Perioperative Systemic Antibiotics in Open Reduction and Internal Fixation (ORIF) of Maxillofacial Fractures: A Systematic Review and Meta-Analysis

Background: Maxillofacial fractures, commonly caused by road traffic accidents or interpersonal violence, represent a substantial global health challenge. Surgical management via open reduction and internal fixation (ORIF) is standard but is associated with risks of surgical site infections (SSIs) due to the polymicrobial oral environment. Perioperative systemic antibiotic prophylaxis (PAP) is routinely used, but debates persist on its necessity, duration, and role in antimicrobial resistance (AMR). Objective: This systematic review and meta-analysis assess the efficacy and safety of systemic PAP in preventing SSIs following ORIF for maxillofacial fractures, emphasizing infection reduction versus no prophylaxis and short (≤24 hours) versus extended (>24 hours) regimens. Methods: Adhering to PRISMA guidelines, searches were performed in PubMed, Embase, Cochrane CENTRAL, Scopus, and Web of Science up to August 31, 2025. Inclusion criteria covered RCTs and cohort studies in adults undergoing ORIF, comparing PAP regimens or versus no prophylaxis. Primary outcome was SSI incidence; secondary outcomes included osteomyelitis and AMR. Risk ratios (RRs) were pooled using random-effects meta-analysis, with subgroup analyses by fracture site. Results: From 1,856 records, 16 verified studies (8 RCTs, 8 cohorts; n=3,285) were included. Perioperative antibiotics reduced SSI risk compared to no prophylaxis (RR 0.48, 95% CI 0.32–0.72; p=0.0004; I²=52%). Mandibular fractures showed pronounced benefits (RR 0.41, 95% CI 0.25–0.67), while midface results were inconclusive. Extended prophylaxis (>24 hours) provided no additional advantage over short regimens (RR 1.0; I²<25%). Infection rates ranged 3–12%, with limited data on AMR. Conclusions: Systemic PAP effectively lowers SSI risk in maxillofacial ORIF, particularly for mandibular fractures. Limiting to a preoperative dose discontinued within 24 hours is sufficient, promoting stewardship by reducing AMR and costs. Further RCTs are required for site-specific protocols.