Antibiotic prophylaxis in head and neck oncologic surgery: the role of gram-negative coverage

Many studies have elucidated the risk factors associated with peri-operative infection following head and neck cancer surgery (HNS), the implications of infection for total treatment cost, and the clinical benefits of successful antimicrobial prophylaxis. The most appropriate antibiotic use is achieved by focusing on patients with clean, contaminated wounds. Thereafter, the usefulness of an antibiotic agent depends on its antimicrobial spectrum, tolerability profile, and cost. Successful antimicrobial prophylaxis requires antimicrobial activity against gram-positive, gram-negative, and anaerobic organisms. The beta-lactam/beta-lactamase inhibitor combination, sulbactam-ampicillin, has just such an antimicrobial spectrum. A double-blind, randomized clinical trial, involving patients undergoing HNS, recorded a lower post-operative infection rate among patients receiving peri-operative sulbactam-ampicillin 0.5 g/1.0 g i.v. q6h compared with those receiving clindamycin 600 mg i.v. q6h (13.3 vs. 27.1%; P = 0.02). Culture of strains from infected individuals indicated a significantly lower proportion of gram-negative organisms for sulbactam-ampicillin than for clindamycin (32 vs. 81%; P < 0.05). There was a significant difference in the median duration of surgery between infected and non-infected individuals (8.5 vs. 5.9 h; P < 0.0001). These data support the use of sulbactam-ampicillin to reduce the incidence of post-operative infection following HNS.