The normal floras in the upper airways and the risk of postoperative infections

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MATERIAL AND METHODS

Patient population and period of time

This study was designed as a retrospective study of medical records carried out at the department of Otolaryngology-Head and Neck Surgery at USÖ. Patients included in the study were the 10 most recent patients from 2013 undergoing laryngectomy and oral cavity resection with free flap surgery, respectively, giving a total of 20 patients. This was possible by searching on the operation code of these procedures. Patients undergoing the surgery procedures mentioned above do always receive antibiotic prophylaxis due to the great risk of infection. The mean age of the patients included was 67 years (range, 44 – 81 years), with 6 women (30%) and 14 men (70%).

What have been studied?

A protocol to investigate patient characteristics, antibiotic prophylaxis and the occurrence of possible SSI and possible adverse effects of the antibiotic dosage was developed. By using information from the database “Kliniska Portalen” (the software containing medical records) and paper charts, the protocol of all twenty patients was completed. One laryngectomy patient was excluded from the final evaluation of 2 parameters, (the duration of surgery and the antibiotic prophylaxis), due to the missing of a paper chart.
Parameters included in the protocol were sex, age, diagnosis, type of surgery, antibiotic medication, timing of the first dosage and the duration of the antibiotic prophylaxis given. Factors indicating a possible SSI such as body temperature, elevated B-LPK (white blood cell count) and CRP and possible positive culture results were also investigated. Potential risk factors for postoperative infections were parameters of interest as well. The following factors were investigated: diabetes mellitus, smoking, alcoholic consumption, cortisone therapy, preoperative radiotherapy and duration of surgery. Finally, parameters indicating possible adverse effects of the antibiotic prophylaxis were also included: gastrointestinal effects (diarrhoea, constipation and nausea), Clostridium Difficile enterit and rashes.

Definitions

In the current study the definition of SSI was based on a publication by The Centers for Disease Control and Prevention (CDC) [17]. However, in addition to the CDC definitions, the occurrence of possible fistulas or flap necrosis was considered as SSI in the study as well. Moreover the suspicion of SSI was supported through parameters as elevated CRP, B-LPK and body temperature and positive culture results from the wound.

Statistics

The statistical method used in the evaluation of the results was fisher’s exact test.
Values of p < 0.05 were considered statistically significant.

Ethics consideration

The head of the department of the Otolaryngology-Head and Neck Surgery at USÖ has approved of the study, including the analysis of medical records.
The overall infection rate of the 20 patients included was 20% (4 patients) (see table 2 and 5). Of those developing SSI 2 of the 4 patients developed a fistula or flap necrosis. All 4 patients who developed SSI received broad-spectrum antibiotic prophylaxis consisting of both metronidazole and cefuroxime. A total of 16 patients received both metronidazole and cefuroxime; however, there were 3 patients who only received prophylaxis consisting of cefuroxime alone. The majority (15 patients) received the complete preoperative dosage of antibiotic prophylaxis within 60 minutes prior the incision. Remaining 4 patients, (1 was excluded due to the missing of a paper chart), received the complete dosage at the time of incision. However, none of these patients developed SSI. The duration of the antibiotic prophylaxis varied widely among the patients, from 4 days up to 17 days (excluding the patients who developed SSI) (See table 1 and 3). No difference of SSI frequency was seen for patients receiving antibiotics for more than 7 days, compared to those receiving antibiotics for 7 days or less. The patients (patient number 2, 3, 13 and 20 in table 2) who developed SSI were considered to receive antibiotic therapy from the time of verified SSI. Patient number 2 continued with the same antibiotic therapy as the prophylaxis given, (metronidazole + cefuroxime). Remaining 3 patients received another antibiotic therapy than the previous antibiotic prophylaxis. They switched from metronidazole and cefuroxime to one or several antibiotics. Patient number 3 initially switched from metronidazole and cefuroxime to Tazocin (piperacallin/tazobaktam), then from Tazocin to amoxicillin and ciprofloxacin. Patient number 13 continued with metronidazole during the whole treatment, but cefuroxime was switched to Tienam (cilastatin/imipenem) + vancomycin and later to Eusaprim forte (trimethoprim and sulfamethoxazole). Patient number 20 switched from the antibiotic prophylaxis to flucloxacillin.
5 patients were encountered with positive culture results from their surgical wounds (see table 2). However, 2 of these patients were considered not to have a SSI, due to that no further signs of infection were observed. The most common wound culture result was Enterococcus Faecalis. The majority of the positive culture results were of mixed flora. Only 1 of the 5 patients was infected with a Gram-negative bacterium (coliform bacterium).
When investigating adverse effects of the antibiotic prophylaxis, GI effects were the most common discovered (6 patients, 20%). Clostridium Difficile enterit was developed in 1 patient, and 1 patient suffered from rashes (which disappeared when terminating the antibiotic therapy) (see table 2). Only the patients receiving metronidazole and cefuroxime suffered from adverse effects (see table 4). This was not statistically significant when compared to those receiving cefuroxime alone.
A total of 17 patients were smokers and they were the only ones who developed postoperative infections. It is also notable that 2 of the 6 patients with cortisone treatment developed SSI. Of those receiving preoperative irradiation 2 patients developed SSI and both developed fistula or flap necrosis, P = 0,59 when compared to the rest of the group who did not receive preoperative radiotherapy. Noteworthy is also that 3 of the 11 surgical procedures exceeding a duration of 500 minutes developed SSI. (See table 5).
When investigating surgery characteristics the mean duration of a procedure was 592,6 minutes, (see table 6). An overall infection rate of 20% (2 patients) was observed in those undergoing laryngectomy and reconstructive surgery, respectively. No statistically significance was found when comparing these two groups.

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Table of contents :

ABSTRACT
INTRODUCTION
Head and neck cancer
Oral cavity cancer
Laryngeal cancer
Hypopharyngeal cancer
The normal floras in the upper airways and the risk of postoperative infections
Antibiotic prophylaxis
Aim of the study
MATERIAL AND METHODS
Patient population and period of time
What have been studied?
Definitions
Statistics
Ethics consideration
RESULTS
DISCUSSION
CONCLUSION
ACKNOWLEDGEMENT
REFERENCES

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