title: Antibiotics and facial fractures: evidence-based recommendations compared with experience-based practice.
abstract: Efficacy of prophylactic antibiotics in craniofacial fracture management is controversial. The purpose of this study was to compare evidence-based literature recommendations regarding antibiotic prophylaxis in facial fracture management with expert-based practice. A systematic review of the literature was performed to identify published studies evaluating pre-, peri-, and postoperative efficacy of antibiotics in facial fracture management by facial third. Study level of evidence was assessed according to the American Society of Plastic Surgery criteria, and graded practice recommendations were made based on these assessments. Expert opinions were garnered during the Advanced Orbital Surgery Symposium in the form of surveys evaluating senior surgeon clinical antibiotic prescribing practices by time point and facial third. A total of 44 studies addressing antibiotic prophylaxis and facial fracture management were identified. Overall, studies were of poor quality, precluding formal quantitative analysis. Studies supported the use of perioperative antibiotics in all facial thirds, and preoperative antibiotics in comminuted mandible fractures. Postoperative antibiotics were not supported in any facial third. Survey respondents (n = 17) cumulatively reported their antibiotic prescribing practices over 286 practice years and 24,012 facial fracture cases. Percentages of prescribers administering pre-, intra-, and postoperative antibiotics, respectively, by facial third were as follows: upper face 47.1, 94.1, 70.6; midface 47.1, 100, 70.6%; and mandible 68.8, 94.1, 64.7%. Preoperative but not postoperative antibiotic use is recommended for comminuted mandible fractures. Frequent use of pre- and postoperative antibiotics in upper and midface fractures is not supported by literature recommendations, but with low-level evidence. Higher level studies may better guide clinical antibiotic prescribing practices.
authors.affiliation: Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland.
authors.forename: Gerhard S
authors.initials: GS
authors.lastname: Mundinger
authors.affiliation: Division of Plastic Surgery, University of Montreal, Montreal, Canada.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Borsuk
authors.affiliation: Division of Plastic and Reconstructive Surgery, Brown University, Providence, Rhode Island.
authors.forename: Zachary
authors.initials: Z
authors.lastname: Okhah
authors.affiliation: Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Christy
authors.affiliation: Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland.
authors.forename: Branko
authors.initials: B
authors.lastname: Bojovic
authors.affiliation: Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland.
authors.forename: Amir H
authors.initials: AH
authors.lastname: Dorafshar
authors.affiliation: Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland.
authors.forename: Eduardo D
authors.initials: ED
authors.lastname: Rodriguez
keywords: antibiotic prophylaxis; craniofacial trauma; facial fracture; frontal sinus fracture; mandible fracture; surgical site infection