Review of prophylactic prescribing of antibiotics during the management of fractured mandibles.

OBJECTIVES: To provide evidence based guidance on the optimum prophylactic antibiotic prescribing regimens in the treatment of fractured mandibles to protect against surgical site infections. MATERIAL AND METHODS: OVID and Pubmed databases were searched for articles published between 1946 and 2020. Inclusion criteria was for articles to be in English, involve adult patients aged 14 and over, and involve patients treated with oral or IV antibiotics preoperatively, perioperatively or postoperatively during treatment of open or closed fractures of the mandible. Exclusion criteria included infected fractures on presentation, immunocompromised patients, fractures resulting from gunshot and pathological fractures. RESULTS: A number of retrospective and prospective, randomised, double blind placebo-controlled trials were identified as suitable for inclusion. The age range within these trials was 14-77 years old. The numbers of patients contained within each trial ranged from 30 to 642. The most commonly prescribed antibiotics were penicillin, administered orally or intravenously. Duration of administration ranged from hospital admission to five days postoperatively. Analysis of these studies failed to demonstrate a statistical difference on the number of surgical site infections and the duration of antibiotic course. CONCLUSIONS: The available evidence reveals no statistical difference in infection rates whether antibiotics are prescribed pre, peri, or postoperatively. The duration of antibiotics therapy also appears not to be important. Current evidence does not support the recommendation of an optimum antibiotic prescribing regimen. Additional prospective studies looking at the duration and timing of antibiotics during the management of fractured mandibles are required to identify the optimum prescribing regimen.

Nationwide randomised trial evaluating elective neck dissection for early stage oral cancer (SEND study) with meta-analysis and concurrent real-world cohort.

BACKGROUND: Guidelines remain unclear over whether patients with early stage oral cancer without overt neck disease benefit from upfront elective neck dissection (END), particularly those with the smallest tumours. METHODS: We conducted a randomised trial of patients with stage T1/T2 N0 disease, who had their mouth tumour resected either with or without END. Data were also collected from a concurrent cohort of patients who had their preferred surgery. Endpoints included overall survival (OS) and disease-free survival (DFS). We conducted a meta-analysis of all six randomised trials. RESULTS: Two hundred fifty randomised and 346 observational cohort patients were studied (27 hospitals). Occult neck disease was found in 19.1% (T1) and 34.7% (T2) patients respectively. Five-year intention-to-treat hazard ratios (HR) were: OS HR = 0.71 (p = 0.18), and DFS HR = 0.66 (p = 0.04). Corresponding per-protocol results were: OS HR = 0.59 (p = 0.054), and DFS HR = 0.56 (p = 0.007). END was effective for small tumours. END patients experienced more facial/neck nerve damage; QoL was largely unaffected. The observational cohort supported the randomised findings. The meta-analysis produced HR OS 0.64 and DFS 0.54 (p < 0.001). CONCLUSION: SEND and the cumulative evidence show that within a generalisable setting oral cancer patients who have an upfront END have a lower risk of death/recurrence, even with small tumours. CLINICAL TRIAL REGISTRATION: NIHR UK Clinical Research Network database ID number: UKCRN 2069 (registered on 17/02/2006), ISCRTN number: 65018995, ClinicalTrials.gov Identifier: NCT00571883.