Surgical site infections are common after head and neck surgeries and can increase hospital stays. Properly administered preventative antibiotics can lower infection rates when given before potentially contaminating procedures. Guidelines recommend administering antibiotics 30 minutes before incision and additional doses for long or complex surgeries. Post-operative antibiotics are not needed unless actively treating an infection. Common antibiotic regimens for different head and neck surgeries are provided along with alternatives for penicillin allergies.

1. Prophylactic Use of Antibiotics in
Otolaryngology & Head-Neck
Surgery
Dr. Muhammad Lipu Sarwer
Medical Officer
Medical Department
Beximco Pharma

2. Introduction
Surgical site infection (SSI) is one of the most common healthcare
associated infections resulting in an average additional hospital stay of
6.5 days per case.
In operations with a higher risk of infection (e.g. clean-contaminated
surgery), perioperative antibiotic prophylaxis has been shown to lower
the incidence of infection.
High antibiotic levels at the site of incision for the duration of the
operation, are essential for effective prophylaxis.

3. Risk of infection
The risk of SSI depends on a number of factors; these can be related to the
patient or the operation and some of them are modifiable
• Age
• Nutritional status
• Diabetes
• Smoking
• Obesity
• Coexistent infections at a remote body site
• Colonization with microorganisms (e.g. Staph. aureus)
• Immunosuppression (inc. taking glucocorticoid steroids)
• Length of preoperative stay
• Coexistent severe disease
Patient

4. Risk of infection
Operation
• Duration of surgical scrub
• Preoperative shaving/ preoperative skin prep.
• Length of operation
• Appropriate antimicrobial prophylaxis
• Operating room ventilation
• Inadequate sterilization of instruments
• Foreign material in the surgical site
• Surgical drains
• Surgical technique inc. haemostasis,
• poor closure, tissue trauma
• Post-operative hypothermia

5. The risk is also related to the amount of contamination with
microorganisms which is called “class” of the operation
Class Definition
Clean Operations in which no inflammation is encountered and the
respiratory, alimentary or genitourinary tracts are not entered.
There is no break in aseptic operating theatre technique.
Clean-contaminated Operations in which the respiratory, alimentary or genitourinary
tracts are entered but without significant spillage.
Contaminated Operations where acute inflammation (without pus) is
encountered, or where there is visible contamination of the
wound. Examples include gross spillage from a hollow viscus
during the operation or compound/open injuries operated on
within four hours
Dirty Operations in the presence of pus, where there is a previously
perforated hollow viscus, or compound/open injuries more than
four hours old.

6. Prophylactic antibiotics
• Prophylaxis with antibiotics has decreased the high incidence of
wound infection after head and neck operations that involve
incisions through oral or pharyngeal mucosa.
• Prophylactic administration of antibiotics can decrease
postoperative morbidity, shorten hospitalization, and reduce overall
costs attributable to infections.
• Additional doses during the procedure are advisable if surgery is
prolonged (i. e, >4 h), major blood loss occurs, or an antimicrobial
with a short half-life is used

7. The aim of prophylaxis
• The aim of prophylaxis is to augment host defense
mechanisms at the time of bacterial invasion.
• Prophylaxis is an attempt to attack organisms before
they have a chance to induce infection.

8. Antibiotic Prophylaxis
 Timing for Administration
 Additional Intra-operative doses
 Post-operative antibiotic prophylaxis

9.  Timing for Administration
Antibiotic prophylaxis administered too early or too late
increases the risk of SSI. Studies suggest that
antibiotics are most effective when given 30 minutes
before skin is incised.

10.  Additional Intra-operative doses
High antibiotic levels, at the site of incision, for the duration of the
operation, are essential for effective prophylaxis.
For operations lasting more than 4 hours re-dosing may be necessary.
Antibiotic Recommended re-dosing
interval/dose to give
Cefuroxime 4 hours, give 750mg IV
Clindamycin 4 hours give 300mg IV
Co-amoxiclav 4 hours, give 1.2g IV
Metronidazole 8 hours, give 500mg IV

11.  Post-operative antibiotic prophylaxis
Studies have shown that giving additional antibiotic
prophylaxis after wound closure does not reduce infection
rates further. Post-operative antibiotics should only be
given to treat active/on-going infection unless specifically
recommended against the surgical procedure.
Surgical antibiotic prophylaxis guidelines within Maxillofacial and ent for adult
patients by NHS published in 2013

