Role Of Systemic Antibiotics in Managing Infection Related to Oro-Facial Trauma

With infection rates after maxillofacial fractures varying from 0% to 62%, infection following orofacial trauma is a severe complication that concurs significant health and socioeconomic consequences if left untreated. (2)

Systemic antibiotic prophylaxis is a recognized infection prevention method in routine clinical practice. However, a spiking rise in antimicrobial resistance (AMR) and a lack of a globally accepted expert consensus guideline on the use of antibiotics in orofacial trauma has re-ignited research on the rationality of systemic antibiotics in orofacial trauma. Moreover, despite the wide acknowledgment that systemic antibiotic prophylaxis minimizes the risk of infection in the treatment of maxillofacial fractures, there exists a lack of data on the choice and regime of appropriate antibiotics for the same. (2)

This review aims to summarise the current data supporting the use of antibiotics in treating maxillofacial fractures while elaborating on the efficacy of Amoxycillin in successfully containing trauma-related infections.

Besides the type and the extent of the oro-facial injury, which is a well-documented factor that affects the healing process, research highlights that healing may be drastically compromised and cause unwanted complications if bacteria access the site of injury. (3)

• Left untreated, bacterial contamination can cause the post-trauma reparative process to pivot into an infectious process (ongoing pulp revascularization to progress to infected pulp necrosis, repair-related surface resorption to infection-related resorption, and ankylosis to progress to infection-related resorption ). (3)
• Fractures of the mandible or maxilla that communicate with the oral cavity and saliva via lacerations in the mouth or periodontal ligament area create a chance for the exposed bone to become contaminated ; and may increase the risk of osteomyelitis and deep-seated wound infections.(4)
• Life-threatening maxillofacial space infections are often related to orofacial trauma. (5)Such serious complications underscore the need to initiate timely antibiotics to manage the spread of bacterial infection.

With these proven oral trauma-bacteria links, it is prudent that research focuses on excluding or reducing the bacterial burden during the healing period. (3)

• JAW BONE FRACTURES-Among all maxillofacial fractures, mandibular fractures are said to have the highest prevalence of infection. Studies indicate that infection rates for mandibular fractures are usually high due to their proximity to tooth-bearing areas of the jaws ( regarded as “open fractures”), and the infection rates vary from 3.3% to 43.9%. Since microorganisms infect most open fractures, it is crucial to administer immediate antibiotics and debride the incision, cover it with soft tissue, and stabilize the fracture. (2)
• Chole and Yee (6 ) also showed that the administration of antibiotics in orofacial fractures drastically reduced the incidence of infectious complications from 42.2% to 8.9%.
• Resonating with these findings, the literature highlights that a rational antibiotic regime, together with the aseptic technique, reduces infection rates (after repair of mandibular fractures) from 7.3% to 15.2%. (1)

TEETH FRACTURES-Bacteria are primarily responsible for periodontal and pulpal healing difficulties following tooth trauma. Antibiotics administered systemically reduce the tooth resorption processes on the root surface following replantation. (3)

Managing bacteremia in orofacial trauma-

• Bacteremia, a common consequence of post-trauma surgical procedures, is another frequent challenge the dental fraternity faces. Bacteremia appears immediately following invasive dental operations and becomes less severe with time. In otherwise healthy individuals, bacteria are typically removed from the circulation by the host defense system between a few minutes and an hour following dental surgery. Still, they can linger in individuals with impaired immune systems. Studies further confirm that “oral viridans group streptococci” (VGS) bacteremia and subsequent infective endocarditis (IE) can develop in “high-risk” individuals, thus necessitating an optimum prophylactic antibiotic therapy in such cases. (7 )

Broad-spectrum beta-lactam antibiotics are the agents of choice in maxillofacial trauma and repair surgery, where a plethora of diverse microorganisms exist and are dominated by the oropharyngeal flora. (Streptococcal species; oropharyngeal anaerobes; specifically, Peptostreptococcus species) (2,7,8 )

• Amoxicillin interferes with and inhibits cell wall biosynthesis of the microorganism, which leads to the death of the bacteria. (7,9,10)
• It also prevents fracture site infections by reducing the amount and virulence of microorganisms at the surgical site before, during, and after an operative procedure. (9)
• Due to its modest range, strong disponibility, high plasmatic concentrations when taken orally, and minimal side effects, Amoxicillin is frequently used as the recommended first-line therapy, particularly for infection prevention. (7)

• Though the antibiotic duration varies from a single dose up to 7 or even ten days postoperatively (1), recent studies highlight that infection rates were similar when comparing antibiotic prophylaxis for up to 24 hours with extended periods; thus concluding that prolonged antibiotic prophylaxis can be avoided. (2)
• These findings are consistent with the updated recommendations on Antimicrobial Prophylaxis for the Prevention of Surgical Site Infection, which emphasize discontinuing antibiotic prophylaxis after 24 h for all fracture types. (10)

Key pointers-

• Traumatic dental injuries cause tissue damage, serve as direct contamination sites and increase the risk of infection.
• Direct teeth trauma like enamel infractions, dentinal tubules, exposed pulps, injured periodontal ligament (PDL), and exposed alveolar bone have all been identified as pathways for bacterial invasion. Jaw bone and associated soft tissue injuries also have potential bacterial entry and spread sites. Left untreated, bacterial colonization in a wound continues and interferes with healing.
• Research consistently highlights that prudent and rational use of antibiotics in surgical interventions in high risk patients for orofacial fractures can significantly reduce postoperative infections.
• Amoxicillin is a well-documented broad-spectrum antibiotic with a proven history of potency in maxillofacial trauma cases. Owing to its modest range, high plasmatic concentrations when taken orally, and minimal side effects, this drug has reinforced its position as a “go-to” antibiotic among the dental fraternity.