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British Journal of Oral and Maxillofacial Surgery 46 (2008) 107–109

Prophylactic antibiotics and surgery for primary clefts

A.G. Smyth a,∗ , G.J. Knepil b
a Clarendon Wing, Leeds General Infirmary, Belmont Grove, Leeds, West Yorkshire LS2 9NS, United Kingdom
b Leeds Dental Institute, Clarendon Way, Leeds, West Yorkshire, United Kingdom

Accepted 19 July 2007

Available online 29 September 2007

Abstract

There are currently no evidence-based guidelines about the use of antibiotic prophylaxis in repair of cleft lip and palate. After the designation
of regional cleft centres in the UK, a postal questionnaire was sent to cleft surgeons in 2004 to enquire about the use of routine antibiotic
prophylaxis for primary repair of cleft lip and palate. The results showed a lack of consensus and wide disparity among centres. The findings
show that there is a need for a random control clinical trial to establish national recommendations for the rational use of prophylactic antibiotics
in primary cleft surgery.
© 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Cleft lip; Cleft palate; Antibiotics; Prophylaxis

Introduction in 1994 that the use of preoperative swabs and prophylac-

Bacterial wound infection after repair of cleft lip and palate
is a recognised complication, which can result in systemic
toxicity for the infant, prolonged hospital stay, and break-
down of the wound. Subsequent morbidity may include
secondary haemorrhage, impaired appearance, palatal fistu-
las, poor speech, a need for further intervention, and impaired
facial growth. The pathogens implicated in such clinical
wound infections are often Staphylococcus aureus or a ␤-
haemolytic streptococcus, although other micro-organisms
are also important.1 Infants with cleft lip and palate are more
likely to have S. aureus in their saliva than those with no cleft.2
Although there is little evidence about the potential bene-
fits of prophylactic antibiotics, the consequences of a wound
infection can be devastating. Consequently, some surgeons
advocate their routine use during repair. The disadvantages
of widespread use are, however, well-known and include the
emergence of resistant strains of bacteria, hypersensitivity,
and cost to the health service.3–6 Das Gupta et al. reported
∗ Corresponding author at: Cleft Lip and Palate Service, A Floor, Claren-
don Wing, Leeds General Infirmary, Belmont Grove, Leeds, West Yorkshire
LS2 9NS, United Kingdom. Fax: +44 113 3925115.
E-mail address: alistair.smyth@leedsth.nhs.uk (A.G. Smyth).
tic antibiotics varied across the UK (Das Gupta et al. A two
centre study investigating the routine antibiotic prophylaxis
in primary cleft palate surgery. Paper presented at the win-
ter meeting of the British Association of Plastic Surgeons,
London, 1993). They also reported that the use of swabs or
prophylactic antibiotics, or both, made no difference to the
morbidity after repair, but unfortunately these results were
never published.
Method
A questionnaire was sent to 27 surgeons who were doing
primary cleft surgery in the UK and Ireland in 2004 after the
designation of regional centres as recommended in the CSAG
report.7 Their details were obtained from the special interest
group of the Craniofacial Society of Great Britain and Ireland.
The questionnaire was in two parts – repair of isolated cleft
lip and repair of isolated cleft palate. For each operation,
the surgeon’s preference for routine preoperative swabs or
antibiotic prophylaxis was established for a child who was
otherwise fit and well. Eighteen completed questionnaires
were returned (response rate 67%). All surgeons repaired the

0266-4356/$ – see front matter © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2007.07.207
108 A.G. Smyth, G.J. Knepil / British Journal of Oral and Maxillofacial Surgery 46 (2008) 107–109

lip at about 3 months of age and the palate between 6 and 9 Ten surgeons continued to give the antibiotic postoper-
months. atively, often a 5-day course. Eight surgeons did not use
antibiotics postoperatively and six relied on a single dose
given immediately preoperatively.
Results The most popular antibiotics were co-amoxiclav, phe-
noxymethylpenicillin, or flucloxacillin and ampicillin
Isolated cleft lip combined.

