Presentation about the prevention of infections arising in postoperative oral surgery procedure taking account of oral administration of antibiotics

1. Prophylaxis & Prevention
of Postoperative Surgical
Wound Infections in Oral
Surgery
Dr. Giuseppe Bruno PitassiDr. Giuseppe Bruno Pitassi
Medical DoctorMedical Doctor
Dental SurgeonDental Surgeon
Specialist Maxillofacial SurgerySpecialist Maxillofacial Surgery
PgPg/Dip. Clinical Periodontology/Dip. Clinical Periodontology
Pitassi GB 2016

2. “Il Cavadenti”
(Oil painting on canavas)
Michelangelo da Caravaggio, 1637
Firenze, Galleria Palatina

3. Prophylaxis, from GreekProphylaxis, from Greek
προφυλάσσωπροφυλάσσω,, means in English,means in English,
defend or anticipate.defend or anticipate.
Prophylaxis is any medicalProphylaxis is any medical
procedure or public health whoseprocedure or public health whose
purpose is to prevent, rather thanpurpose is to prevent, rather than
cure or treat, diseases.cure or treat, diseases.
Pitassi GB 2016

4. Wound infection is a term that hasWound infection is a term that has
caused a lot of confusion amongcaused a lot of confusion among
surgeons anywhere.surgeons anywhere.
In order to remedy such problem theIn order to remedy such problem the
Centre for Disease Control (CDC)Centre for Disease Control (CDC)
released some definitions andreleased some definitions and
protocols in 1999 that nowadays haveprotocols in 1999 that nowadays have
been taken worldwide.been taken worldwide.
Pitassi GB 2016

5. Pitassi GB 2016

7. CDC DefinitionCDC Definition
Pitassi GB 2016

8. As per the CDC classification there areAs per the CDC classification there are
three types of Surgical Site Infection (SSI):three types of Surgical Site Infection (SSI):
1. Superficial Incisional SSI1. Superficial Incisional SSI
2. Deep Incisional SSI2. Deep Incisional SSI
3. Organ/Space SSI3. Organ/Space SSI
These are the mostThese are the most
frequent clinicalfrequent clinical
manifestation seenmanifestation seen
in Oral Surgeryin Oral Surgery
Pitassi GB 2016

9. Surgical Site InfectionsSurgical Site Infections
((SSSSI)I)
Pitassi GB 2016

10. Cross-section of abdominal wall depicting CDCCross-section of abdominal wall depicting CDC
classifications of surgical site infectionclassifications of surgical site infection
Pitassi GB 2016

11. Superficial Incisional Surgical Site InfectionSuperficial Incisional Surgical Site Infection
To call an infection a superficial SSI itTo call an infection a superficial SSI it
should meet the following criteria:should meet the following criteria:
Pitassi GB 2016

12. Deep Incisional Site InfectionDeep Incisional Site Infection
Involves fascia & muscles, usually,Involves fascia & muscles, usually,
with infection and pus collectionwith infection and pus collection
Drainage, control of any source ofDrainage, control of any source of
continuing infection & antibioticcontinuing infection & antibiotic
therapy are indicated.therapy are indicated.
Pitassi GB 2016

13. Organ Space Surgical Site InfectionOrgan Space Surgical Site Infection
These infections usually occur inThese infections usually occur in
the organ previously operated.the organ previously operated.
Postoperative peritonitis is onePostoperative peritonitis is one
such infection. These are verysuch infection. These are very
difficult problems to manage anddifficult problems to manage and
have got a very high mortality.have got a very high mortality.
Pitassi GB 2016

15. Rationale about PreoperativeRationale about Preoperative
Antimicrobial ProphylaxisAntimicrobial Prophylaxis
((AMPAMP))
Pitassi GB 2016

16. Antimicrobial ProphylaxisAntimicrobial Prophylaxis (AMP)(AMP)
Any surgical incision exposes sterile tissues to non sterileAny surgical incision exposes sterile tissues to non sterile
environment, therefore invariably some contaminationenvironment, therefore invariably some contamination
occurs during all surgeries.occurs during all surgeries.
In some conditions linked to the bacterial load and theIn some conditions linked to the bacterial load and the
immunological defences of the host this contaminationimmunological defences of the host this contamination cancan
flare up till to became a frank infection.flare up till to became a frank infection.
The rationale about the prophylactic administration ofThe rationale about the prophylactic administration of
antibiotic is based on the assumption that achievement ofantibiotic is based on the assumption that achievement of
a sufficient concentration of antimicrobial in the tissuesa sufficient concentration of antimicrobial in the tissues
prevent wound colonization by bacteria.prevent wound colonization by bacteria.
The scientific basis of antimicrobial prophylaxis againstThe 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

