JOURNAL CLUB
PRESENTER-KARAN MIT TAL
DATE-27/10/23
MODERATOR-DR.KALPA PANDYA
CONTENTS
INTRODUCTION
AIM/PURPOSE
METHODS
RESULTS
DISCUSSION
INTRODUCTION
Prophylactic antibiotics are routinely prescribed for patients with facial fractures.
Risk(adverse reaction, resistance) vs benefit(reducing infectious complications) ratio must be
assessed before giving antibiotics.
When surveying doctors - 66% of respondents prescribe antibiotics sometimes or always for
nonoperative facial fractures, while 34% responded that they never prescribe antibiotics in this
scenario.
It has been found that prescribing antibiotics is the default treatment of choice among
surgeons in non-operative facial fractures.
However recent studies have questioned the efficacy of this clinical practice.
CRITICALLY ILL PATIENTS WITH FACIAL FRACTURES
RISK FOR THE DEVELOPMENT OF SINUSITIS.
MAXILLARY SINUSITIS
VENTILATOR-ASSOCIATED PNEUMONIA (VAP)
MORBIDITY AND MORTALITY IN ICU SETTINGS
While recent literature suggests antibiotics are not needed in patients with nonoperative facial
fractures involving sinuses, the existing studies do not focus on critically injured patients who are
known to be at higher risk for sinusitis and VAP which could be exacerbated by their facial
fracture.
PURPOSE
To determine if antibiotics reduce the rate of infectious complications in critically injured
patients who have blunt midfacial trauma treated nonoperatively
Hypothesis- Rate of infectious complications that arose from facial fractures with sinus
involvement was similar in patients who received antibiotics and in those who did not
STUDY DESIGN
Retrospective cohort study
Study population-Patients who were admitted to the Trauma ICU at University Medical Center in
New Orleans with midfacial fractures sustained from nonpenetrating trauma between August 13,
2012, and July 30, 2020
INCLUSION
CRITERIA
CRITICALLY ILL ON ADMISSIONICU ADMISSION
EXCLUSION
CRITERIA
ONLY MANDIBLE AND OR
TEMPORAL BONE
FRACTURE
AGE > 18 YEAR
UNDERWENT OPERATIVE
MANAGEMENT
FACIAL FRACTURE INCLUDING
FRONTAL,MAXILLARY OR ETHMOID SINUS
NON-OPERATIVE MANAGEMENT
DIED WITHIN 5 DAYS OF
ADMISSION
VARIABLES
Primary predictor variable- Antibiotic administered or not--------considered to have been
treated with antibiotics if they received at least 2 doses of antibiotics within that 7-day period
Primary outcome variable - Development of one or more of the following complications:
sinusitis, soft tissue infection at the fracture site, or any type of pneumonia, including ventilator
associated pneumonia
 Secondary outcome variables - Development of each specific complication, such as
ventilator-associated pneumonia, any other form of pneumonia, or Clostridioides difficile
infection
 Other variables recorded - Age, gender, race, Glasgow Coma Scale (GCS) on arrival, Injury
Severity Score, the presence of lacerations or foreign bodies around the fracture site, packed
red blood cell (pRBC) transfusion (measured in number of units administered), and hospital
length of stay (in days)
RESULTS
307 patients met the inclusion criteria.
Mean age - 40.6 years and 85.0% of patients were men.
Facial lacerations were noted in 34.5%.
Of the 307 patients, 229 (74.6%) were administered antibiotics.
Patients were more likely to receive antibiotics if they had a higher Injury Severity Score , facial
lacerations , increased pRBC transfusions , and a longer hospital length of stay
Complications developed in 13.6% of patients.
These complications included: sinusitis (0.3%), ventilator-associated pneumonia (7.5%), and
other pneumonia types (5.9%).
C difficile colitis developed in 2 patients (0.6%) in this cohort.
There were no soft tissue infections overlying the fractures in the study population.
