Surgical and remote site infections after reconstructive surgery of the head and neck: A risk factor analysis

Abstract

The aim of this study was to identify risk factors for surgical (SSI) and remote site (RSI) infections, pathogens and antibiotic resistances in patients after pedicled and free flap reconstruction in the head and neck area. SSI criteria implicated infections affecting superficial or deep tissue in the flap area with purulent discharge, fistula, abscess formation and local infections signs. RSI criteria were defined as infections remote from the surgical site presenting with systemic symptoms like fever, leucocytosis, increase in C-reactive protein, purulent tracheobronchial secretion or deterioration of blood gases. Focus adequate specimen sampling and aerobic and anaerobic incubation and cultivation was performed. Epidemiological data, factors directly related to surgery or reconstruction, perioperative antibiotic regimen, length of stay, autologous blood transfusion and microbiological aspects were retrospectively analysed in 157 patients. 10.8% of patients presented SSI, 12.7% RSI. Cultivated bacteria were sampled from flap sites, blood cultures, central catheters and sputum including mainly gram-negative bacteria (70.3%) being frequently resistant against penicillin (85%) and third generation cephalosporine derivates (48%). Autologous blood transfusion (p = 0.018) and perioperative clindamycin use (p = 0.002) were independent risk factors for overall (SSI and RSI combined) infections. Prior radiation (p = 0.05), autologous blood transfusion (p = 0.034) and perioperative clindamycin use (p = 0.004) were predictors for SSIs. ASA >2 (p = 0.05) was a risk factor for remote site infections and prolonged ICU stay (p = 0.002) was associated with overall infections, especially in irradiated patients. Efforts need to be made in improving patient blood management, antibiotic stewardship and accurate postoperative care to avoid postoperative infections after head and neck reconstructive surgery.

Introduction

Flap reconstruction after extensive ablative surgery in the head an neck area has been successfully established and extended over the last decades (Meier et al., 2019; Kainulainen et al., 2020). Despite further improvement there is, however, a wide field of factors that can create serious post-operative complications. Alongside pneumonia, surgical site infections (SSI) have up to 40% prevalence among the most common health-care associated infections and have a significant impact on the patient's morbidity and the health system (de Lissovoy et al., 2009; Magill et al., 2014; Abt et al., 2018; Ramos-Zayas et al., 2021). As head and neck surgery and patient clientele become more complex, it is important to identify and stratify variables that contribute to surgical and remote site infections and to develop strategies that support patients' convalescence in maxillofacial surgery (Cannonet al., 2017). Among others, extended operation times, high ASA scores and certain antibiotic regimens have been investigated for their influence on the development of surgical site infections in literature (Karakida et al., 2010; Kamizono et al., 2014; Goyal et al., 2017; Qiu et al., 2019). Nevertheless, exact mechanisms remain unclear. In this study the authors elaborate risk factors that may contribute to the development of postoperative infections. For this purpose, patient related data, as well as therapeutic procedures in patients who had undergone reconstructive flap surgery in the head and neck area were analysed. Pathogens were isolated from site of infection and antibiotic resistance patterns were identified.