18. Principles of Antimicrobial ProphylaxisPrinciples of Antimicrobial Prophylaxis
Pitassi GB 2016

19. PreamblePreamble
Pitassi GB 2016

20. Surgical Antimicrobial Prophylaxis (AMP) refersSurgical Antimicrobial Prophylaxis (AMP) refers
to a very brief course of an antibiotic to start justto 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, butis not an attempt to sterilize tissues, but
a complement used to reduce the microbial loada complement used to reduce the microbial load
of intraoperative contamination to a level thatof intraoperative contamination to a level that
cannot overwhelm host defenses.cannot overwhelm host defenses.
Essentially AMP indications pertain to electiveEssentially AMP indications pertain to elective
operations in which tissue incision take place inoperations in which tissue incision take place in
the operating room or as well as in controlledthe operating room or as well as in controlled
contamination environment as the dentalcontamination environment as the dental
surgery, and then there surgical wounds aresurgery, and then there surgical wounds are
closed.closed. Pitassi GB 2016

21. Four principles must be followed to maximizeFour principles must be followed to maximize
the benefits of AMP:the benefits of AMP:
The antibiotics to be used for prophylaxisThe antibiotics to be used for prophylaxis
againstagainst
postoperative infections must:postoperative infections must:
1)1) Be effective against pathogenic microorganism causing theseBe effective against pathogenic microorganism causing these
infections.infections.
2) Use an antibiotic safe, with a broad spectrum that covers the most2) 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 in3) Administer the antibiotic in a manner to achieve a high level of drug in
both serum & tissues so that the bactericidal concentration of theboth serum & tissues so that the bactericidal concentration of the
drug is established in the tissues by the time of the incision anddrug is established in the tissues by the time of the incision and
permanent in them during the entire duration of the operation, until, atpermanent 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.
Pitassi GB 2016

22. The incidence of postoperative infections after oral andThe incidence of postoperative infections after oral and
dentoalveolar surgerydentoalveolar surgery is usually lowis usually low ..
In healthy patient prophylactic administration of antibiotics is notIn healthy patient prophylactic administration of antibiotics is not
necessary.necessary.
The sameThe same must be appliedmust be applied to patients with metabolic diseasesto patients with metabolic diseases
that are controlled, as diabetic patients,that are controlled, as diabetic patients, having a good metabolichaving a good metabolic
balancebalance..
On the other hand patients under antineoplastic chemotherapyOn the other hand patients under antineoplastic chemotherapy
must be treated prophylactically with antibiotics, if the surgicalmust 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 pharmaceuticalThe same applies to patients affected by pharmaceutical
immunosuppression secondary to transplantation of solidimmunosuppression secondary to transplantation of solid
organs.organs.
Principles of Antimicrobial ProphylaxisPrinciples of Antimicrobial Prophylaxis
Pitassi GB 2016

23. Pitassi GB 2016

24. It must be emphasized that clean surgicalIt must be emphasized that clean surgical
technique & prophylactic utilization oftechnique & prophylactic utilization of
antibiotics in certain patients mayantibiotics in certain patients may
significantly reduce the incidence ofsignificantly reduce the incidence of
postoperative infections.postoperative infections.
Pitassi GB 2016

26. Methodology of prophylactic administrationMethodology of prophylactic administration
Pitassi GB 2016

27. Use full dose of chosen antibioticUse full dose of chosen antibiotic..
The antibiotic level in tissues during theThe antibiotic level in tissues during the
surgical procedure must be high.surgical procedure must be high.
This occurs administering higher dose thanThis occurs administering higher dose than
usual, 1 hour prior to starting the surgicalusual, 1 hour prior to starting the surgical
procedure, if the surgery implies localprocedure, if the surgery implies local
anesthesia or panesthesia or preferably at the onset of generalreferably at the onset of general
anesthesiaanesthesia if the procedure should beif the procedure should be
performed under general anesthesia.performed under general anesthesia.
Methodology of prophylactic administrationMethodology of prophylactic administration
Pitassi GB 2016

