Osteosynthesis-associated infection in maxillofacial surgery by bacterial biofilms: a retrospective cohort study of 11 years

Abstract

Objectives The aim of this retrospective cohort study was to determine risk factors for osteosynthesis-associated infections (OAI) with subsequent necessity of implant removal in oral and maxillofacial surgery. Materials and methods A total of 3937 records of patients who received either orthognathic, trauma, or reconstructive jaw surgery from 2009 to 2021 were screened for osteosynthetic material removal due to infection. Treatment-intervals, volume of applied osteosynthetic material, and respective surgical procedures were also assessed. Moreover, intraoperatively harvested microbial flora was cultured and subsequently identified by MALDI TOF. Bacteria were then screened for antibiotic resistance via VITEK system or, if necessary, via agar diffusion or epsilometer test. Data was analyzed utilizing SPSS statistical software. For statistical analysis of categorical variables, chi-square tests or Fisher exact tests were used. Continuous variables were compared via non-parametric tests. The level of significance for p-values was set at < 0.05. Descriptive analysis was also performed. Results The lower jaw was more prone to OAI than the mid face region. Larger volumes of osteosynthetic material led to significantly more OAI, resulting in reconstruction plates bearing the highest risk for OAI especially when compared to small-volume mini-plates frequently applied in trauma surgery. Among OAI associated with implant volumes smaller than 1500 mm3, the detection of Streptococcus spp., Prevotella spp., Staphylococcus spp., and Veillonella spp. was significantly elevated, whereas implant volumes larger than 1500 mm3 showed a significant increase of Enterococcus faecalis, Proteus mirabilis and Pseudomonas aeruginosa. High susceptibility rates (87.7–95.7%) were documented for 2nd- and 3rd-generation cephalosporines and piperacillin/tazobactam. Conclusion High material load and lower jaw reconstruction bear the greatest risks for OAI. When working with large volume osteosynthetic implants, gram-negative pathogens must be considered when choosing an appropriate antibiotic regime. Suitable antibiotics include, e.g., piperacillin/tazobactam and 3rd-generation cephalosporines. Clinical relevance Osteosynthetic material utilized in reconstructive procedures of the lower jaw may be colonized with drug-resistant biofilms.

Sixty Years of Innovation in Biomechanical Orthognathic Surgery: The State of the Art and Future Directions

“…When infection did occur, 92.7% occurred in the mandible and 7.3% in the maxilla, with an average time between surgery and infection of 31.5 days. Moreover, 12.2% required hardware removal for plate loosening and 4.9% developed chronic osteomyelitis [82][83][84][85]. To determine and compare the operative time and length of inpatient stay for orthognathic procedures and to assess the reoperation rate, the authors of [86] found that the mean operative time for single jaw procedures was 80.3 min for a BSSO; the mean postoperative hospital stay was 1.2 ± 0.2 days; 96.4% of patients spent only one postoperative night in hospital; and 2.4% of patients required a re-operation.…”

Diagnosis and management of postoperative wound infections in the head and neck region

“…The exact extent of the infection should be estimated intraoperatively and the infected region should be drained, in addition to an incision and antiseptic lavage [ 20 ]. Depending on the specific operation (e.g., facial fracture with osteosynthesis), concomitant infection of osseous structures and introduced foreign material must be considered [ 21 ].…”

“…There is a particular risk of a prolonged chronic infection with regard to possible biofilm formation when osteosynthesis material is inserted. Therefore, it may be necessary to exchange the foreign material through (re-)osteosynthesis [ 21 ]. Furthermore, targeted therapy for sepsis often requires an intensive care setting.…”