ก penicillin g ˙˝ amoxicillin and clavulanic acid ... · 4 abstract title : the comparison of...

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1 ก Penicillin G Amoxicillin and clavulanic acid ( Cavumox) กกก clean-contaminated The comparison of Penicillin G and Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated wound in head and neck cancer surgery at Rajavithi hospital กกกกก กกก ก ก 2551

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Page 1: ก Penicillin G ˙˝ Amoxicillin and clavulanic acid ... · 4 Abstract Title : The comparison of Penicillin G and Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated

1

ก���������������� ��������� Penicillin G �� Amoxicillin and clavulanic acid ( Cavumox) ()ก���*��ก+)ก��,�-�./0�����1�12�,+-.)�-

clean-contaminated ()156�78�9��:�;��<���=�>� �?@����������.8�A�

The comparison of Penicillin G and Amoxicillin and

clavulanic acid( Cavumox) prophylactic in clean-contaminated wound in head and neck cancer

surgery at Rajavithi hospital

���

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� # 4�+ $� � �ก��� #������� �-�5$�ก� 1 2551

Page 2: ก Penicillin G ˙˝ Amoxicillin and clavulanic acid ... · 4 Abstract Title : The comparison of Penicillin G and Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated

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Page 3: ก Penicillin G ˙˝ Amoxicillin and clavulanic acid ... · 4 Abstract Title : The comparison of Penicillin G and Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated

3

�>+-�2� ��/?�� : ก�������"����)3�"@��������� Penicillin G !�) Amoxicillin and clavulanic acid ( Cavumox) -�ก��Q��ก�ก�.� �52�����!�����. 5�� clean-contaminated -��4��S �,)�T�&�()!�)�%��� "�#���������5 �6� 1568�N+� : !�"��0��� ������ �ก � ��! �

�)=� : !,� ��ก�-0����U�5� �)ก���ก����. �)5� �� �.�ก�.� �52��!�����. 5�� clean-contaminated -��4��S �,)�T�&�()!�)�%���!.�กT,��)� T�� !��� ���)-5����U�5� �)- "�#�0,�)3,"�#3/ 8+,AP����>Q : ��2#�������"����)3�"@���� )0 ����� Penicillin G ก�Amoxicillin and clavulanic acid ( Cavumox) -�ก��Q��ก�ก�.� �52��!�����. -��4��S �,)�T�"�#&�()!�)�%��� �5������8� �ก��;Rก<� : ����ก�&'ก(�!�� experimental study-��4��S ����. ,)�T�"�#&�()!�)�%��� 126 �� � �� ��2�ก!��3/�,-0�$ �� Amoxicillin and clavulanic acid (Cavumox) 02� Penicillin G � �-0���ก������. ½ - 1 5# �,�!�).����2#������ 24 5# �,� 1�ก��;Rก<� : ��กก�&'ก(��� ��,��.�ก�.� �52��!�����. "��0, 7.1%( 9/126) -�ก�/�,�4��S �"�#$ �� Penicillin G,��.�ก�.� �52��!�����. 9.2% (6/65 )!�) 4.9% (3/62) -�ก�/�,�4��S �"�#$ �� Amoxicillin and clavulanic acid c'#�!.ก.��������$,�,���3%���"��36�.� ��P� : ��กก�&'ก(��52#� ���)3�"@������� Penicillin G !�) Amoxicillin and clavulanic acid $,�,�� �,!.ก.���ก��,2#��%�,�-5�-�ก�� ��/,ก�.� �52��-�ก��Q��ก�ก�.� �52�����!�����. 5�� clean-contaminated -��4��S �,)�T�&�()!�)�%��� >=��=�>+S : Penicillin G, Amoxicillin and clavulanic acid ( Cavumox) ,!��.� �52�� , ก����. 5�� clean-contaminated,,)�T�&�()!�)�%���

Page 4: ก Penicillin G ˙˝ Amoxicillin and clavulanic acid ... · 4 Abstract Title : The comparison of Penicillin G and Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated

4

Abstract Title : The comparison of Penicillin G and Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated wound in head and neck cancer surgery at Rajavithi hospital Name of researcher : Wilaporn Phakdeedindan Background : Although appropriate perioperative antibiotic prophylaxis has significantly reduced wound infection rates in clean-contaminated head and neck surgical procedures, controversy remains regarding the optimal antibiotic regimen Objectives : To compare efficiency of Penicillin G and efficiency of Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated wound in head and neck cancer surgery Materials and method :Experimental study, clinical trial,126 patients undergoing head and neck procedures involving clean-contaminated wound were randomized to receive Penicillin G or Amoxicillin and clavulanate intravenously up to ½-1 hour before surgery tills to 24 hours Results : An overall wound infection rate of 7.1%( 9/126) was observed. Six (9.2%) infections occurred in the Penicillin G group and 3(4.9%) in the Amoxicillin and clavulanic group, which was not statiscally significant . Conclusion : Penicillin G and Amoxicillin and clavulanic group seem to have similar efficacy when administered prophylactically in clean-contaminated head and neck surgical procedures Keywords : Penicillin G, Amoxicillin and clavulanic acid ( Cavumox) ,infected wound , clean-contaminated surgery , head and neck cancer

