From the Guidelines
The literature supports the use of antibiotics in mandible fractures to prevent infection, with recommendations for a short course of prophylactic antibiotics.
Key Points
- First-line options include penicillin-based antibiotics such as amoxicillin-clavulanate (875/125 mg twice daily) or, for penicillin-allergic patients, clindamycin (300-450 mg four times daily) 1.
- Antibiotic duration should typically be limited to 3-5 days post-operatively for closed fractures, though compound fractures involving oral mucosa or skin may warrant 7-10 days of coverage.
- Prophylactic antibiotics should be administered preoperatively, ideally within one hour before incision, with intravenous options including cefazolin (1-2g) or clindamycin (600-900mg) for allergic patients.
- Extended antibiotic courses beyond these recommendations have not shown additional benefit and may contribute to antibiotic resistance.
Rationale
The rationale for antibiotic use stems from the high bacterial load in the oral cavity and the risk of infection when fractures communicate with this environment. Infection rates without antibiotics can reach 25-50% in compound mandibular fractures, while appropriate antibiotic prophylaxis can reduce this to 5-10% 1.
Considerations
For non-operative management of simple, non-displaced fractures, a shorter 3-day course may be sufficient. It is essential to consider the potential risks of antibiotics, including allergies, the emergence of resistance, and clostridium difficile infections, as highlighted in the most recent guideline summary 1.
From the Research
Antibiotic Use in Mandible Fractures
- The literature suggests that the use of antibiotics in mandible fractures is a common practice, but the evidence supporting this practice is of poor quality 2.
- A study published in 2017 found that the time from initial injury to the first dose of antibiotic was important, with patients who waited more than 72 hours after the injury having a higher rate of postoperative infection 3.
- Another study published in 2018 found that the use of preoperative antibiotics between the time of injury and surgery had no impact on postoperative infection rates, and may even be associated with an increased incidence of postoperative infection 4.
- A review of the evidence published in 2022 suggested that prophylactic antibiotics may not be necessary for all patients with mandibular or non-mandibular facial fractures undergoing non-operative or operative procedures 5.
- A prospective randomized trial published in 2006 found no statistically significant difference in infection rates between patients who received postoperative antibiotics and those who did not 6.
Timing and Duration of Antibiotic Use
- The study published in 2017 found that patients who received their first dose of antibiotic within 8 hours of injury had a lower rate of postoperative infection compared to those who waited longer 3.
- The review published in 2022 suggested that a narrow-spectrum antibiotic such as cefazolin administered within 1 hour of surgery and no longer than 24 hours after surgery may be a logical choice for prophylaxis 5.
Quality of Evidence
- The systematic review published in 2011 found that the overall evidence to support the use of prophylactic antibiotics in mandible fractures is of poor quality, with most studies having methodological limitations 2.
- The review published in 2022 noted that the evidence supporting the use of prophylactic antibiotics in facial fractures is limited, and that large randomized controlled trials are needed to guide clinical practice 5.