Development of surgical site infections (SSI) after vascularized reconstruction of the upper aerodigestive tract (UADT) can lead to significant morbidity including prolonged hospital length of stay, impaired wound healing, as well as, worsened aesthetic and functional outcomes. The variability of perioperative prophylaxis practices between institutions, particularly pre- and intraoperative topical antisepsis, and their association with SSI incidence is unknown.
To assess the association between perioperative topical antisepsis and SSIs in patients undergoing vascularized reconstruction of the UADT
DESIGN: Prospective observational cohort
INCLUSION CRITERIA: Patients undergoing open surgical procedures requiring a communication between the upper aerodigestive tract and cervical skin with either a regional pedicled and/or free flap. Patients had to demonstrate no evidence of active infection at the time of surgical procedure.
MAIN MEASURES AND OUTCOMES: The primary outcome measure was SSI within 30 days of head and neck surgery. The association of demographics, perioperative antibiotic prophylaxis, surgical details, and post-operative care factors with SSIs was assessed using univariable and multivariable logistic regression models.
RESULTS: 554 patients who fulfilled inclusion criteria from 7/1/2020 to 6/1/2021 were included from twelve academic medical centers. The number of patients included per center ranged from 13 to 91. The median age was 64 years (range 21-95 years). Overall SSI rate was 20% (n=116), varying between centers from 6.0% to 42.9%. Most infections involved the head and neck surgical site only (n=91, 78.4%). The mean time to SSI diagnosis was 11 days (range 1-28 days). Topical mucosal antisepsis was performed in 35% (n=195) of cases preoperatively. Most frequently with povidone-iodine alone (n= 99, 17.9%), followed by chlorhexidine alone (n=47, 8.5%) and both povidone-iodine and chlorhexidine (n=47, 8.5%). Postoperatively, 52% (n=289) of cases performed topical mucosal antisepsis. Intraoperative antiseptic irrigations were performed in 11% (n=61) of cases. Systemic antibiotic prophylaxis choices and duration varied, the most common choice was ampicillin/sulbactam (n=367, 66.2%) followed by piperacillin/tazobactam (n=83, 15.0%) with the most common duration being 24 hours (n=363, 65.5%) followed by 48 hours (n=97, 17.5%). The oral cavity was the most frequently involved head and neck subsite (n=394, 71.1%) followed by the larynx (n=71, 12.8%). While indications for the surgical procedures varied, cancer ablation was the most frequent (n=480, 86.6%). On multivariable analysis preoperative topical mucosal prep was associated with a decreased risk of postoperative SSI (OR 0.55; 95% CI 0.34- 0.88). Other factors associated with a decreased risk of postoperative SSI on multivariable analysis included antibiotic prophylaxis with piperacillin/tazobactam (OR 0.42; 95% CI 0.20- 0.85), use of a soft tissue only vascularized flap (OR 0.45; 95% CI 0.29- 0.74), and use of greater than 24 hours of prophylactic antibiotics (OR 0.57; 95% CI 0.35-0.95).
CONCLUSION: While perioperative practices varied between academic centers performing vascularized flap reconstruction of UADT defects, pre-operative topical mucosal preparation was significantly associated with decreased SSI in a 12-center multi-institutional prospective cohort. Further investigation of the impact of individual perioperative practices on the incidence of post-operative SSIs is necessary to develop evidence-based protocols to reduce SSIs after UADT reconstruction.