Orbital trauma : Antibiotic prophylaxis needs to be given only in certain circumstances

Editor—In their lesson of the week Shuttleworth et al suggest that all patients with fractures involving the orbit should receive prophylactic antibiotics.1 These fractures are largely managed in maxillofacial surgery units, and the prescription of prophylactic antibiotics for all such cases is not routine.2 At least 500 patients with periorbital fractures are seen in our units in a year. Many more patients with undisplaced fractures of the periorbital region do not present to any medical practitioner, the fractures being self diagnosed as a bad black eye. In the past 25 years we have seen only two cases of orbital cellulitis following nose blowing after orbital fracture. This would give a maximum incidence of 1:6250. The true incidence will be lower. Our practice is to give prophylactic antibiotics in only four circumstances: for fractures compound to skin; when surgical emphysema is present; when open reduction and internal fixation is performed; and in orbital grafting. Patients having conservative treatment or closed or indirect reductions of periorbital fractures are not prescribed antibiotics. The overuse of antibiotics has implications for adverse effects in individual patients and increasing antimicrobial resistance within the community. Orbital cellulitis is serious but rare. The possible gains to the individual of antibiotic prophylaxis must be balanced against the potential losses, both to the individual and to the community. We believe that it is difficult to justify the routine prescription of prophylactic antibiotics but would agree that patients with diagnosed or suspected periorbital fractures should be advised about nose blowing and seeking help if signs of infection develop.