12. Summary Table for Maxillofacial / ENT Antibiotic
Prophylaxis Regimens in Patients
Procedure Standard
Antibiotic
Dose / Route
Mild Penicillin
Allergy
Severe Penicillins /
Cephalosporin
Allergy
Alveolar
bone
grafting
(Intra-oral)
No
prosthesis
Co-amoxiclav 1.2g
IV at Induction
Cefuroxime 1500mg
IV and
Metronidazole
500mg IV at
induction
Clindamycin 600mg
IV on
induction
Prosthesis
for
internal
fixation
Co-amoxiclav 1.2g
IV at
induction + 2
further
post-op doses at 8
and
16 hrs
Cefuroxime 1500mg
IV and
Metronidazole
500mg IV
+ 2 further post-op
doses at
8 and 16 hrs
Clindamycin 600mg
IV on
induction + 3 further
post-op
doses at 6, 12 and
18 hrs
Head and Neck Surgery

13. Procedure Standard
Antibiotic
Dose / Route
Mild Penicillin
Allergy
Severe Penicillins /
Cephalosporin
Allergy
Open
reduction
and
internal
fixation
of
fractures
(ORIF):
No
prosthesi
s
Co-amoxiclav 1.2g
IV at
induction
Cefuroxime 1500mg
IV and
Metronidazole
500mg IV at
induction
Clindamycin 600mg
IV on
induction
Prosthesi
s for
internal
fixation
Co-amoxiclav 1.2g
IV at
induction + 2
further
post-op doses at 8
and
16 hrs
Cefuroxime 1500mg
IV and
Metronidazole
500mg IV
+ 2 further post-op
doses at
8 and 16 hrs
Clindamycin 600mg
IV on
induction + 3 further
post-op
doses at 6, 12 and
18 hrs
Head and Neck Surgery

14. Procedure Standard
Antibiotic
Dose / Route
Mild Penicillin
Allergy
Severe Penicillins /
Cephalosporin
Allergy
Open fractures for
conservative
treatment
Co-amoxiclav
625mg
PO TDS for 3 days
Cefradine 500mg
QDS PO and
Metronidazole
400mg TDS PO for
3 days
Clindamycin 450mg
QDS PO for 3 days
Head and Neck Surgery

15. Procedure Standard
Antibiotic
Dose / Route
Mild Penicillin
Allergy
Severe Penicillins /
Cephalosporin
Allergy
Major head and
neck surgery (with
mucosal breach)
Co-amoxiclav 1.2g
IV at
induction
Cefuroxime 1500mg
IV and
Metronidazole
500mg IV at
induction
Clindamycin 600mg
IV on
induction
Salivary
gland
surgery
Co-amoxiclav 1.2g
IV at
induction
Cefuroxime 1500mg
IV and
Metronidazole
500mg IV at
induction
Clindamycin 600mg
IV on
induction
Head and Neck Surgery

16. Procedure Standard
Antibiotic
Dose / Route
Mild Penicillin
Allergy
Severe Penicillins /
Cephalosporin
Allergy
Complex
procedures
e.g. ‘free’ cartilage
replacement
Co-amoxiclav 1.2g
IV at
induction
Cefuroxime 1500mg
IV and
Metronidazole
500mg IV at
induction
Clindamycin 600mg
IV on
induction
Closure of CSF leak
with intranasal
pathology / pack in
position
Co-amoxiclav 1.2g
IV at
induction.
Cefuroxime 1500mg
IV and
Metronidazole
500mg IV at
induction
Clindamycin 600mg
IV on
induction
Nasal Surgery

17. Procedure Standard
Antibiotic
Dose / Route
Mild Penicillin
Allergy
Severe Penicillins /
Cephalosporin
Allergy
Cochlear Implants Cefuroxime
1500mg IV
+ 2 post-op doses
at 8
and 16 hrs.
Cefuroxime 1500mg
IV
+ 2 post-op doses at
8 and
16 hrs.
Clindamycin 600mg
IV on
induction + 3 further
post-op
doses of oral
clindamycin
600mg at 6, 12 and
18 hrs
Ear Surgery

18. Antibiotics
Tab. Cefuroxime 250/500 mg
Inj. Cefuroxime 750 mg
Sus. Cefuroxime 125 mg/5 ml

19. Antibiotics
Amoxicillin & Clavulanic acid (Co-amoxiclav)

20. Antibiotics
Clindamycin 150 mg and
300 mg capsules

21. Metronidazole Tablet,
Suspension, IV Infusion

22. Inj. Ceftriaxone 250/500 mg/1g/2g IM/IV

23. Tab. Cefixime 200 mg

24. Thank You
www.beximcopharma.com