Preoperative Antibiotics Study
Information source: Children's Hospital of Pittsburgh
ClinicalTrials.gov processed this data on August 23, 2015
Link to the current ClinicalTrials.gov record.
Condition(s) targeted: Cleft Palates
Intervention: Unasyn (Drug); saline solution (Other)
Phase: Phase 2
Sponsored by: Children's Hospital of Pittsburgh
Official(s) and/or principal investigator(s):
Joseph Losee, MD, Principal Investigator, Affiliation: Children's Hospital of Pittsburgh of UPMC
The primary objective of this study is to determine the efficacy of administering a single
dose of preoperative antibiotics to prevent complications in patients undergoing primary
closure of a cleft secondary palate. Secondary objective of this study is to evaluate the
effects of preoperative antibiotics administered on post operative outcome following primary
closure of cleft secondary palate. The study aims to assess the efficacy of prophylactic
antibiotics in cleft surgery to
- decrease the incidence of surgical sight infections
- speed the progression of postoperative healing
- improve the final quality of wound healing achieved
- decrease the rate of palatal fistula formation
Official title: Efficacy of Preoperative Prophylactic Antibiotics in Preventing Complications in the Primary Repair of Cleft Palates
Study design: Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Caregiver, Investigator), Primary Purpose: Treatment
Primary outcome: The study aims to assess the efficacy of prophylactic antibiotics in cleft surgery.
Secondary outcome: Secondary objective of this study is to evaluate the effects of preoperative antibiotics administered on post operative outcome following primary closure of cleft secondary palate.
During the initial clinical visit, the clinical diagnosis of a cleft secondary palate or
submucous cleft will be made. Other associated clinical findings such as
unilateral/bilateral cleft lip, unilateral/bilateral cleft primary palate, Veau cleft palate
classification, and associated syndromic diagnosis will be recorded. The severity of the
cleft palate will be documented by measuring the width of the cleft and the hard-soft palate
juncture. The patients will proceed through the standardized cleft treatment protocol as
mandated by their specific anatomic findings. These include possible naso-alveolar molding,
lip-adhesion procedures, and cleft lip repair procedures. The patients will be followed
regularly in clinic and will undergo a palatoplasty procedure to repair their cleft
secondary palate when clinically indicated, typically between the age of 9 and 14 months.
Patients who present for treatment late will be operated on when clinically appropriate, as
determined by the plastic surgeon. A Furlow palatoplasty procedure is the typical
palatoplasty procedure performed by the primary investigator, but other procedures such a
Von Langenbeck pushback palatoplasty may be performed as dictated by the clinical scenario.
Subjects will be randomized via aid from statisticians in the Clinical and Translational
Science Institute (CTSI) here at the University of Pittsburgh. This will enable the
research pharmacist at Children's Hospital of Pittsburgh, to send either the antibiotic or
the saline placebo to the operating room in a blinded manner. All subjects enrolled in the
study will receive a single dose of antibiotic or saline solution (placebo control)
intravenously, as the IV will already be in place as standard of card for surgery. Subjects
will receive the antibiotic or the saline placebo 30 minutes prior to the initial incision
in their palatoplasty procedure. The FDA approved antibiotic used for this study is Unasyn.
Unasyn is a first-line measure, used by ENT surgeons at Children's Hospital of Pittsburgh
for antibiotic treatment of virtually all ear, nose and throat infections. The use of
Unasyn for this study is off-label as with the majority of antibiotics used with children.
Subjects will receive a one time dose of 50mg/kg prior to surgery, not to exceed a total of
2gm. This constitutes the focus of the study, and is the only variation from standard
Patients will be admitted to the hospital, and will be discharged home when they are in no
respiratory distress, have adequate pain control, and are able to tolerate adequate PO
intake. This is generally on post-operative day 2. All patients will be prescribed pain
medications. Parents will be provided with, and counseled how to properly use arm splints
for 14 days postoperatively. They will also be taught how to feed the child with syringe
feeds. These measures prevent the child from traumatizing the suture lines with bottles,
hands and foreign bodies.
