Prophylactic antibiotics in head and neck free flap surgery: A novel protocol put to the test

ObjectiveRecent evidence supports the use of ampicillin-sulbactam as a favored choice for antibiotic prophylaxis following head and neck free flap reconstructive surgery. However, there is a paucity of evidence guiding the optimal duration of antibiotic prophylaxis. The aim of this study is to compare the infection rates of short courses of ampicillin-sulbactam versus extended courses of various antibiotics in head and neck free flap reconstructive surgery.MethodsThis is a retrospective cohort study conducted from 2012 to 2017 at a tertiary academic center on 266 consecutive patients undergoing head and neck surgery with free flap reconstruction. The primary outcome measure was the rate of any infection within 30 days of surgery.ResultsThere were 149 patients who received antibiotic prophylaxis for an extended duration of at least seven days. 117 patients received a short course of antibiotics defined as 24 h for non-radiated patients and 72 h for radiated patients. Postoperative infections occurred in 45.9% of patients, of which 92.6% occurred at surgical sites. There was no significant difference in terms of postoperative infection rate between patients receiving an extended duration of antibiotics versus a short duration (p = 0.80). This held true for subgroups of surgical site infections (p = 0.38) and distant infections (p = 0.59 for pneumonia and p = 0.76 for UTI). Risk factors for infections were identified as hypothyroidism (p = 0.047) and clean contaminated wound classification (p = 0.0002).ConclusionShorter duration of ampicillin-sulbactam prophylaxis in free flap reconstruction of head and neck defects does not negatively affect postoperative infection rates.Level of evidenceLevel 2b.     

The use of prophylactic antibiotics in head and neck oncological surgery

PURPOSE OF REVIEW: An overview of best evidence-based current practice in the use of prophylactic antibiotics in elective oncological head and neck surgery is presented. RECENT FINDINGS: Patients undergoing head and neck oncological surgery are at great risk of developing complications following surgery. The incidence of wound infection has been reported to be as high as 87%, often with devastating effects. Prophylactic antibiotics have helped to reduce significantly the risk of infection; however, clinicians managing these patients should also have a thorough understanding of the risk factors leading to postoperative infections and should apply the most basic surgical principles at all times, to minimize infection rates. SUMMARY: Prophylactic antibiotics usage in clean-contaminated major oncological head and neck surgery is mandatory to reduce the risk of infection. In clean major oncological head and neck surgery their use is also advisable but there is no evidence that in clean surgery for benign disease it offers any advantage. Short antibiotic regimes of four doses per 24 h are as effective as prolonged courses regardless of the complexity of the procedure. A combination of antibiotic agents covering aerobic, anaerobic and Gram-negative bacteria is superior to single agents. High-risk patients should be also given short regimes, as there is no evidence that prolonged courses are of more benefit in these patients. Methicillin-resistant Staphylococcus aureus infection can have devastating consequences for patients undergoing major head and neck surgery. Protocols of prevention and treatment should be in place in all institutions treating patients with head and neck cancer. Close collaboration between surgical, microbiology and infection-control teams is essential.     

Three-dose vs extended-course clindamycin prophylaxis for free-flap reconstruction of the head and neck

BACKGROUND: Twenty-four hours of perioperative antibiotics provides effective prophylaxis for most head and neck cancer resections. Many reconstructive surgeons have been hesitant to apply this standard to free-flap reconstruction of the head and neck. This prospective clinical trial compared short-course and long-course clindamycin prophylaxis for wound infection in patients with head and neck cancer undergoing free-flap reconstruction. METHODS: Seventy-four patients were randomized to receive short-course (3 doses) or long-course (15 doses) clindamycin perioperatively. Wound infections, fistulas, and other postoperative complications were documented by faculty surgeons who were blinded as to treatment group. RESULTS: The differences in wound infections and other complications were statistically insignificant. No other independent predictors of wound complications emerged in this series of patients. CONCLUSIONS: Short-course clindamycin is as effective as long-course clindamycin in preventing wound infections after free-flap surgery for head and neck ablative defects.     

