ANNALS OF IBADAN POSTGRADUATE MEDICINE
O.A. Olawoye1,2; A.I. Michael1,2 and A. Olusanya3
Clefts of the primary and secondary palate represent one of the commonest congenital anomaly for which surgical correction is required. The perioperative care of the patients varies widely across centers and among surgeons and range from preoperative swab of palatal clefts for microbiological studies to prophylactic and or therapeutic antibiotic care. These practices have economic implications especially in the Low and Middle Income Countries (LMIC) where the cost of care are borne directly by the parents. The clinical implications of indiscriminate antibiotic use may also include development of resistant strains and hypersensitivity reactions which may be life threatening. Surgical site infections and its possible sequelae of dehiscence and fistulae is another concern for the surgeon and the patient.
This review examines the microbiological pathogens, surgeon’s perspectives as well as the current evidences for the use of perioperative antibiotic therapy in orofacial cleft surgery and concludes with a need for a large multicenter randomized clinical trial to answer critical aspects of the subject.
Keywords: Cleft lip and palate, Orofacial clefts, Antibiotic in cleft surgery
Dr. O.A. Olawoye
Department of Surgery,
College of Medicine,
University of Ibadan and
Department of Plastic, Reconstructive
and Aesthetic Surgery
University College Hospital, Ibadan
The oral cavity and nasopharynx of children with unrepaired cleft lip and palate are recognized to be at an increased risk of colonization by bacterial pathogens. Significant interest has been generated among clinicians about the role of infections in the development of complications following cleft surgery in these patients. A causal relationship has long been established between infection and failure of surgical repair1-3.
Several publications on children with clefts have identified oral flora of microorganisms pre-operatively and the association of post-operative complications with pathogenic organisms found in the perioperative period4-7. These complications can result in systemic infection for the child, secondary heamorrhage, wound dehiscence, palatal fistulae with resultant prolonged hospital stay. Subsequent morbidities may include poor speech, impaired appearance and impaired facial development8. Hupkens et al.9 reported a strong association between preoperative cultures especially of Group A Streptococcus and Staphylococcus aureus and postoperative palatal dehiscence. Previous studies have also confirmed that patients with orofacial clefts are at increased risk for the development of caries and periodontal diseases compared to noncleft children10,11.
Primary closure of cleft lip and palate is classified as a clean contaminated operation, and wound infection is a recognized risk. The risks are associated with the duration of operation especially with primary cleft operations often requiring 1–2 h of operating time.12 The consequences of surgical wound infection after repair of cleft lip or palate can be devastating in both the short and the long term. A major wound infection after primary repair of a cleft anomaly is likely to require a further admission for a secondary intervention; however, final outcomes such as speech and growth may also be compromised.
Antibiotics are likely to reduce the incidence of wound infection and complications, but this has never been clearly shown in randomized clinical trials in repair of clefts8. Despite the beneficial effects of antibiotics, its widespread use may result in increasing rates of antibiotic resistance in addition to increased cost of care especially for families making out of pocket payment for their children’s care13. This can constitute additional burden on such parents. Unfortunately, there is currently no global, regional or national guidelines for the rational use of antibiotic prophylaxis in repair of orofacial clefts.
This review seeks to evaluate the arguments for or against the use of peri-operative antibiotics therapy for CLP surgeries based on available literature and draw conclusions that could guide rational choice by surgeons and other practitioners.
Bacteremia in Cleft and Oral Surgeries
Several studies have documented significant bacteremia following cleft lip and palate and intraoral surgeries14-19. These procedures were diverse and ranged from cleft lip and palate (CLP) surgeries, tooth extraction and removal of osteosynthesis plates, third molar surgeries and some maxillofacial procedures. Previous assertions have been that bacteremia associated with oral surgeries in healthy individuals is transient without significant sequel20,21. However, a recent study has documented bacteremia following cleft lip and palate surgeries persisting for up to 15 minutes in 53% of the patients19. The bacteremia in this group of patients was also higher than those for oral procedures such as orthodontic procedures and root scaling. The implication of the finding is that cleft-related surgery could be harmful in patients at risk, especially those with associated cardiac anomalies. Factors that were associated with development of bacteremia in patients with CLP anomaly included age less than 62.3 months and the male gender (59.4%), although these factors were not statistically significant. On the relationship between bacteremia and the specific type of surgery, the authors found that the prevalence of bacteremia in cleft lip surgery was 40.9%, whereas the incidence in cleft palate surgery was 33.3%. A prevalence of 50% was recorded for alveoloplasty. No reason was proposed for these differences. It was also found that bacteremia associated with CLP surgeries in the study was polymicrobial, similar to findings from several other studies that reported polymicrobial bacteraemia following other dental procedures14,16,18,22. These organisms in the oral cavity can gain access into the blood stream during these procedures23-25.