Prophylactic antibiotics and surgery for primary clefts

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Abstract

There are currently no evidence-based guidelines about the use of antibiotic prophylaxis in repair of cleft lip and palate. After the designation of regional cleft centres in the UK, a postal questionnaire was sent to cleft surgeons in 2004 to enquire about the use of routine antibiotic prophylaxis for primary repair of cleft lip and palate. The results showed a lack of consensus and wide disparity among centres. The findings show that there is a need for a random control clinical trial to establish national recommendations for the rational use of prophylactic antibiotics in primary cleft surgery.

Introduction

Bacterial wound infection after repair of cleft lip and palate is a recognised complication, which can result in systemic toxicity for the infant, prolonged hospital stay, and breakdown of the wound. Subsequent morbidity may include secondary haemorrhage, impaired appearance, palatal fistulas, poor speech, a need for further intervention, and impaired facial growth. The pathogens implicated in such clinical wound infections are often Staphylococcus aureus or a β-haemolytic streptococcus, although other micro-organisms are also important.1 Infants with cleft lip and palate are more likely to have S. aureus in their saliva than those with no cleft.2 Although there is little evidence about the potential benefits of prophylactic antibiotics, the consequences of a wound infection can be devastating. Consequently, some surgeons advocate their routine use during repair. The disadvantages of widespread use are, however, well-known and include the emergence of resistant strains of bacteria, hypersensitivity, and cost to the health service.3, 4, 5, 6 Das Gupta et al. reported in 1994 that the use of preoperative swabs and prophylactic antibiotics varied across the UK (Das Gupta et al. A two centre study investigating the routine antibiotic prophylaxis in primary cleft palate surgery. Paper presented at the winter meeting of the British Association of Plastic Surgeons, London, 1993). They also reported that the use of swabs or prophylactic antibiotics, or both, made no difference to the morbidity after repair, but unfortunately these results were never published.

Section snippets

Method

A questionnaire was sent to 27 surgeons who were doing primary cleft surgery in the UK and Ireland in 2004 after the designation of regional centres as recommended in the CSAG report.7 Their details were obtained from the special interest group of the Craniofacial Society of Great Britain and Ireland. The questionnaire was in two parts – repair of isolated cleft lip and repair of isolated cleft palate. For each operation, the surgeon's preference for routine preoperative swabs or antibiotic

Isolated cleft lip

Ten surgeons always or often took nasal or throat swabs before repair, whereas eight surgeons never or rarely did so.

Of those who always or often did, all did it fewer than 4 weeks before the planned operation with most preferring within 2 weeks. If a swab grew a pathogen (S. aureus) none of the respondents would postpone the operation, but most would prescribe either a full course of an appropriate antibiotic preoperatively or give a short course perioperatively.

Most respondents (13/18) always

Discussion

Primary closure of cleft lip and palate is classified as a clean-contaminated operation, and wound infection is a recognised risk. The risks are associated with the duration of operation,8 with primary cleft operations often requiring 1–2 h of operating time. 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 is likely to require a further admission for a

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