Pulmonary complications in patients with head and neck and lung neoplasms

BACKGROUND: The occurrence of second primary neoplasms in patients with head and neck carcinoma assumes greater importance as our ability to control local disease improves. Both the primary lesions and the therapeutic interventions can predispose patients to pulmonary complications. OBJECTIVE: To explore the incidence of pulmonary complications in patients with head and neck cancer who also undergo lung surgery. DESIGN: Survey; case series. SETTING: A tertiary care university hospital. RESULTS: The clinic and hospital charts of 32 patients with multiple interventions of the head and neck and lung were retrospectively reviewed, and data were recorded on the clinical and pathologic specifics of primary and secondary neoplasms, pulmonary complications, and treatment outcomes. Twenty-eight (88%) of these patients underwent a diagnostic or therapeutic surgical procedure for a head and neck primary neoplasm. All patients (100%) underwent a pulmonary resection for malignant or nonmalignant pulmonary disease. Overall, 31 patients (97%) experienced either major or minor pulmonary complications after surgery, 51 (79%) of which occurred during the immediate postoperative course. Major complications occurred in 11 patients (34%), which were fatal in one. CONCLUSIONS: Our data suggest that patients with head and neck cancer who also experience a second pulmonary disease requiring lung resection are at high risk of developing serious pulmonary complications. These risks should be considered in planning optimal therapy.     

Pulmonary atelectasis after reconstruction with a rectus abdominis free tissue transfer

BACKGROUND: Atelectasis is one of the most common postoperative complications encountered in head and neck surgery. Risk factors include preexisting pulmonary disease, the procedure performed, and the length of anesthetic. Regional flaps used to reconstruct defects in the head and neck predispose to radiographic atelectasis. The rectus abdominis myocutaneous flap is usually transferred as a free tissue transfer. Harvesting the flap results in abdominal wall pain and postoperative splinting that may contribute to an increased development of atelectasis. To our knowledge, this issue has not been previously examined. DESIGN: Retrospective review. RESULTS: Fifty-three patients underwent rectus abdominis myocutaneous free flap reconstruction following major ablative procedures for head and neck cancer. The flap size ranged from 5 x 7 to 25 x 27 cm. Most flaps were 8 x 15 cm. The cutaneous area transferred ranged from 35 to 600 cm(2) (mean, 120 cm(2)). These patients were compared with a group of 53 patients who were matched for age, sex, length of the procedure, and stage of disease. Postoperative atelectasis was radiographically detected in 37 (70%) of the patients who underwent rectus abdominis myocutaneous free flap reconstruction vs 41 (77%) of the controls. Major atelectasis was not encountered in any patient in either group. Patients with a larger cutaneous paddle (>120 cm(2)) had a higher atelectasis score than patients with smaller cutaneous paddles (< or =120 cm(2)) (P =.02). CONCLUSIONS: The incidence of radiographic postoperative atelectasis in patients undergoing rectus abdominis myocutaneous free tissue transfer is high. The degree of atelectasis is small, and the clinical correlation and relevance are minimal.     

Risk factors of postoperative infection in head and neck surgery

Objectives

Patients undergoing head and neck oncological surgery are at great risk of developing complications following surgery. It is important to clarify risk factors contributing to operative wound infections.

Methods

Two hundred and nine cases with head and neck tumor (87 female, and 122 male, averaged 58.6 years old) were studied at Mie University Hospital within a 24-month interval, during 2002 and 2003.

Results

Twenty-one (10.0%) surgical site infections (SSIs) were recorded. Univariate analysis revealed that the following factors were significantly related to SSI: blood loss, previous chemotherapy, clean-contaminated surgery, tracheotomy, malignant tumor, advanced T-stage, flap reconstruction, and long operative time. Multivariate analysis showed that blood loss, previous chemotherapy, and the type of surgery contributed to SSI. Otherwise, the following factors did not show any significant correlations: age, body mass index, smoking, alcohol intake, diabetes, sex, previous radiotherapy, N-stage or ASA score.

Conclusions

In order to minimize postoperative wound infection, clinicians managing the head and neck tumor patients should have a thorough understanding of the risk factors leading to postoperative infections such as blood loss, previous chemotherapy, and clean-contaminated surgery.     

Role of prophylactic antibiotics in uncontaminated neck dissections

The use of perioperative prophylactic antibiotics in uncontaminated head and neck surgery remains controversial. We performed a retrospective analysis of 192 patients undergoing uncontaminated neck dissections from 1976 to 1989. Wound infection developed in 10% (10/99) of patients who did not receive antibiotics, while only three (3.3%) of 93 patients who received antibiotics developed infections. This difference was not statistically significant. We correlated the use of flaps, length of surgery, prior radiation treatment, and postoperative complications with rate of wound infection. The difference was not statistically significant for any of these variables. Our beta error was, however, greater than 0.2. Our data do not demonstrate efficacy of prophylactic antibiotics in uncontaminated neck dissections with statistical significance; however, a trend exists suggesting its possible value.     