28. Methodology of prophylactic administrationMethodology of prophylactic administration
Is also to be noted,Is also to be noted, once again, that in the case of surgical procedure to beonce again, that in the case of surgical procedure to be
carried out in anatomical areas not previously infected and then with thecarried out in anatomical areas not previously infected and then with the
only purpose of prevention of wound infection the administration ofonly 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 theMust not be started the day before the procedure or hours before the
operation, because we aim for peak drug levels at the site of interventionoperation, because we aim for peak drug levels at the site of intervention
when the procedure is underway, at the time that such effective tissuewhen the procedure is underway, at the time that such effective tissue
concentration will be achieved, generally this will occur when tissueconcentration will be achieved, generally this will occur when tissue
dissection begins, whereupon the possibility of wound infection and thedissection begins, whereupon the possibility of wound infection and the
risk of intraoperative contamination for bacterial penetration into deeprisk 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..
Pitassi GB 2016

29. 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.
Methodology of prophylactic administrationMethodology of prophylactic administration
Pitassi GB 2016

30. Methodology of prophylactic administration
Fundamental principle concerning theFundamental principle concerning the
prophylactic administration of antibiotics isprophylactic administration of antibiotics is
that the benefit from their use must bethat the benefit from their use must be
significantly greater then the possibility ofsignificantly greater then the possibility of
adverse reactions or side- effectsadverse reactions or side- effects
Employ antibiotic prophylaxis whenever theEmploy antibiotic prophylaxis whenever the
risk of wound infection is increasedrisk of wound infection is increased
Pitassi GB 2016

31. Indiscriminate use of prophylactic antibioticsIndiscriminate use of prophylactic antibiotics
for surgical procedures in healthy patients hasfor 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 beresistant bacteria and should therefore be
avoided.avoided.
Minor oral surgery has a low infection rate inMinor oral surgery has a low infection rate in
healthy individuals and studies have found nohealthy individuals and studies have found no
convincing evidence of any benefit fromconvincing evidence of any benefit from
prophylactic antibiotics except where there isprophylactic antibiotics except where there is
overt infection preoperatively. Prophylactic useovert infection preoperatively. Prophylactic use
of antibiotics should therefore comply with theof antibiotics should therefore comply with the
following important principles.following important principles.
Methodology of prophylactic administrationMethodology of prophylactic administration
Pitassi GB 2016

32. Methodology of prophylactic administrationMethodology of prophylactic administration
Because postoperative infections due to anaerobesBecause postoperative infections due to anaerobes
are unusual, prophylaxis must mainly focused onare unusual, prophylaxis must mainly focused on
aerobic streptococciaerobic streptococci..
Based on these data, Penicillin, Amoxicillin orBased on these data, Penicillin, Amoxicillin or
AmoxicillinAmoxicillin--Clavulanate, are the most appropriateClavulanate, are the most appropriate
antibiotics for prophylaxis.antibiotics for prophylaxis.
When there is a history of allergic reactions (usuallyWhen there is a history of allergic reactions (usually
urticarial rash) to Penicillin, Clindamycin isurticarial rash) to Penicillin, Clindamycin is
preferred.preferred.
If the surgical procedure is to be performed troughIf 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.
Pitassi GB 2016

33. Taking a cue from the concepts mentionedTaking a cue from the concepts mentioned
above a scheme of antibiotic prophylacticabove a scheme of antibiotic prophylactic
regime to consider may be the following:regime to consider may be the following:
Pitassi GB 2016

34. Pitassi GB 2016

35. 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.
Pitassi GB 2016

36. 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:
Pitassi GB 2016

38. “Aspects of the Human Face”
(oil on canvas 200 × 120 cm) Marc M. Baltensperger, 2000
Thanks for your attentionThanks for your attention

39. Pitassi GB 2016

40. Pitassi GB 2016

41. Pitassi GB 2016

42. Pitassi GB 2016

43. Pitassi GB 2016

44. Pitassi GB 2016

45. Pitassi GB 2016

46. Pitassi GB 2016

47. Pitassi GB 2016

48. Pitassi GB 2016