Algorithmic Approach to Antibiotic Prophylaxis for Traumatic Craniomaxillofacial Injuries

Abstract

Prophylactic antibiotics are commonly used in the management of traumatic injuries to the maxillofacial complex, yet there are no set guidelines for when and when not to prescribe. The purpose of this review is to present the evidence for antibiotic prophylaxis in different clinical scenarios and to propose algorithms to facilitate the decision making process with the ultimate goal of improving antibiotic prescribing practices. A number of databases were searched using a wide range of keywords to ensure the topic was fully encapsulated. The review is divided into 3 sections: soft tissue trauma, maxillofacial fractures, and ballistic injuries. The algorithms were constructed using the current evidence as well as pathophysiologic principles, especially when there were insufficient studies. This review found the literature on antibiotic prophylaxis to be highly varied and not standardized. Creating an algorithm for providers to follow will help to set a standard of care and decrease the misuse of antibiotics.

Antibiotic prophylaxis in injury: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document

“… 3 A course of 3–5 days of amoxicillin-clavulanate is a suggested regimen, with clindamycin plus trimethoprim-sulfamethoxazole two times per day as an alternative for patients with a penicillin allergy. 4 5 While there is increasing question in the literature about the benefit of treating bite injuries with empiric antibiotics, there seems to be general consensus that injuries in high-risk locations (specifically hands, and over cartilage) and in high-risk patients should be treated. 4–6 Rabies treatment should also be considered and addressed with any mammalian bite wounds ( table 1 ).…”

“…Discussion : Caruso et al wrote a detailed review of the evidence for prophylactic antibiotic therapy in traumatic craniomaxillofacial injuries in 2022, nicely summarizing the available literature. 4 Much of this discussion will draw from that review, as well as the Infectious Disease Society of America guidelines. 29 There is a general lack of adequate evidence to guide decision-making for these injuries, and Caruso et al appropriately counsel that thoughtful consideration of the patient, wound, and underlying pathophysiology must be used to make decisions when there is no clear guidance from the data.…”

“…Compared with injuries to the rest of the body, injuries to the head and neck tend to have the lowest rates of infectious complications. 4 This is likely due to the excellent blood supply to this region of the body. For clinical scenarios of ‘normal’ risk (a simple wound in a healthy patient), prophylactic antibiotics do not confer a benefit and should not be used.…”

“…Lacerations that are confined to the intraoral cavity (including mucous membranes, the lips, and the tongue) and do not communicate with the extraoral environment do not need antibiotics. 4 30 Through-and-through lacerations have been considered at higher risk for infection, and therefore antibiotics are often suggested, although this remains controversial given the limited data. 4 5 30 31 There are almost no specific data to inform antibiotic prophylaxis for scalp wounds specifically, so it seems reasonable to extrapolate from the management of other traumatic soft tissue wounds.…”

“… 4 30 Through-and-through lacerations have been considered at higher risk for infection, and therefore antibiotics are often suggested, although this remains controversial given the limited data. 4 5 30 31 There are almost no specific data to inform antibiotic prophylaxis for scalp wounds specifically, so it seems reasonable to extrapolate from the management of other traumatic soft tissue wounds. Traumatic cartilage exposure (ear, nose) has historically been treated with prophylactic antibiotics (often fluoroquinolones) in addition to local wound care due to concern for perichondritis.…”