Streptococcus milleri: an organism for head and neck infections and abscess

BACKGROUND: Streptococcus milleri, a commensal organism, has the potential to cause significant morbidity. There is a paucity of published data regarding this organism in the head and neck. OBJECTIVES: To identify and assess the presentation, treatment, and outcomes of pediatric patients affected by this pathogen. STUDY DESIGN: Review of the Department of Pathology database at Children's Hospital of Wisconsin, Milwaukee, between 1997 and 1999 identified 26 patients with cultures positive for S milleri group (SMG) bacteria. Retrospective chart analysis examined the demographic data, site of origin of infection, additional organisms cultured, symptoms, treatments, and complications. RESULTS: Sixteen patients had SMG infections involving the head and neck region. Sites of origin included the paranasal sinuses, dental, facial soft tissues, deep neck spaces, peritonsillar region, and a tracheostomy site. The paranasal sinuses were the most common site in 37% (6/16). Streptococcus milleri was the only isolate in 69% (11) of the infections. Significant local extension occurred in 56% (9/16) of the patients and included the orbit, skull base, cranium, and deep neck spaces. All patients had surgical drainage and 15 also received intravenous antibiotic treatment. One complication of osteomyelitis of the frontal bone occurred with resolution after surgical debridement and intravenous antibiotic treatment. CONCLUSIONS: Streptococcus milleri can be an aggressive pathogen in the head and neck with a propensity for abscess formation and local extension of the infection in a pediatric population. Surgical drainage with antibiotics is generally successful in management of the condition. However, emerging penicillin resistance and the ability for local extension require suspicion of incomplete treatment if clinical symptoms persist.     

Phrenic nerve paralysis following neck dissection

Summary One of the complications of neck dissection to control regional metastatic disease in cancer of the head and neck is phrenic nerve paralysis. The resulting elevation of the ipsilateral diaphragm can be diagnosed on a postoperative chest X-ray and confirmed by fluoroscopy. Symptoms can be respiratory, cardiac or gastrointestinal. In a retrospective study, unilateral phrenic nerve paralysis was observed in 14 (8%) of 176 consecutive neck dissections. None of the patients with postoperative phrenic nerve paralysis displayed severe symptoms, although a significantly higher number sustained atelectasis with or without pulmonary infiltrates to complicate the postoperative course.     

Nonwound infections following head and neck oncologic surgery

Little information exists regarding the comorbidity of postoperative nonwound infections (NWIs) in patients with head and neck cancer. Prospectively, 225 patients were randomized in a double-blind fashion to receive either clindamycin or ampicillin sodium/sulbactam sodium for prevention of postoperative wound infection. Of the 113 patients receiving clindamycin, 14 developed nonwound infections, compared with 10 of 112 patients receiving ampicillin/sulbactam. A single site of nonwound infection occurred in 21 patients, and 2 sites occurred in 3 patients. The majority of infections were pulmonary (22), followed by urinary tract (3), septic phlebitis (1), and acute sinusitis (1). Gram-negative organisms were isolated more frequently among patients on clindamycin (18) versus ampicillin/sulbactam (6) (P = .014). Risk factors for pulmonary nonwound infection included: longer surgery, a greater than 70 packs per year smoking history, blood transfusion, and hypoalbuminemia (P < .05). Nonwound infections produce significant postoperative morbidity and the predominance of gram-negative organisms isolated from these infections has therapeutic implications.     

Risk factors for postoperative complications in oral cancer and their prognostic implications.