Page 5: ก Penicillin G ˙˝ Amoxicillin and clavulanic acid ... · 4 Abstract Title : The comparison of Penicillin G and Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated

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Page 7: ก Penicillin G ˙˝ Amoxicillin and clavulanic acid ... · 4 Abstract Title : The comparison of Penicillin G and Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated

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0�กก�!�)�0./��

ก�.� �52��!�����. ,)�T�"�#&�()!�)�%�����������4�$ ��2#��r c'#��/�.�ก���ก�.� �52��!�����. ��กก�"�#$ � review ���),�� 3.5 u 87%[1] "�#����,�ก�-0� ���U�5� �)ก���ก����. 5� �� �/�.�ก��� ก�.� �52����$ � [1,2,3,4 �52��"�#����3��0./���ก�.� �52�����!�����. "�#&�()!�)�%��� $ �!ก� Gram-positive aerobes �5�� S. aureus, S. epidermidis, streptococcus species , Corynebacterium Gram-negative aerobes �5�� H. influenzae, Neisseria, Moraxella species, Enterobacter aerogens, Escherichia coli, Klebsiella pneumoniae !�) Pseudomonas aeruginosa Anaerobic bacteria �5�� Bacteroides , Fusobacterium !�) Peptostreptococus species[1,5,7,8,9] . ��"�#-5�-�ก��Q��ก�,�0���5�� �5�� Cefazolin, Cefotaxim, Ampicillin plus Clindamycin, Amoxicillin and clavulonic acid (Cavamox)[5,6,9,10]

-��7 2551���������5 �6� ���/�.�ก��� ก�.� �52��!�����. ,)�T�"�#&�()!�)�%��� ���� 19.80% ,�ก�'����ก �/�.�ก���-��7 2550 (16.66%) � ��� ��ก�-5����U�5� �)3� �-0�����"�� �.�5 �6�-��7 2550 ก�-5����U�5� �)3� �-0��)���� Penicillin G .��-��72551,�ก��%� Amoxicillin and clavulanic acid (Cavumox),�-5�� ,ก� Penicillin G ,�ก�'�� � �)�)� ��-�ก�-0���-��4��S �!.��)��กT�),�� �,!.ก.���ก� �����-0�.��!.�ก���"%�ก����. �),�� ½ - 1 5# �,� ��6'�0�����. .��!.� 1 u 7 � �'��ก�5�� ���!�����.

-�ก� ������ �)"%�ก�������"����)3�"@����-�ก��Q��ก�ก�.� �52�����!�����. )0 ����� Amoxicillin and clavulanic acid( Cavumox) !�) Penicillin G

��กก�&'ก(����Juan P Rodrigo !�) ��)[5] �� �� Amoxicillin and clavulanic acid c'#����� board spectrum antibiotic �����/,"���52�� Gram-positive aerobes, Gram-negative aerobes, anaerobe 3�,�6�Q��ก�ก�.� �52�����!�����. $ � � �-0���ก������. ½ 5# �,�!�)-0�.��"/ก 8 5# �,����� 3 dose c'#��.�ก�.� �52��� ����4�"�# 22.8%c'#�3� �����ก�ก�&'ก(� Neven !�) ��)[6],��.�ก�.� �52��� ����4�"�# 21%

3� � Penicillin G �����/,�52�� Gram-positive aerobes ( �>��) streptococcus species),anaerobe( �>��) Peptostreptococus species ) !.�$,������/, Gram-negative [10,11,12]

��"��3��5�� ��,�� �,!.ก.���-�ก�-0���.�� � "���%�� ����!�)� �,6�#� � Amoxicillin and clavulonic acid (Cavumox) �)-0� 3 ���.�� � 3� � Penicillin G �)-0� 6 ���

Page 8: ก Penicillin G ˙˝ Amoxicillin and clavulanic acid ... · 4 Abstract Title : The comparison of Penicillin G and Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated

8

.�� � !�)���-5������ � ,กT.���ก� � � Amoxicillin and clavulonic acid( Cavumox) = 438.75 ��", Penicillin G = 152.5 ��" 0�ก��ก� ����� ����"�� 2 5�� ,��)3�"@����-�ก��Q��ก�ก�.� �52�����!�����. ,)�T�"�#&�()!�)�%���$,�.���ก� กT3�,�6��2�ก Penicillin G ,�-5�-�ก��Q��ก�ก�.� �52�����!�����. ��2#�5� ��)0� ���-5����������������$ �

/2 �2 ก��/� *

Penicillin G �������U�5� �)-�ก�/�, natural penicillin ,�s"@�������/,�52�� Streptococcus "/ก

species �52�� N.meningitis �52��!��"����$,��'#���กc�����%�� ก Peptococcus,

Peptospectococcus,Furobacterium !�) Clostridium spp. �52#��2#�r$ �!ก� Treponema

pallidum,Leptospira spp.,Streptobacillus !�) Spirillum

Penicillin G ���,-5�-�4�!����>� ��2#����ก��$,�"�ก -�ก)���)��0� ��� "�#-5� 43,000-300,000 units/kg/day !���-0�"/ก 4 5# �,� ��� .#%�3%�0��52��ก�/�, aerobe !�).� �52��$,�/�!� ��� 34�3%�0��52��"�#$,�'#���ก�&!�).� �52��/�!� PGS,�ก�ก)�������34���2����2#���ก�c���$ � � ��������34� CSF $ �����!�),�ก���"�����ก CSF !�� active Penicillin G 64ก��"���"��$. ,�)�)�'#�5� �.�'#�5# �,� c'#��)�� ��ก$�����3��5# �,�-��4��S �"�#$.�3��,�ก Penicillin G "%�-0��ก� ก�!��$ �,�ก ����ก� ก�!��$ �"�� 4 !���2� anaphylaxis , serum sickness ,�,T ��2� ! �!.ก (Coomb positive),contact dermatitis ��ก��ก�������)�ก� �U�ก����$,��'��)3���$ � �5�� neutrophil .#%� 02�,�ก�5ก ��2#����กก�-5������ 34�,�ก Amoxycillin Clavulanic acid

�������U�5� �)-�ก�/�, betalactams-batalactamase inhibitors ,�s"@��3�,�6.������$c,�"�#ก%�ก� � ����3,� $ �!ก� penicillinase ��ก�52��!��"����!ก,� ก !�)!��"����!ก,�� ���$c,�5�� broadspectrum c'#�$ �!ก�ก�/�, TEM-1 TEM-2 !�) SHV-1 ��ก!��"����ก�/�, Enterobacteriaceae !�)��.���"�� enzyme ก�/�,-0,��2� extended-spectrum betalactamase ��ก � � �)ก�3/ "������,�� �,3%��������,�ก �����$กT.�, Amoxycillin Clavulanic acid $,�,�� �,.���"��.�� cephalosporinase ���

Amoxycillin Clavulanic acid ��ก��ก 4 c',$ � �-�"��� ����0� ��3�,�6-0���0���� �ก�>� $ � � � ก��3, Clavulanic acid ก� Amoxycillin $,�����,����ก ������35���&�3.�!ก�ก�!�)ก� ,�����'#�5� �.-�ก�ก%�� ����ก���3,��),�� 0.9-1.15# �,� Clavulanic acid ��ก���.��-����3,��$ �.#%� ��64ก����#��3���$ ��),���'#�0�'#� ,���4�

Page 9: ก Penicillin G ˙˝ Amoxicillin and clavulanic acid ... · 4 Abstract Title : The comparison of Penicillin G and Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated

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!��� �,64ก��"��.�!�)�� ����-���33� )$ � 50% ������ "�#$ �� c'#���ก���"���"�����,�ก-� 6 5# �,�!ก probenecid $,��ก �ก�����

�U�ก����$,��'��)3�������� �5�� ��2#�$3� ������� �/���)�0� �/���)� � �2#��'�� .� �52���-�5������ ����� �� ) �c��� 02�.��ก�3�$ �

>=�)���9@�>,�-�./0��1�12�,+-,�9���;5)�Qก���ก��>8�>P9���*��ก+)@�> (centers for disease control and prevention) ������;�Z�+\��9��ก� �.;. 2531 �)ก�� � � 1. incisional surgical wound infection �2� ��.� �52����� ���!�����. c'#��ก� �'�����-� 30 � 0�����. !�)����ก�.� �52��"�#�� 0�� 5��-.��� 0�� 02�ก���,��2��"�#��4��0�2�5�����2 � ,ก����- ���0�'#� �.��$���� 1.1,�0���.�.%�!0���"�#"%�ก����. 02���ก��ก5����2����2#�"�#��4��0�2�5�����2 1.2!�ก�52����$ ���ก����0� "�#��ก,���ก!��c'#�� �,�� �!�� 1.3&��!�"��. 3��-���� !��!,� ��ก����)�52���)-0����� 1.4&��!�"��02�!�"���4� 4!��4��S �-0�ก� ����>� ��,�ก�.� �52���ก� �'�� 2. deep surgical wound infection �2� ก�.� �52��"�#�ก� .�.%�!0���"�#���. ���-� 30 � 0�����. -�ก��"�#$,�,�ก���4ก6��� (implantation) 02����-� 1 �7 -�ก��"�#,�ก���4ก6���3�#�!��ก���, �5�� ����0 -��"��, !�)ก�.� �52��,�� �,3,��@�ก�ก����. !�)�ก� �'��ก���2����2#�02�5���-.�5�����2 � ,ก����- ���0�'#� �.��$���� 2.1,�0���-.�5�����2 2.2 !��!�ก��� 02�64ก��� � �&��!�"�� -�ก���4��S �,�$��,�กก �� 38 ��&��c��c��3 !�),���ก�� �>��)"�#02�ก ��T���� ����. !,���ก����)�52��-0����� 2.3 ,�*70��� 02�0�ก����2#�"�#�����ก ��,�ก�.� �52�� c'#���)0 ���ก�. �ก����. 02�� �ก�. �"�� ���@� �"�� 2.4&��!�"��-0�ก� ����>� ��,�ก�.� �52���ก� �'��

Page 10: ก Penicillin G ˙˝ Amoxicillin and clavulanic acid ... · 4 Abstract Title : The comparison of Penicillin G and Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated

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�&�)��)�5�ก �$!ก% � ��%&������ก���! �

� ��%&������'� ก ��2#�������"����)3�"@���� )0 ����� Penicillin G ก�Amoxicillin and clavulonic acid ( Cavumox) -�ก��Q��ก�ก�.� �52��!�����. -��4��S �,)�T�"�#&�()!�)�%���

� ��%&���������

���"�$!ก% �B�������"�+ C��"*�<�+ �ก ��ก��<�+��1������< +��

����(�ก���! �

����ก �$!ก% �)) experimental study

���.��!�)ก� %�����ก� ���

1. �กT����,4�"�#.'ก�4��S �-� !��ก0�� ���� �3. &� ��3�ก ���������5 �6� .��!.�

,ก��, 2551-@� ��, 2552 2. � ��2�ก�4��S �.�, Inclusion !�) Exclusion Criteria �.��$����

Inclusion criteria 1. �4��S �"�#����,)�T�"�#&�()!�)�%���5�� squamous cell carcinoma !�) $ ��

ก����. 2. 5�� ���!������!�� clean u contaminated ( defined as sterile initially, but

mucosal barrier was crossed or a potentially infected anatomical cavity was entered during the operation

3. ���/ ≥ 18 �7 Exclusion criteria

1. �4��S �"�#$ ��ก�>��!3�,�ก��� 2. �4��S �"�#$ ��ก����. c��,!c, � � flap "��5�� local !�) distant

Page 11: ก Penicillin G ˙˝ Amoxicillin and clavulanic acid ... · 4 Abstract Title : The comparison of Penicillin G and Amoxicillin and clavulanic acid( Cavumox) prophylactic in clean-contaminated

11

3. �4��S �"�#���� recurrent cancer 4. �4��S �"�#,� ,)�T�5�� �2#�r� , � � 5. �4��S �"�#������. ,)�T�"�#&�()!�)�%���,�ก��� 6. �4��S �"�#!��.�� Penicillin G 02� Amoxicillin and clavulonic acid (Cavumox)

3. ��"'ก���,4�����4��S ��4����� ,���ก���-�!�����,��� ��� � ���"'ก���,4��4��S �!.��)�� �.��$���� ��& ���/ �) .����)�%�. �s.�ก,ก�34��/0�#!�)ก� 2#,3/� ���) �� �,���,��������2� ,) ���.�����4,��,.%�!0���,)�T�!�))�)���,)�T�

4. �4� ���3/�,!�ก�4��S �����3��ก�/�, �2� ก�/�, penicillin G !�)amoxicillin clavulanic acid 5. �3���������!�)0��4��S ��3. &� ��3�ก -0����U�5� �)-�ก�/�, �ก��� ���-��'#�-

0�'#�5# �,�ก���ก����. )0 ���ก����. !�).����2#������ 24 5# �,� � � �@�ก�-0���"��3��5�� .���ก� ���� 5.1 Penicillin G

-Penicillin G 5 mu v ½ - 1 hr. ก���ก����. -Penicillin G 3 mu v q 4 hr. × 6 dose 5.2 amoxicillin clavulanic acid

-amoxicillin clavulanic acid 1.2 g v ½ - 1 hr. ก���ก����. -amoxicillin -clavulanic acid 1.2 g v q 8 hr. × 3 dose

6. �)�,���ก ���!��(Brand et al.,1982)!�)��"'ก�ก(�)!��"/ก � ��)0�'#����

.� .��ก���T �� �!�"���)�%�����, ������0��4��S ��3. &� ��3�ก 0�ก�� ��!��,��ก(�)�ก 4 �'��$��)62� ������!��.� �52��0��ก����. �)"%�ก����)�52����ก!�� !�)����#��ก�/�,���U�5� �).�,�� sensitivity

,�����?1 !3 �ก��)�,��5�� ���!��.� �52�� (Brand et al., 1982)

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12

ยาปฏิชีวนะ จํานวนประชากรรวม อัตราการติดเช้ือ อัตราการไมติดเช้ือ p value

Penicillin G 65 (51.59%) 6 (7.1%) 59(90.81%) 0.494

amoxicillin-clavulanate 62 ( 49.2%) 3 (4.9%) 58(95.1%)

7. ��ก����%����,4���กก�&'ก(�,� ����)0���2#�������"����)3�"@��������� !�)�)�,��������3�#��-�ก��ก� !��.� �52�� � �-5���!ก, SPSS version11.0 1( Chi Square test -x2 test !�) Fisher �s Exact test ) � ���� P < 0.05 �)62� ��,���3%���"��36�.�

