Antimicrobial prophylaxis for major head and neck surgery in cancer patients: sulbactam-ampicillin versus clindamycin-amikacin

Abstract

A total of 99 patients with head and neck cancer who were to undergo surgery were randomized in a prospective comparative study of sulbactam-ampicillin (1:2 ratio; four doses of 3 g of ampicillin and 1.5 g of sulbactam intravenously [i.v.] Wound infections occurred in 14 (33%) sulbactamampicillin-treated patients and 9 (21%) clindamycin-amikacin-treated patients (P = 0.19; not significant). The rates of bacteremia were 2 and 4%, respectively. The rates of bronchopneumonia were 14.3 and 23.2%, respectively (P was not significant). Most infections were polymicrobial, but strict anaerobes were recovered only from patients who received sulbactam-ampicillin. Antimicrobial treatment was required within 20 days after surgery for 42% of the sulbactam-ampicillin-treated patients and 44% of the clindamycin-amikacintreated patients. By comparison with previous studies, we observed a decreased efficacy of antimicrobial prophylaxis in patients with head and neck cancer undergoing surgery because of the increased proportion of patients who were at very high risk for infection (extensive excision and plastic reconstruction in patients with recurrent stage III and IV cancers) and because of the longer durations of surgery.It has been proven and widely accepted that patients with head and neck cancer undergoing surgery (clean contaminated procedures) benefit from preoperative antibiotic prophylaxis once the skin and oropharyngeal cavities are opened (5,17,18,27,30). Simple laryngectomy has been associated with a very low risk of infection (<4%) (5, 20). Placebo-controlled studies are considered unethical in patients undergoing surgery for head and neck cancer (excluding simple laryngectomy), and any new regimen should be compared with an effective regimen, which has been clindamycin plus an aminoglycoside (netilmicin or amikacin), as determined from studies previously performed in our center (11,27). The combination of a P-lactam antibiotic with a 1-lactamase inhibitor has a spectrum of activity very similar to that of the clindamycin-amikacin combination, including strict anaerobes. However, in recent studies, we have documented that a significant number of failures were due to methicillin-resistant staphylococci (11,27). The in vitro activity of the combination ampicillin-sulbactam against methicillin-resistant staphylococci is high (21,23,34), and the combination of amoxicillin-clavulanic acid was found to be effective in a rat model of endocarditis (7). On the other hand, the combination of clindamycin-amikacin is consid-* Corresponding author. t Present address: European Organization for Research and Treatment of Cancer Central Office, 1200 Brussels, Belgium. ered to be ineffective against those bacteria, since methicillin-resistant staphylococci are frequently resistant to clindamycin and should probably be considered to be resistant to amikacin as well.As far as the choice of the ,-lactamase inhibitor is concerned, sulbactam has two advantages over clavulanic acid; it is more potent (up to 100-fold) in inhibiting the cl...

Prognostic significance of wound infections following major head and neck cancer surgery: an open non-comparative prospective study

“…Short antibiotic prophylaxis reduces the risk of drug side effects and the risk of colonization and superinfection due to resistant pathogens. However, in major head and neck cancer surgery there is no consensus concerning antibiotic prophylaxis policy [6,11,12,17,19,24,25,28,34]. In the present study, an amoxicillin and clavulanic acid regimen failed to prevent WI in 50% of patients.…”

Surgical prophylaxis with gram‐negative activity for reduction of surgical site infections after microvascular reconstruction for head and neck cancer

“…Many different systemic regimens have been reported in the setting of postoperative antimicrobial coverage: clindamycin plus aminoglycoside, cephalosporin monotherapy, and b-lactam/b-lactamase inhibitor. 5 One study also suggested to use antimicrobials that are resistant to b-lactamases, as many gram-negative bacteria possess these enzymes. 23 Additionally, studies that utilized topical antimicrobials preoperatively to decolonize the surgical area have not been shown to be beneficial.…”

“…Surgical site infections after general head and neck cancer surgery have an incidence rate of 8% to 45% with standard surgical infection prophylaxis, [1][2][3][4][5][6][7][8][9][10][11] but can be seen in up to 87% without surgical infection prophylaxis. 2,7,8,[12][13][14] Few studies have examined patients undergoing clean or cleancontaminated microvascular reconstruction for head and neck cancer.…”

Head and neck free flap surgical site infections in the era of the Surgical Care Improvement Project

“…The reported rates of surgical site infection in head and neck free flap surgery range from 8.1% to 41% . The risk of surgical site infection after head and neck reconstruction is postulated to be higher than other anatomic sites because of the creation of communication between the aerodigestive tract and neck, contamination with saliva and respiratory secretions, and postoperative tissue dead space .…”