BACKGROUND: The surgical treatment of head and neck cancer can be limited by the risk of postoperative complications. Early identification of risk factors based on clinical characteristics may assist therapeutic planning. OBJECTIVES: To identify risk factors for these complications and to evaluate their prognostic significance. METHODS: The medical records of 110 patients with oral squamous cell carcinoma admitted from January 1, 1990, to December 31, 1994, who underwent radical surgery were reviewed. Data collected included demographic information, comorbidities, extended clinical severity stage, treatment, complications, and survival. The chi(2) test was used to verify the association between the variables. Survival analysis was performed with the Kaplan-Meier method. Logistic and Cox proportional hazards regression were used to build models with independent predictive factors for the risk of complications and death, respectively. RESULTS: The overall complication rate was 50%. Dehiscence and infection rates were 20.9% and 22.7%, respectively. The death rate was 3.6%. Forty-seven patients (42.7%) were electively referred to the intensive care unit (ICU). The occurrence of postoperative complications was associated with extended clinical severity stage (P =.02), type of surgery (P =.03), ICU (P =.03), type of reconstruction (P =.02), Functional Severity Index (P =.03), neck dissection (P =.002), and APACHE II (Acute Physiology and Chronic Health Evaluation II) (P =.008). The number of complications was significantly correlated with the length of hospital stay (r = 0.24, P =.01) and with the Functional Severity Index (r = 0.19, P =.04). Five-year overall survival was affected by the type of complications (none, 41.7%; local, 34.1%; and local plus systemic, 0% [P<.001]), ICU (no, 46.3%; yes, 20.7% [P =.001]), and extended clinical severity stage (stage 1, 75.6%; stage 2, 50%; stage 3, 28.6%; and stage 4, 10.2% [P<.001]). In a multivariate analysis bilateral neck dissection (relative risk = 3.57, P =.01) and an APACHE II score greater than 10 (relative risk = 3.86, P =.02) were independent risk factors for complications. The predictive prognostic model consisted of the following: staying in the ICU (hazard ratio = 1.83), local plus systemic complications (hazard ratio = 6.27), and extended clinical severity stage (stage 3, hazard ratio = 3.57; stage 4, hazard ratio = 6.34). CONCLUSIONS: Bilateral neck dissection and the APACHE II score were identified as risk factors for postoperative complications in oral cancer, which also increase the length of hospital stay. The occurrence of systemic complications, advanced extended clinical severity stage, and staying in an ICU adversely affect the prognosis. Therefore, the prompt recognition of the adverse risk factors for postoperative complications may guide proactive interventions that may improve survival and achieve cost-effectiveness.     

Chest infection following head and neck surgery: a pilot study

This paper reports the results of a pilot study which examined factors associated with chest infection following head and neck surgery. The overall rate of chest infection was 11%, but was 20% in those patients having a tracheotomy. No infection developed in patients with an intact airway. Other factors which emerged as possibly important were the duration of surgery and heavy regular alcohol intake. We recommend that prophylactic antibiotics be continued for at least 48 h in patients requiring a tracheotomy as part of their head and neck surgery. This is against the trend of shorter antibiotic regimens recommended for prevention of wound infections.     

Local repair of persistent tracheocutaneous fistulas

Tracheocutaneous fistulas may persist after tracheostomy. Suture closure of the fistula may result in complications, including infection, wound dehiscence, and pneumomediastinum. We present a simplified and relatively safe technique to close persistent fistulas that may be performed under local anesthesia. A retrospective chart review was performed on 13 patients who were successfully treated, including 1 with incomplete closure that was successfully addressed by additional procedures. Our review included analysis of reported risk factors for persistence of tracheocutaneous fistulas: previous irradiation of the neck, an extended duration of cannulation, previous tracheostomies, obesity, and use of a Bjork flap or 4-flap epithelial-lined tracheostomy. All 13 patients in the study were found to have at least 1 of these risk factors.     

Postoperative complications after en bloc salvage surgery for head and neck cancer

OBJECTIVE: To analyze the frequency of and risk factors for postoperative complications after en bloc salvage surgery for head and neck cancer. DESIGN: Retrospective cohort study. SETTING: Patients were evaluated from February 7, 1990, to November 17, 1999, in a tertiary cancer center hospital. PATIENTS: Consecutive sample of 124 patients from the hospital database. Only patients with recurrent head and neck squamous cell carcinoma undergoing en bloc salvage resection were eligible for the study. MAIN OUTCOME MEASURES: We analyzed the frequency of and risk factors for complications after salvage surgery. RESULTS: The tumor location was the lip in 6 patients, oral cavity in 55, oropharynx in 31, larynx in 24, and hypopharynx in 8. Previous treatment was surgery alone in 20 patients, radiotherapy alone in 68, surgery and radiotherapy in 21, and radiotherapy and chemotherapy in 14. An additional patient received chemotherapy alone before salvage surgery. The clinical stage of the recurrent tumor was I or II in 23 patients and III or IV in 101 patients. Postoperative complications occurred in 66 patients (53.2%). Fifty-three patients (42.7%) had minor complications, and 23 patients (18.5%) had major ones. There were 4 postoperative deaths (3.2%). The major factor associated with the overall occurrence of postoperative complications was the clinical stage of the recurrent tumor (P =.02). The occurrence of minor complications correlated with the previously treated site, with complications occurring more often in patients undergoing locoregional vs local treatment (P =.04). Major complications were associated with the time between initial treatment and salvage surgery (P =.05). CONCLUSIONS: Salvage surgery can be performed with acceptable rates of postoperative complications. The clinical stage of the recurrent tumor and the previous site treated were the 2 major factors associated with the occurrence of postoperative complications.     