Ten surgeons always or often took nasal or throat swabs

before repair, whereas eight surgeons never or rarely did so. Discussion
Of those who always or often did, all did it fewer
than 4 weeks before the planned operation with most pre- Primary closure of cleft lip and palate is classified as a clean-
ferring within 2 weeks. If a swab grew a pathogen (S. contaminated operation, and wound infection is a recognised
aureus) none of the respondents would postpone the oper- risk. The risks are associated with the duration of operation,8
ation, but most would prescribe either a full course of an with primary cleft operations often requiring 1–2 h of operat-
appropriate antibiotic preoperatively or give a short course ing time. The consequences of surgical wound infection after
perioperatively. repair of cleft lip or palate can be devastating in both the
Most respondents (13/18) always used an antibiotic imme- short and the long term. A major wound infection after pri-
diately before repair of an isolated cleft lip (Table 1), but mary repair of a cleft is likely to require a further admission
half did not continue after the operation. The most popular for a secondary intervention; however, final outcomes such as
antibiotic was co-amoxiclav followed by flucloxacillin. speech and growth may also be compromised. Antibiotics are
likely to reduce the incidence of wound infection and compli-
cations, but this has never been clearly shown in randomised
Isolated cleft palate
clinical trials in repair of clefts.
The widespread use of antibiotics has disadvantages
The same 10 surgeons always or often took swabs before
including increasing rates of antibiotic resistance, and a dra-
repair of an isolated cleft palate, whereas 8 surgeons never or
matic increase in the number of cases of colitis caused by
rarely did so.
Clostridium difficile in the UK.3,9
Of those who took swabs preoperatively all did it fewer
Unfortunately, there are no current national guidelines
than 4 weeks before the operation, most preferring within 2
or recommendations for the appropriate and rational use of
weeks.
antibiotic prophylaxis in repair of clefts.
If a culture grew a pathogen (␤-haemolytic strepto-
The results of our survey show a lack of consen-
coccus) four would have postponed the operation to a
sus and considerable disparity among cleft centres in
later date. The remainder would proceed with the orig-
the UK about antibiotic prophylaxis for primary cleft
inal operation date and either provide a full course of
surgery.
appropriate antibiotic preoperatively or give a short course
The routine use of preoperative nose and throat swabs
perioperatively.
before repair seems irrational, as all the respondents who
Again, most surgeons (12/18) said that they always gave
usually used swabs made no changes to their clinical manage-
an antibiotic immediately before repairing a cleft palate, but
ment if the swabs grew a pathogen, and all these respondents
4 said that they would never use an antibiotic for surgical
routinely prescribed antibiotics regardless of the result in
prophylaxis before palatal surgery (Table 1).
all patients. As far as repair of a cleft palate was con-
cerned, although four surgeons would postpone repair if a
Table 1 pathogenic organism was reported in a preoperative swab,
Respondents who give antibiotics before or after operations, or both, for they still prescribed antibiotics to cover the subsequent pro-
isolated cleft lip or isolated cleft palate (n = 18)
cedure. Although supportive evidence is lacking, most of the
Isolated cleft lip Isolated cleft palate surgeons surveyed still used routine nose and throat swabs
Before preoperatively.
Always 13 12 Most cleft surgeons in the UK use an antibiotic for pro-
Depending on culture 2 2
Never 3 4
phylaxis during repair of a cleft lip. Four surgeons continue
this for 5 days although there is no supporting evidence of
After
additional benefit.
None 9 8
One dose 1 2 Unusually, a slightly higher proportion of surgeons would
Two doses 1 0 not use any form of antibiotic prophylaxis for repair of a
Three doses 3 2 cleft palate than for isolated repair of a cleft lip, and although
Five days 4 6 nearly half would not use any antibiotic prophylaxis after-
Seven days 0 0
wards, a third would continue to give it for 5 days.
 A.G. Smyth, G.J. Knepil / British Journal of Oral and Maxillofacial Surgery 46 (2008) 107–109
References
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INTERESTING CASE: Photographic documentation with a mobile phone
camera
We recently received a complaint from a patient who insisted that she had been
photographed with a mobile phone camera. She had had severe soft tissue injuries
to the face examined in the accident and emergency department by the max-
illofacial senior house officer. He denied the accusation but it is possible that
someone may have taken a photograph, or the patient believed that one had been
taken.
She made an official complaint, and was particularly concerned that such
images could be shown or texted to people who were unrelated to the profession,
thereby causing a breach of confidentiality.
The incident has indicated a potential “grey area”. The technology is readily
available, but its application in a medical setting has yet to be defined.
109
5.Adkinson Jr NF. Risk factors for drug allergy. J Allergy Clin Immunol
1984;74:567–72.
6.Cook RJ, Sackett DL. The number needed to treat: a clinically useful
measure of treatment effect. BMJ 1995;310:452–4.
7.Clinical Standards Advisory Group Report. Cleft lip and palate. London:
HMSO; 1998.
8.Culver DH, Horan TC, Gaynes RP, Eykyn SJ, et al. Surgical wound
infection rates by wound class, operative procedure and patient risk
index. National Nosocomial Infections Surveillance System. Am J Med
1991;91(Suppl. 3B):152–7.
9.Wilcox MH, Smyth ET. Incidence and impact of Clostridium difficile
infection in the UK, 1993–1996. J Hosp Infect 1998;39:181–7.
We have advised all doctors in our maxillofacial department that
photographic documentation for medicolegal purposes should always
be arranged by the medical illustration department after appropriate
consent has been arranged. Out-of-hours we recommend that a Polaroid, con-
ventional film, or digital camera is used after written consent has been obtained.
Christian J. Siegmund
Jason Niamat
Christopher M. Avery