of time-Must be administrated for limited period of time..

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Usually the antibiotic used for preoperative prophylaxis is administrated in a single dose half an hour to one hour before the surgery begins . If operation is prolonged for more than 3 hours a second dose of antibiotic 4 h after the initial dose is recomended.

The administration of antibiotics for a longer period of time is not recommended, because it has been proved that, on the hand, better prophylaxis is not achieved, while on the other hand, the possibility of untoward side-effect or resistance to antibiotics is increased.


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Methodology of prophylactic administration

Fundamental principle concerning the Fundamental principle concerning the prophylactic administration of antibiotics is prophylactic administration of antibiotics is that the benefit from their use must be that the benefit from their use must be significantly greater then the possibility of significantly greater then the possibility of adverse reactions or side- effectsadverse reactions or side- effects

Employ antibiotic prophylaxis whenever the Employ antibiotic prophylaxis whenever the risk of wound infection is increasedrisk of wound infection is increased

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Indiscriminate use of prophylactic antibiotics Indiscriminate use of prophylactic antibiotics for surgical procedures in healthy patients has for surgical procedures in healthy patients has favored the survival and increase of drug-favored the survival and increase of drug-resistant bacteria and should therefore be resistant bacteria and should therefore be avoided. avoided. Minor oral surgery has a low infection rate in Minor oral surgery has a low infection rate in healthy individuals and studies have found no healthy individuals and studies have found no convincing evidence of any benefit from convincing evidence of any benefit from prophylactic antibiotics except where there is prophylactic antibiotics except where there is overt infection preoperatively. Prophylactic use overt infection preoperatively. Prophylactic use of antibiotics should therefore comply with the of antibiotics should therefore comply with the following important principles.following important principles.


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Methodology of prophylactic administrationMethodology of prophylactic administrationBecause postoperative infections due to anaerobes Because postoperative infections due to anaerobes are unusual, prophylaxis must mainly focused on are unusual, prophylaxis must mainly focused on aerobic streptococciaerobic streptococci..

Based on these data, Penicillin, Amoxicillin or Based on these data, Penicillin, Amoxicillin or AmoxicillinAmoxicillin--Clavulanate, are the most appropriate Clavulanate, are the most appropriate antibiotics for prophylaxis.antibiotics for prophylaxis.

When there is a history of allergic reactions (usually When there is a history of allergic reactions (usually urticarial rash) to Penicillin, Clindamycin is urticarial rash) to Penicillin, Clindamycin is preferred.preferred.

If the surgical procedure is to be performed trough If the surgical procedure is to be performed trough the skin, Cefazolin (first generation cephalosporin) the skin, Cefazolin (first generation cephalosporin) it is used.it is used.

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Taking a cue from the concepts mentioned Taking a cue from the concepts mentioned above a scheme of antibiotic prophylactic above a scheme of antibiotic prophylactic regime to consider may be the following:regime to consider may be the following:

Pitassi GB 2016

Pitassi GB 2016

In conclusion and according to recent data, should be made clear that the administration of antibiotics in some oral surgery procedures may be be justified for a short period to starting close to the surgical event.

Antimicrobial administration should not be protracted over a period greater than 24 to 48 hours after the operation; a second dose is recommended only in the case of extensive and prolonged surgery, an eventual eventual should not be considered prophylaxis but therapy.

The usual recommended route for antibiotic administration is IV, albeit even if in a hospital outpatient services it is more manageable that per Os.

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a) Presence of edema with pain or sensitivity suggesting cellulitis or an abscess that must absolutely be drained

b) Presence of trismus, unless it is secondary to postoperative edema, hematoma, trauma.

c) Presence of purulent exudate, unless the cause was removed and the focal site of infection is far from the airway passages

d) No improvement of symptoms 48 h. later or worsening 36 h. or more after surgical procedure

e) Tachycardia (>100 beats per min) and fever (>38°C). Fever is not necessarily a symptom of infection.

Indications for antibiotic therapy are limited and include:

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“Aspects of the Human Face” (oil on canvas 200 × 120 cm) Marc M. Baltensperger, 2000

Thanks for your attentionThanks for your attention

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prophylaxis & prevention of postoperative surgical wound infections in oral surgery

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