��ก�&'ก(�

��กก�&'ก(��4��S �"�#���. ,)�T�&�()!�)�%���!�)$,�,�ก�c��,!c,0�����. � �ก�-5���2����2#����������02���2����2#���ก3� ��2#�������ก�����&4���ก�!�"���>��)"���3. &� ��3�ก ���������5 �6� .��!.� 1 ,ก��, 51 6'� u 31 @� ��, 52 �%�� � 126 �� $ �!����4��S ���ก���� 2 ก�/�,� � �@�3/�,��2�ก �2� ก�/�,"�#$ ���� Penicilln G 65 �� !�) ก�/�,"�#$ ���� Amoxicilin-clavulanate 61 �� ,��4��S �"��0, 9 �� ( 7.1%) ,�ก�.� �52��"�#!�����. 0��ก����. ,�ก�.� �52��"�#!�����. 0��ก����. -�ก�/�,"�#$ ���� Penicilln G 6 (9.2%) �� !�) 3 (4.9%) �� -�ก�/�,"�#$ ���� Amoxicilin-clavulanate ( .���"�# 2 )!3 �-0��0T� ��ก�$ �����U�5� �)!.��)5�� $,�,���.���.�ก�.� �52��!.������- ( p= 0.494 )

,�����? 2 !3 ���������U�5� �)!.��)5�� .���.�ก�.� �52��

�)5�ก-�ก�/�,. ����� ������&5�� 106 �� ( 84.1%) ��&0��� 20 �� (15.9%) ,����/��4�-�5� �30-80 �7 � �,�ก�)��4����/-�5� � 30-80 �7 ,��) .��������)�%�. �5�� �����0 �� 17 �� (13.5%) ��6/��,��S���� 11 �� (8.7%) ���2#�r 12 �� (9.5%) !�)$,�,����)�%�. 86 �� (68.3 %) ) ���.�����4,��-�ก)!3��2� ,�กก ��3.8 ,��%�� �108 ��(85.7%) ,�) �� �,���,�����2� "�#,�กก �� 13 mg/dl 94 �� (74.6%) 34��/0�# 99 ��(78.57%) 2#,3/� 101��(80.16%)( .���"�# 3 ) �� �� ��& ,���/ ,���)�%�. , ) ���.�����4,��-�ก)!3��2� ) �� �,���,�����2� ,ก�34��/0�#!�)ก� 2#,3/�$,�,���.���.�ก�.� �52��!.������- ( p > 0.05)

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13

,�����? 3 !3 �� �,3,��@� )0 ������������4��S � ก� �.�ก�.� �52�� �����"�� ���. ���,)�T��� �� �.�ก�.� �52��"�#!�����. ,�� �,3,��@�ก�.%�!0������,)�T� �����,���3%���"��36�.� ( P =0.01 ) c'#�.%�!0������,)�T�"�#oral cavity !�) oropharynx ��,�ก"�#3/ !.�.%�!0������,)�T�"�# Hypopharynx ,��.�ก�.� �52��"�#!�����. ,�ก"�#3/ 4�� (44.4%)( .���"�# 4 )

,�����? 4 !3 �� �,3,��@�)0 ��� .%�!0������,)�T�!�)�.�ก�.� �52��"�#!�����.

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14

ชนิดของการผาตัด จํานวนประชากรรวม อัตราการติดเช้ือ อัตราการไมติดเช้ือ P value

wide excision 14 (11.1%) 0(0%) 14 (12%) 0.255

hemiglossectomy 24 (19.0%) 0(0%) 24 (20.5%)

maxillectomy 6 (4.8%) 0(0%) 6 (5.1%)

mandibulectomy 7 (5.6%) 1 (11.1%) 6 (5.1%)

larynxectomy 75(59.5%) 8 (86.9%) 67 (57.3%)

ก�"�#,)�T�!��ก)���$���.��,��%��0�2��(N stage) ,�� �,3,��@�ก��.�ก�.� �52��"�#

!�����. �����,���3%���"��36�.� ( P =0.044 ) � ��� ���4��S �"�#,�ก�.� �52��"�#!�����. !�),�,)�T�!��ก)���$���.��,��%��0�2�� (N stage) 66.7% ,�,�กก ���4��S �"�#$,�,�ก�.� �52��"�#!�����. !�),�,)�T�!��ก)���$���.��,��%��0�2��(N stage)33.3%��� ���,)�T�(T stage))�)"�#3�,!�)3�#��,�กก ��91��(72.2%)!�),��.�ก�.� �52��"�#!�����. ,�ก"�#3/ 100%[9/9]�5��� �� ก�,)�T�)�)"�#3�,!�)3�# ��,�ก3/ 81 �� (64.3%) !�),��.�ก�.� �52��"�#!�����. ,�ก"�#3/ 100%[9/9] !.��� ����� ���,)�T�(T stage)!�))�)���,)�T�$,�,�� �,3,��@�ก��.�ก�.� �52��"�#!�����.

(P >0.05 )

,�����? 5 !3 �� �,3,��@�)0 ��� )�)���,)�T�!�)�.�ก�.� �52��"�#!�����.

�����"�� ���ก����. �� ��ก����. Total Laryngectomy ��,�ก3/ 75 ��

(59.5%)!�),��.�ก�.� �52��"�#!�����. ,�ก"�#3/ 88.9%[8/9]c'#�5�� ���ก����. $,�,�� �,3,��@�ก��.�ก�.� �52��"�#!�����. (P =0.336 ) ( .���"�# 6 )

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15

Group operation time(minute) P value

infection 286 ± 90 0.34

non-infection 248 ± 119

Group admit time(day) P value

infection 28 ± 10.6 0.002

non-infection 11.86 ± 4.4

,�����? 6 !3 �� �,3,��@�)0 ��� ��� ���ก����. !�)�.�ก�.� �52��"�#!�����.