Patients with complications were more likely to have a lower GCS on arrival (P < .001), a
higher Injury Severity Score (P < .001), received more units of pRBCs (P < .001), and a
longer hospital stay (P < .001)
Antibiotic administration was not associated with the development of complications.
The complication rate was 13.1% in patients who received antibiotics was and 15.4% in
those who did not
 AFTER ADJUSTING FOR RACE, PRESENCE OF LACERATIONS AND FOREIGN BODIES, AND
GCS, ANTIBIOTIC ADMINISTRATION WAS STILL NOT STATISTICALLY SIGNIFICANTLY
ASSOCIATED WITH COMPLICATIONS
 FURTHERMORE, NONE OF THE SECONDARY OUTCOMES VARIABLES (SINUSITIS, VAP,
OTHER PNEUMONIA TYPES, AND C DIFFICILE INFECTION) WERE ASSOCIATED WITH
ANTIBIOTIC ADMINISTRATION
DISCUSSION
The authors hypothesized that treatment with antibiotics would not reduce the rate of
infectious complications.
The results of this study support their hypothesis that antibiotics for nonoperative facial
fractures do not reduce the rate of infectious complications.
The rate of sinusitis was exceedingly low (0.3%).
Pneumonias, which were postulated to be linked to sinusitis and facial fractures, occurred at no
different rates regardless of antibiotic use in either the adjusted or unadjusted analysis.
In the study population, facial fractures do not appear to be a significant risk factor for sinusitis
regardless of antibiotic administration.
Additionally, C difficile colitis occurred at a rate of about 0.9% in the antibiotic group in this
study
There were a number of variables measured which were correlated with both the predictor,
antibiotic use, and the outcome, complications.
These variables, length of stay, GCS, Injury Severity Score, and total blood infusions are all
markers for severity of trauma.
More severely injured patients were more likely to have complications and receive antibiotics
related to one of their injuries.
In the adjusted analysis, only GCS was retained in the model, likely because of its relatively high
correlation to the other variables but better correlation with infectious complications
The findings of this study are in agreement with that of Malekpour et al, which also showed
no benefit from antibiotics for nonoperative fractures with sinus involvement, though they did
not examine critically injured patients specifically.
Their study also found no incidence of soft tissue infections, but did not evaluate sinusitis or
pneumonia.
C difficile colitis was again found only in the antibiotic group, but not with sufficient prevalence
to reach statistical significance.
Zosa et al came to similar conclusions when they evaluated the use of prophylactic antibiotics
in critically ill patients with facial fractures.
Their study compared patients receiving less than 24 hours of antibiotics to patients that
received longer than 24 hours of antibiotics.
They found no significant difference in the rate of head and neck infections between groups in
patients with nonoperative facial fractures.
Unlike this study, theirs included penetrating trauma and mandible fractures.
Pessino et al, zygomaticomaxillary complex fractures, orbital fractures, and zygomatic arch
fractures managed nonoperatively without antibiotics in a large case series showed not a single
incident of soft tissue infection or sinusitis.
Their results are consistent with the present study, although they did not include critically
injured patients.
 Esce et al, for nonoperative orbital fractures, there were no infectious complications in either
an antibiotic group or a group that did not receive antibiotics
In summary, regardless of fracture type or population, nonoperative midfacial fractures that
develop infections are exceedingly rare.
Though the present study is the first to examine critically injured patients and to measure
pneumonia rates, the findings mirror the previously published data that examined this question
specifically
The results of the present study support the hypothesis that intervening prophylactically with
antibiotics for facial fractures does not change the risk of sinusitis or feared infectious sequelae
of sinusitis in the intubated patient, such as VAP
MERITS AND DEMERITS
MERIT
• Sample Size
• Multiple variables
• Critically injured
patients
DEMERIT
• Retrospective study
• Systemic co-morbids
• Type/Extent of fracture
• Subjective bias
• Reproducibility
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