Factors predicting severe infections during chemotherapy in head and neck cancer patients

Conclusions: The head and neck cancer patients with more co-morbidities and those dependent on tube feeding are at a high risk of severe infections during chemotherapy. Therefore, prophylaxis with colony-stimulating factors and/or antibiotics should be considered for those patients. Objectives: To investigate the risk factors for severe infection during chemotherapy in head and neck cancer patients. Methods: A retrospective study was conducted of 129 patients with head and neck cancer who received taxane-based and platinum-based chemotherapy between 2008–2013. Logistic regression models were used to evaluate risk factors. Results: Febrile neutropenia occurred in 50 patients out of the 129 (39%), severe infections occurred in 24 patients (19%), and bacteremia in two patients (2%). In univariate analysis, low serum albumin levels and tube feeding were significantly associated with severe infections (p = 0.015 and < 0.001, respectively). In multivariate analysis, the odds ratios for a higher modified Charlson co-morbidity index and tube feeding were 2.80 and 9.74, respectively. These two were independent predictive factors for severe infections (p = 0.020 and 0.001, respectively).     

Pulmonary Atelectasis After Reconstruction With a Latissimus Dorsi Myocutaneous Flap

Atelectasis is the most common postoperative complication encountered in head and neck surgery. Risk factors include preexisting pulmonary disease, type of surgery performed, and the length of anesthetic. It is controversial whether reconstruction of defects with regional myogenous flaps predisposes to atelectasis. The latissimus dorsi myocutaneous flap requires the patient to be placed on his side for a period of time. Whether it is the position or the surgery that contributes to the development of atelectasis has not been examined. Eighteen patients underwent latissimus dorsi myocutaneous flap reconstruction following major ablative procedures for head and neck cancer. The cutaneous area transferred ranged from 70 to 225 cm² (mean, 128 cm²). The flap size ranged from 7 × 10 to 15 × 15 cm. The majority of flaps were 10 × 15 cm or greater. These patients were compared to 18 patients who did not undergo pedicled myocutaneous chest flap reconstruction. Patients were matched for age, sex, length of operation, site of primary, and stage of disease. Postoperative atelectasis was radiographically detected in 89% of flap patients vs. 79% of controls. Major atelectasis was encountered in 16% of patients undergoing flap surgery vs. 11% of patients in the control group. Patients with large cutaneous paddles on their flaps (>120 cm²) had significantly more atelectasis than patients with smaller cutaneous paddles (P<.05, chi-squared). The incidence of radiographic postoperative atelectasis in patients having a latissimus dorsi myocutaneous flap is high. The size of the skin paddle harvested as well as the position change may contribute to this.     

Short-term versus long-term antibiotic prophylaxis in cochlear implant surgery.

OBJECTIVE: The objective of this study to evaluate antibiotic prophylaxis options for cochlear implant surgery. Does long-term antibiotic prophylaxis have any advantage over a single perioperative dose in preventing postoperative infection? STUDY DESIGN: We conducted a retrospective case review. PATIENTS: A total of 292 adult and pediatric patients who underwent cochlear implantation during a 15-year period (1988-2003) were reviewed. MAIN OUTCOME MEASURE: Minor and major postoperative wound infections in first 4 weeks. RESULTS: There were four major and eight minor complication among 292 patients (complication rate 4.1%). The infection rate was higher in patients who had either C incision (11.1%) or extended endaural incision (7.5%) and in patients with a preexisting medical condition. The infection rate was also higher in patients who had long-term antibiotics (5.6% and 13% in the 5-d and 7-d regimes) compared with short-term (single-dose) group. CONCLUSION: Long-term antibiotic prophylaxis did not have any advantage over single perioperative dose. Predisposing medical conditions and extensive surgical incisions were associated with a greater severity of infections and higher risk of wound complications.     

Analysis of risk factors for postoperative pulmonary complications in head and neck surgery.

Preoperative pulmonary function tests (PFTs) are unproven in their predictive value for postoperative pulmonary complications. There is a lack of prospective outcome studies upon which to form an opinion, particularly regarding noncavitary surgery. Seventy-three head and neck surgery patients were prospectively evaluated with preoperative PFTs, arterial blood gas analysis (ABG), medical history, and physical examination. Age, anesthesia duration, forced expiratory volume in 1 second (FEV1), peak flow (PF), PaO2, Roizen class, and pack years of smoking were significantly correlated with postoperative pulmonary complications. As similar studies in head and neck surgery patients have not been previously taken, it is hoped that these results will serve as a basis for future endeavors.     

