Assessing the Gap: Surgical Infection Society Guidelines Versus Real-World Antibiotic Agent Use in Facial Fractures

Facial fractures account for over 400,000 emergency department visits annually in the United States. They are managed operatively, non-operatively, or via observation with diet and activity modification. Regardless of management, antibiotic agents are commonly prescribed. The Surgical Infection Society (SIS) published the 2020 guidelines limiting antibiotic agent use to the peri-operative period.

We performed a retrospective chart review to evaluate antibiotic agent prescribing practices for patients with isolated facial fractures at an academic level-one trauma center. We assessed potential antibiotic agent days saved by adhering to SIS guidelines. Patients 18 and older presenting to the trauma service with a facial fracture from January 2019 to August 2024 were identified from the trauma registry. Patients with clear antibiotic agent indications (e.g., open fractures) were excluded. Descriptive and chi-square analyses were used.

The number of potentially saved antibiotic agent days was 495. Of 119 patients, 89.1% received antibiotic agents, 57.6% at least twice. A total of 80.2% of antibiotic agents given were against SIS recommendations. The antibiotic agent administration rate for mandibular fractures was 97%. Operative management accounted for 93.2% of cases. Antibiotic agent use did not significantly differ between operative and non-operative management (p = 0.18) or between open and closed operative cases (p = 0.99). In operative cases, appropriate peri-operative antibiotic agents were used 89.9% of the time, with 47.5% pre-operative and 63.6% post-operative non-guideline use. Segmented logistic regression showed no statistically significant reduction in non-guideline antibiotic agent use after the guidelines were published. The 30-day post-operative surgical site infection rate was 3.4%, with no significant difference between guideline and non-guideline use.

There is substantial discordance between real-world antibiotic agent prescribing practices and SIS guideline recommendations for facial fractures. Quantifying excess non-guideline antibiotic agent use highlights an important opportunity for antimicrobial agent stewardship and provides a foundation for future quality improvement initiatives.