Screening procedures will consist of a medical history and physical examination by a
Pediatric Plastic Surgeon to determine what type of cleft palate repair is necessary. This
is the same standard exam and medical/surgical work-up that any patient would receive if
they were treated by the Cleft-Craniofacial Clinic in Children's Hospital of Pittsburgh of
UPMC and not enrolled in this study. This aspect of care will not vary from routine
treatment. All patients will be seen in weekly postoperative follow-up in the
Cleft-Craniofacial Center. Documentation of these postoperative visits will include
notation of signs of surgical sight infections, such as continued fevers, erythema,
swelling, discharge, dehiscence, pain, and the presence of nonviable tissue. The
progression of wound healing will be quantified on a scale of 1 to 4. Wounds will be
classified as Stage 1 healing when there is complete union of the mucosa, and no
irregularities or separation. Stage 2 healing will be documented for wounds with minor
incisional irregularities or incomplete healing. Stage 3 healing will be documented when
the wound exhibits worrisome mucosal viability, partial dehiscence of the oral mucosal
closure, erythema, purulent drainage, or exposure of the alloderm patch. Stage 4 healing
will include patients with a palatal fistula. Any patients with clinical signs and symptoms
of thrush, a fungal infection of the mouth and esophagus, will have cultures of the lesions
sent to confirm the diagnosis. These patients will be immediately started on a seven day
course of oral fluconazole, with an initial dose of 6mg/kg, followed by daily dose of
3mg/kg, as recommended by Dr. Andrew Nowalk, MD. Patients will be seen in clinic weekly
until they have reached stage 1 healing, or until the presence of a palatal fistula is
documented. We anticipate a minimum of less than 2 months to a maximum of 1 year for
follow-up will be necessary to document either stage 1 healing or the presence of a palatal
fistula in nearly all cases. The primary endpoints measured will be 1) the incidence of
surgical sight infections, 2) the incidence of palatal fistula 3) the average time needed to
achieve stage 1 healing, 4) the incidence of cases with healing delayed more than one
standard deviation from the average, 5) the incidence of thrush, a fungal infection of the
mouth and esophagus, and 6) the incidence of allergic/drug reactions to the study drug.
Surveillance for other factors such as hospital length of stay, postoperative bleeding
events, postoperative respiratory distress, and diagnosis of a sepsis will be recorded as
Data collection will include patient characteristics such as, but not limited to, Veau cleft
classification, width of the cleft defect, presence of associated cleft lip or primary
palate, presence of syndromic diagnosis, and use of alloderm for repair augmentation, and
the administration of intraoperative steroids. The two study groups will be compared on the
basis of these characteristics to determine if statistically significant differences exist
between the two groups. Endpoint data will be collected as discussed above, and the
outcomes for the placebo and antibiotic group will be compared.
Minimum age: 3 Months.
Maximum age: 18 Years.
- Children diagnosed as having cleft palates undergoing palatoplasty between the ages
of 3 months and 18 years will be included in this study. Palatoplasty is the current
standard of care in the sequence of treatment for cleft secondary palates. Pediatric
plastic surgeons work primarily with children, and have undergone extensive training
during their residencies and pediatric surgical fellowships to do so. Children will
be evaluated initially at the Cleft-Craniofacial Center at the Children's Hospital of
Pittsburgh of UPMC, which is set up to accommodate children of all ages and their
families. Approximately 300 children will be required to contribute to a meaningful
- All patients requiring prophylactic antibiotics for spontaneous bacterial
endocarditis, with documented allergic reactions to the ampicillin-sulbactam, and
with known immunodeficiencies or immunodeficiency associated syndromes, such as the
22q chromosomal deletion, will be excluded from study participation.
- Selection will be based on the parent's willingness to allow their child to
participate in the study.
- Children already receiving antibiotics at the time of their surgery will be evaluated
distinctly, though they will not be included in the antibiotic or the placebo groups
Locations and Contacts
Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15213, United States
1. Centers for Disease Control and Prevention (CDC). Improved National prevalence estimates for 18 selected major birth defects—Unites States, 1999-2001. MMWR Morb Mortal Wkly Rep. 2006; 54:1301-1305. 2. Chuo CB, Timmons MJ. The bacteriology of children before primary cleft lip and palate surgery. The Cleft Palate-Craniofac J. 2005; 42:272-276. 3. Mercer NSG. The use of preoperative swabs in cleft lip and palate repair [letter to the editor]. Br J Plast Surg. 2002; 55:176-177. 4. Jolleys A, Savage JP. Healing defects in cleft palate surgery-the role of infection. Br J Plast Surg. 1963; 16:134-139. 5. Lowbury EJL. Infection of Burns. Proc Soc Med. 1954; 47:231-232. 6. Jackson DM, Lowbury EJL, Topley E. Chemotherapy of Streptococcus pyogenes infection of burns. Lancet. 1951; 2:705-711. 7. McClelland RMA, Patterson TJS. The influence of penicillin on the complication rate after repair of clefts of the lip and palate. Br J Plast Surg. 1963; 16:144-145. 8. Marzoni FA, Kelly DR. Bacteraemia following cleft palate repair-a prospective study. Ann Plast Surg. 1983; 10:473-474. 9. Crawford JJ, Fischer ND. Oral and respiratory flora of individuals with normal and repaired palatal clefts. Cleft Palate J. 1971; 8:166-176.
Starting date: May 2008
Last updated: August 6, 2015