Antibiotic prophylaxis to prevent surgical site infection after jaw surgery with a focus on the Iraqi clinical context

Abstract

Background: Surgical site infections are among the most frequent and costly complications of maxillofacial surgery, including orthognathic surgery and the management of mandibular and midface fractures. Although routine preoperative antibiotic prophylaxis is widely used to prevent these complications, the specific protocol varies and remains controversial. In settings such as Iraq, where antibiotic resistance is growing and prescribing is often inconsistent, this issue becomes more complex. Objective: To summarize the available evidence on the efficacy, regimen, and duration of antibiotic prophylaxis in maxillofacial surgery, and to analyze this evidence in light of the realities of antibiotic prescribing and resistance in Iraq. Methods: A comprehensive literature search was conducted across PubMed/MEDLINE, Scopus, Embase, the Cochrane Library, Web of Science, and Google Scholar to identify systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and cross-sectional surveys, primarily published between 2018 and 2026, with earlier seminal studies consulted where appropriate. Eligible studies addressed antibiotic prophylaxis in orthognathic surgery, mandibular fracture fixation, or maxillofacial injuries, or described antibiotic prescribing and resistance patterns in oral and maxillofacial infections, with a particular focus on Iraqi and regional data. Results: Forty-two studies met the inclusion criteria. A single intravenous dose of a beta-lactam antibiotic preoperatively (usually amoxicillin–clavulanate or cefazolin, with clindamycin as an alternative for patients with penicillin allergy) appears sufficient for most orthognathic procedures, with no proven benefit from prolonged postoperative use. In mandibular fracture surgery, perioperative prophylaxis is strongly recommended, whereas prolonged postoperative use beyond 24–72 hours does not appear to reduce surgical site infection rates and may contribute to increased selective pressure for resistance. Iraqi data present a strikingly contradictory picture: maxillofacial infection isolates exhibit resistance rates ranging from 57.6% to 65.8% (penicillin 65.8%, tetracycline 61.3%, gentamicin 58.1%, ampicillin 57.6%), while surveys of Iraqi dentists and trainees document inconsistent and often guideline-contradictory prescribing of broad-spectrum antibiotics and prolonged courses. Conclusion: Global evidence supports short-acting, narrow-spectrum antibiotics for most maxillofacial surgeries; however, their application in the Iraqi context is challenged by high antibiotic resistance and inconsistent prescribing. There is a pressing need for a localized, culturally appropriate, and well-governed antibiotic protocol based on single-dose or short-term perioperative regimens, regular local antibiogram monitoring, and structured prescriber training.