Clinical relevance of the Streptococcus milleri group in head and neck infections

Streptococcus constellatus, S. intermedius, and S. anginosus, the 3 species of the S. milleri group, form part of the normal flora commonly found in the mouth, throat, and gastrointestinal and genital tracts. This group has become known as an important pathogen in infections and abscesses, but data on the anatomical distribution of these species is lacking in relation to clinical significance. We obtained 275 strains of the S. milleri group from different departments at our hospital over the last 3 years, including 54 strains from dental surgery, 47 from internal medicine, 44 from otolaryngology (head and neck), 43 from surgery, 32 from gynecology, 17 from urology, 16 from dermatology, 11 from brain surgery, 6 from pediatrics, 3 from orthopedics, and 2 from opthalmology. The 44 strains from head and neck were found in 42 patients,--23 with primary infection and 19 with secondary infection induced by cancer treatments. The primary infection group included 4 deep neck abscesses, 1 peritonsillar abscess, 5 tonsillitis, 4 paranasal sinusitis, 3 congenital aural fistula infections, 2 dental infections, 2 paranasal sinus cysts, 1 supprative parotitis, and 1 postoperative wound infection. The secondary infection group included 7 postoperative wound infections, 3 postoperative pulmonary infections, 3 laryngitis and pharyngitis, 3 terminal pneumonias, and 3 infections of the local recurrence site. The S. milleri group was the only isolated organism in 13 cases (56.5%) of primary infection and in 5 (26.3%) of secondary infection. Among other organisms from the primary infection group, no so-called major pathogens were found. Antimicrobial susceptibility tests of the S. milleri group showed that 50% were resistant to CCL and 33% to CTM. ABPC, CPDX, and CFDN were also found to be less sensitive, although no resistant strains were detected. To adequately culture the S. milleri group, incubation in air containing carbon dioxide or in an anaerobic atmosphere is required, and differentiation of the 3 requires biochemical reactivity tests. Since not all facilities use identical techniques in routine bacteriological examination, a considerable number of the S. milleri group could be missed in unknown species of alpha-,beta-, and gamma-streptococci and culture-negative cases. With antibiotics now being used widely, normal flora such as the S. milleri group may have become an important pathogen in head and neck infections due to an imbalance between organisms and host defense.     

The role of topical antibiotic prophylaxis in patients undergoing contaminated head and neck surgery with flap reconstruction

OBJECTIVES/HYPOTHESIS: Patients undergoing contaminated head and neck surgery with flap reconstruction have wound infection rates of 20% to 25% with parenteral antibiotic prophylaxis. Studies suggest that perioperative antimicrobial mouthwash reduces oropharyngeal flora and may prevent wound infections. We hypothesized that the addition of topical antibiotics to a parenteral prophylactic regimen would reduce the incidence of wound infection in these high-risk patients. STUDY DESIGN: We performed a randomized, prospective clinical trial. METHODS: Patients received either 1) parenteral piperacillin/tazobactam (3.375 g every 6 hours for 48 h) or 2) parenteral piperacillin/tazobactam plus topical piperacillin/tazobactam administered as a mouthwash immediately before surgery and once a day for 2 days postoperatively, with piperacillin/tazobactam added to the intraoperative irrigation solution. The wounds of all patients were evaluated daily using predefined objective criteria. RESULTS: Sixty-two patients met inclusion criteria and were enrolled in the study. The overall wound infection rate was 8.1% (95% confidence interval [CI], 2.7%-17.8%). Two of 31 patients (6.4%) who received parenteral antibiotics alone developed a wound infection compared with 3 of 31 patients (9.7%) randomly assigned to receive topical plus parenteral antibiotics. This difference was not statistically significant (P = >.05). Infection rate was not associated with flap type (rotational vs. free tissue transfer), mandibular reconstruction, age, gender, tumor site, stage, surgical duration, or blood loss. CONCLUSIONS: These results suggest that piperacillin/tazobactam is a highly effective antibiotic for prevention of wound infection in patients undergoing flap reconstruction following contaminated head and neck surgery. However, the addition of topical piperacillin/tazobactam does not appear to enhance the prophylactic benefit of parenteral antibiotics alone.