)�)� ���>��#�-�ก����. -��4��S �"�#,�ก�.� �52��"�#!�����. 286 + 90 ��"�

������"���ก�)�)� ���>��#�-�ก����. -��4��S �"�#$,�,�ก�.� �52��"�#!�����. 248 + 119 ��"� �� �� )�)� ��-�ก����. $,�,�� �,3,��@�ก��.�ก�.� �52��"�#!�����. (p= 0.211 ) ( .���"�# 7)

,�����? 7 !3 �� �,3,��@�)�)� ��-�ก����. ก��.�ก�.� �52��

)�)� ���>��#�-�ก����ก(�������������4��S �"��0, 12.9 + 6.4 � c'#� )�)� ���>��#�-�ก����ก(���������-��4��S �"�#,�ก�.� �52��"�#!�����. 0��ก����. 28 + 10.6 � ������"���ก�)�)� ���>��#�-�ก����ก(�-��4��S �"�#$,�,�ก�.� �52��"�#!�����. 0��ก����. 11.86 +4.4 �c'#��� ��)�)� ��-�ก����ก(���������,�� �,� �,3,��@�ก��.�ก�.� �52��"�#!�����. (p=0.001) ( .���"�# 8)

,�����? 8 !3 �� �,3,��@�)�)� ���>��#�-�ก����ก(���������ก��.�ก�.� �52�� �,2#�!�ก�52��!��"������ก0���"�#����� �!�����. "�#.� �52��0��ก����. $ � 6 �52��

� �,��4��S � 4 ��!�ก�52��!��"����$ ����) 1 �52�� ,��4��S � 4 ��!�ก�52��!��"����$ ����) 2 �52��,��4��S � 1 ��!�ก�52��!��"����$ ����) 3�52�� Gram negative aerobe ��,�ก"�#3/ (12/15[80%] ) !�)�� Gram positive aerobe ( 3/15[20%] ) �� ��!�ก�52�� Gram negative

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16

organism penicillin G amoxicillin-clavulanate

acrobes

Gram-positive

corynebacterium sp. 1 0

streptococcus virridans 2 0

Gram-negative

Acinobacter sp. 0 1

Enterobacter cloacao 0 2

Klebsiella pneumoniae 3 0

Pseudomonas aeroginosa 5 1

aerobe $ �����ก ��-��4��S �"�#$ � penicillin G [6case]�,2#��"���ก��4��S �"�#$ � Amoxicilin-clavulanate (Cavumox) [3 case]

,�����? 9 !3 �!��"����"�#!�ก$ ���ก!��.� �52��

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17

��������

-�ก�&'ก(��������� ����ก�4��S ��%�� � 126 �� ,��.�ก�.� �52��!�����. 9.2% c'#�����ก ���������กก� ����2#�r � � �5�� de Melo !�)��)[13] �����$ �"�# 22.7%, -��7Panel N !�)��)[14] �����$ �"�# 45 %

��กก�&'ก(������ �� �.�ก�.� �52��!�����. -�ก�/�,"�#$ ���� Penicilln G 6 (9.2%) 34�ก �� -�ก�/�,"�#$ ���� Amoxicilin-clavulanate3 (4.9%) �� !.�$,�,���3%���"��36�.� c'#�!3 �-0��0T� �� !,� �� Penicillin G �),�s"@�������/,�52�� Gram-positive aerobes ( �>��) streptococcus species),anaerobe( �>��) Peptostreptococus species ) !.�$,�,�s"@�������/, Gram-negative c'#�������"���ก�ก�Amoxicillin and clavulanic acid (cavumox)c'#����� board spectrum antibiotic �����/,"���52�� Gram-positive aerobes, Gram-negative aerobes, anaerobe !.� Penicillin G กT��,��)3�"@����-�ก��Q��ก�ก�.� �52��!�����. �"����"��ก� Amoxicillin and clavulanic acid (cavumox) !�) ��กก����)�52����ก!��.� �52������4��S �-���� �������� �� �52��3� �-0������ Gram negative �5�� Acinetobacter sp. ,Enterobacter clocae, !�) Pseudomonas aeroginosa c'#�6'�!,� Amoxicillin and clavulanic acid (cavumox) ���� board spectrum antibiotic !.�กT$,�,�s"@��.���!��"���� �ก��� �'��������3��0./"%�-0��ก� ก�.� �52��$ �[11,12]

-��71992 Weber RS !�) ��)[18]$ �&'ก(� �2#��� �,�%�����������U�5� �)"�#��/,�52��gram negative $ ����52�� Enterobacter clocae !�) Pseudomonas aeroginosa �5��ก�

-�ก�&'ก(����$,���!��"����-�ก�/�, Anaerobe c'#�!.ก.�����ก��� ����2#�r[6,9,15,16] ����������)�%�� ��)5�ก. ���������,��%�� ����� !�) �"����-�ก�!�ก�52�� Anaerobe ก)"%�$ ���ก ���,�� �,�� ��� -�ก�!�ก�52��$ � �,2#�������������2#�r����4��S �"�#,���.���.�ก�.� �52�� �� ����& ,���/ ,���)�%�. ) ���.�����4,��-�ก)!3��2� ) �� �,���,�����2� ,ก�34��/0�#!�)ก� 2#,3/�$,�,���.���.�ก�.� �52��!.������- c'#�3� �����ก��������� Shih-An!�)��)[17] �����$ � �� ��&,���/, �� )���0 �� ) �� �,���,�����2� ,) ���.��-�ก)!3��2� ก���ก����. $,�,���.��ก�.� �52��"�#!��0�����. c'#�!.ก.�����ก�������� Ali Sepehr !�)��)[18] "�#$ ������$ � �� ) ���.�����4,��-�ก)!3��2� ,���.���.�ก�.� �52��,!�).�����ก�������� Carlos Jorge Lotfi !�)��)[19] "�#�����$ � �� ก�34��/0�# ,���.��ก�.� �52��"�#!��0�����. ,"��$,�3� �����ก� Juan P. Rodrigo !�)��)[5] "�#�����$ � �� ��

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18

�)�%�. ����4��S � �5�� �����0 �� !�)��6/��,��S����,�� �,3,��@�ก�ก�.� �52��"�#!��0�����. � �,!.ก.����������ก� ��ก�)5�ก-�ก�/�,"�#&'ก(�,������ก��$� -�ก�&'ก(��� ��.%�!0������,)�T�,�� �,3,��@������,���3%���"��36�.�ก��.�ก�.� �52��"�#!�����. � ��� ��.%�!0������,)�T�"�# Hypopharynx ,��.�ก�.� �52��"�#!�����. ,�ก"�#3/ (44.4%) ��,��2� supraglottic (33.3%) 3� � oral cavity and oropharynx !�) glottic ,��.�ก�.� �52��"�#!�����. �"��ก� (11.1%) c'#�3� �����ก������ ��� Neven !�)��) [6] !�)Juan P. Rodrigo !�)��)[5] -�ก�&'ก(������ ���.�ก�.� �52��"�#!�����. ,�!� ���,���#,�'��.�,��� ���,)�T�(Tstage) !�) )�)���,)�T� (Clinical stage) !.�$,�,���3%���"��36�.� 3� �)�)"�#,)�T�!��ก)���$���.��,��%��0�2�� (Nstage) ,�� �,3,��@�ก��.�ก�.� �52��"�#!�����. �����,���3%���"��36�.� c'#�3� ���������� Carlos Jorge Lotfi !�)��)[19] "�#�� �� ��� ���,)�T�!�) )�)���,)�T� )�)"�#,)�T�!��ก)���$���.��,��%��0�2�� ,�� �,3,��@�ก��.�ก�.� �52��"�#!�����. 3� �"�#ก�&'ก(������ �� ��� ���,)�T� !�) )�)���,)�T�!.�$,�,���3%���"��36�.� �����2#����ก�%�� ��)5�ก"�#�����ก��$�

-�ก� ����� ��,�ก����. 5�� Total Laryngectomy ,�ก"�#3/ !�),��.�ก�.� �52��"�#!�����. ,�ก"�#3/ c'#�3� �����ก���� ������ Juan P. Rodrigo !�)��)[5] 3� �)�)� ���>��#�-�ก����. -��4��S �"�#,�ก�.� �52��"�#!�����. 286 + 90 ��"� ������"���ก�)�)� ���>��#�-�ก����. -��4��S �"�#$,�,�ก�.� �52��"�#!�����. 248 + 119 ��"� �� �� )�)� ��-�ก����. $,�,�� �,3,��@�ก��.�ก�.� �52��"�#!�����. !.ก.�����กก�&'ก(�-��7 1992 � � Weber RS!�)��)[15] c'#������ ���.�ก�.� �52��"�#!�����. ���#,�'��3,��@�ก�)�)� ��-�ก����. "�#��� �����2#����ก��� ������ Weber RS !�)��) -5�� ��-�ก����. ,�กก ��(�>��#� 510 ��"�) ก����. -�ก�&'ก(����

�� ��)�)� ��-�ก����ก(���������,�� �,� �,3,��@�ก��.�ก�.� �52��"�#!�����. � �)�)� ���>��#�-�ก����ก(���������-��4��S �"�#,�ก�.� �52��"�#!�����. 0��ก����. �>��#� 28 + 10.6 � ������"���ก�)�)� ���>��#�-�ก����ก(�-��4��S �"�#$,�,�ก�.� �52��"�#!�����. 0��ก����. 11.86 +4.4 � c'#�3� �����ก���� ������ Johnson JT!�)��)[9] c'#��� ��)�)� ��-�ก����ก(���������,�� �,� �,3,��@�ก��.�ก�.� �52��"�#!�����. �5��ก� ��ก��ก��� "%�ก� ��������� �%�ก �����-�!��ก!��ก �3. &� ��3�ก ���������5 �6�"�#� �� �"����� !�)"%�-�ก�/�,�)5�ก����� 126 �� 0�ก,�ก�&'ก(�-�36��"�#"�#.�����ก$�02����#,�)5�ก�%�� �,�ก�'�����-0���ก� ���"�#!.ก.���$���ก��� � �

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19

��-�<�ก �$!ก%

��กก�&'ก(��52#� ���)3�"@������� Penicillin G !�) Amoxicillin and clavulanic

acid (cavumox) $,�,�� �,!.ก.���ก��,2#��%�,�-5�-�ก�� ��/,ก�.� �52��-�ก�"%�&��ก,&�()!�)�� "�����0�ก,�ก�&'ก(�"�#,��%�� ��)5�ก���#,�'�� 02�"%� ���-�36��"�#"�#.�����ก$� ���-0���ก� ���"�#!.ก.���$���ก��� � �

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20

���[�)Pก�9 1. Ricard S., Gary F. : The use of prophylactic antibiotics in head and neck oncological surgery. Current Opinion in Otolaryngology & Head and Neck Surgery 2006; 14:55 - 61. 2. Anne white.: Improving compliance with prophylactic antibiotic administration guidelines. AORN journal 2007;85:1-10 3. Dor P , Klastersky J.: Prophylactic antibiotics in oral,pharyngeal and laryngeal surgery for cancer : a double blind study. Laryngoscope 1973;75:387-394 4. Johnson JT, Myers EN, Sigler BA, Thearle PB, Schramm VL.: Antimicrobial prophylaxis for contaminated head and neck surgery. Laryngoscope 1984;94:46-51 5. Juan PR., Juan CA., Justo RG. : Comparision of three prophylactic antibiotic regimen in clean-contaminated head and neck surgery. Head Neck 1997;19: 188-193. 6. Neven S., Miro M., Darko M. :Antibiotic prophylaxis in clean-contaminated head and neck oncological surgery. Journal of Cranio-Maxillofacial Surgery 2007;35:15-20. 7. Carey PP. ,John MAB., Raymond F, Alberd TM.,Joseph SS., Dietmar HW.: Antimicrobial ProphylaxisFor surgical wounds: Guidelines for Clinical Care. Arch Surg. 1993;128:79-88 8. Gary DB. , G. Joseph P., David FB.: The Non-value of preoperative and intraoperative cultures in predicting the bacteriology of subsequent wound infection in patients undergoing major head and neck cancer surgery. The laryngoscope 1980;90 :1933-1940 9. Jonas T, Johnson, Victor LY. ,Eugene NM.Robin LW. :An assessment of the Need for Gram-Negative Bacterial Coverage in Antibiotic Prophylaxis for Oncological Head and neck surgery. The Journal of infectious disease 1987;155:331-333 10.Laurence L. Brunton, (Ed.),:Penicillins,Cephalosporins, and Other β-lactam Antibiotics. Goodman & Gilman's Pharmacology 2009; 44:1-33 11.David N. Gilbert ,MD : Guide to antimicrobial therapy 2009. SANFORD GUIDE ;52

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21

12.���5� �/"����� : Penicillin 01234567890:;<2 >?@01234A92BCD <E956789:38<E6F: ;2 : 26-46 13. De Melo GM,Ribeiro KC,Kowalski LP:Risk facter for postoperative complications in oral cancer and their prognostic implication. Arch Otolaryngol 2001;127:823-833 14. Panel N, Fournier C Lefebvre D, Lefebvre JL. Multivariated analysis of risk facters for WI in head and neck squamous cell carcinoma surgery with opening of mucosa. Study of 260 surgical procedures. Oral Oncol 2005;41:294-303 15. Weber RS,Raad I Ampicillin-Sulbactam Vs Clindamycin in Head and Neck Oncologic Surgery ; The need for Gram-negative Coverage. Arch otolaryngol Head

and Neck Surg 1992;118:1159-1163

16.K.T.Robbins, R.M. Byers Wound prophylaxis with metronidazole in head and neck surgical oncology Laryngoscope198;98:803-806

17.Shih-An, Yong-Kie Wong,Chiu-Kwan Poon. Risk factors for wound infection after surgery in primary oral cavity cancer patients. Laryngoscope 2007;117:166-171 18. Ali sepehr, Barbara-Jean Gutierrez Santos. Antibiotics in Head and neck Surgery In the setting of Malnutrition, Tracheostomy, and Diabetes : The Laryngoscope 2009;119:549-553

19.Carlos Jorge Lotfi, Rito de Cassia Cavalcanti Risk factors for surgical-site infections in head and neck cancer surgery. Otolaryngology-Head and Neck Surgery

2008;138:74-80

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22

���)���$ก��ก*�+��$��(��&,��

No. ��% &- � �

Diagnosis stage

Surgery

Status

Albumin

Hb

Underlying

No DM

COPD Other

Smoking

Alcohol

Antibiotic

o PGS 5 mu before OR 1 hr, then 3 mu q 4 hr × 6 time o Cavumox 1.2 g before OR 1 hr, then 1.2 g q 8 hr × 3 time

Duration of operation time Min.

Wound

Culture from wound infection : (52#��52��!��"����)

Duration of admit. days

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Grade

0

Grade

1

Grade

2

Grade

3

Grade

4

Grade

5

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23