Antibiotics for Facial Fractures

By Dr. Johannes Sobotta (Sobotta Atlas and Text-book of Human Anatomy 1909) [Public domain], via Wikimedia Commons

The issue

The orthopedic literature has shown strong evidence that open fractures are at risk for infectious complications (leading to osteomyelitis, deep space infections, and non-union of fractures), and supports the use of antibiotics for open fractures.  Theoretically, similar risks exist with facial fractures that extend into adjacent sinus and oral cavities, due to the bacterial flora within these spaces. 

The problem

Open facial fractures can theoretically lead to orbital cellulitis (from orbital fractures extending to the sinuses), osteomyelitis, superficial and deep space infections, and poor fracture healing.  However, antibiotic use can lead to unnecessary costs, antibiotic resistance, c. difficile infections, and allergic reactions. 

Prior evidence

Several studies have been performed, with varying results, regarding the efficacy of antibiotics as prophylaxis in facial fractures.  This variability may be partially due to the many types and severities of fractures that can occur in the face.  Additionally, studies have revealed that prescribing habits and recommendations by surgeons vary greatly.  I have referenced a review article by Mundinger from 2015 (1) that attempted to summarize the literature to this point. The main findings are that most mandibular fractures, since they are often open to the oral cavity, should receive antibiotics; but the evidence isn’t strong either way regarding the remainder of facial fractures.

Current guidelines

Given the relative lack of evidence, it should come as no surprise that there are no current guidelines (either in the plastic surgery, otolaryngology, trauma, or EM literature) regarding the use of antibiotics in facial fractures.  Guidelines are often institution-specific, but even then, vary from surgeon to surgeon.  Not surprisingly, almost every paper on this topic states that further research is needed.

Our maxillofacial surgery department’s stance

I discussed the issue with Drs. David Hom and Ryan Collar, who were kind enough to share their recommendations and preferences.  They both acknowledge the lack of evidence in the literature.  Fractures that communicate with open wounds of the skin (including nasal fractures) should always receive prophylactic antibiotics.  Mandibular fractures should also receive antibiotics, due to their communication with oral flora.  Antibiotics should be considered for orbital fractures that extend into the sinus cavities, especially the maxillary sinus.  When in doubt, they would rather we err on the side of caution and administer antibiotics. However, they are more than happy to talk about things on a case-by-case basis, especially given the lack of evidence.

Their antibiotic of choice is Augmentin for one week, but for penicillin-allergic patients, they opt for Clindamycin. 

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Bottom Line

Though the literature is mixed, Drs. Hom and Collar would suggest the following, but are happy to talk about things on a case-by-case basis, as every patient is different:

Give antibiotics for: 

• Facial fractures communicating with open wounds of the skin
• Mandibular fractures that extend into the oral cavity (including the dentoalveolar ridge)

Strongly consider antibiotics for:

• Orbital wall fractures with extension into the maxillary, ethmoid, or frontal sinus

Consider antibiotics for:

• Frontal sinus fractures
• Nasal bone fractures with mucosal disruption (leading to epistaxis)
• Orbital wall fractures that do not extend into the sinuses (lateral)

No need for antibiotics in isolated:

• Closed nasal fractures without septal mucosal disruption
• Closed zygomatic arch fractures
• Closed mandibular condyle fractures (since these typically do not communicate with the oral cavity)

Antibiotic of choice: Augmentin BID x 1 week, or Clindamycin for one week in those with penicillin allergies.

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References

1. Gerhard S. Mundinger, MD,1 Daniel E. Borsuk, MD, CM, MBA,2 Zachary Okhah, MD,3 Michael R. Christy, MD,1 Branko Bojovic, MD,1 Amir H. Dorafshar, MBChB,1 and  Eduardo D. Rodriguez, MD, DDS.  Antibiotics and facial fractures: evidence-based recommendations compared with experience-based practice. Craniomaxillofacial Trauma Reconstruction. 2015 Mar; 8(1):64-78. doi: 10.1055/s-0034-1378187. Epub 2014 Sep 17.