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Jacobo M, Grigorian A, Swentek L, Goodman LF, Guner Y, Delaplain PT, Nahmias J. Antibiotics Within One Hour for Pediatric Open Lower Extremity Fractures May Not be Warranted as a Quality Metric. Am Surg 2024:31348241269392. [PMID: 39097815 DOI: 10.1177/00031348241269392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2024]
Abstract
BACKGROUND Open fractures have been associated with a higher risk of infection if antibiotics are not administered within 1 h of presentation in adult trauma patients. Time to antibiotic administration for open fractures is frequently used as a quality metric for trauma centers, but there have been no large studies evaluating this topic for pediatric patients. METHODS The 2019 Trauma Quality Improvement Program dataset was queried for patients ≤ 16 years old with isolated open femur or tibia fractures undergoing operative intervention after blunt trauma. Patients transferred from another hospital were excluded. Pediatric patients receiving early antibiotics (EA) within 1 h were compared to patients receiving delayed antibiotics (DA) greater than or equal to 1 h from arrival. Multivariate logistic regression was used to evaluate risk of surgical site infection (SSI). RESULTS There were 150 patients with open lower extremity fractures: 98 (64.9%) EA vs 52 (34.4%) DA. There was no difference in the rate of SSI between the 2 groups (EA: 1.0% vs DA: 1.9%, P = 0.65). There remained similar associated risk of infection after adjusting for lower extremity abbreviated injury scale >3, blood transfusion requirement, and vital signs on arrival (OR 0.62, 95% CI 0.04-10.24, P = 0.74). CONCLUSIONS Most pediatric trauma patients with open lower extremity fracture received antibiotics within 1 h of presentation. However, SSI was rare and the risk of SSI was not associated with antibiotic administration within 1 h. Therefore, timing of antibiotic administration for pediatric open lower extremity fractures should be re-evaluated as a quality metric.Level of Evidence: Level III.
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Affiliation(s)
- Marlene Jacobo
- Division of Trauma, Burns & Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Areg Grigorian
- Division of Trauma, Burns & Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Lourdes Swentek
- Division of Trauma, Burns & Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Laura F Goodman
- Department of Surgery, University of California, Irvine, Orange, CA, USA
- Division of Pediatric Surgery, Children's Health of Orange County, Orange, CA, USA
| | - Yigit Guner
- Department of Surgery, University of California, Irvine, Orange, CA, USA
- Division of Pediatric Surgery, Children's Health of Orange County, Orange, CA, USA
| | - Patrick T Delaplain
- Division of Trauma, Burns & Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns & Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
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Fouad A, Berry A, Gates J, Kuti JL, Keating JJ. Effect of Blood Product Resuscitation on Cefazolin Pharmacokinetics in Trauma Patients. Surg Infect (Larchmt) 2024; 25:436-443. [PMID: 38995850 DOI: 10.1089/sur.2023.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2024] Open
Abstract
Background: Antibiotics are frequently administered prophylactically to trauma patients with various injury patterns to prevent infectious complications. Trauma patients may also require large volume resuscitation with blood products. Limited data are available to support antibiotic dosing recommendations in this population. We hypothesized that we would be able to develop a population pharmacokinetic model of cefazolin, a frequently used antibiotic in the trauma scenario, from remnant blood samples by pharmacokinetic analysis of trauma patients. Methods: Remnant plasma from standard of care chemistry/hematology assessments was retrieved within 48 h of collection and assayed to determine cefazolin concentrations. Population pharmacokinetic analyses were conducted in Pmetrics using R. Linear regression was conducted to assess the effect of blood product resuscitation volume on cefazolin pharmacokinetic parameters. Results: Cefazolin concentrations best fitted a two-compartment model (Akaike information criterion: 443.9). The mean ± standard deviation parameters were total body clearance (4.3 ± 1.9L), volume of the central compartment (Vc: 7.7 ± 6.9L), and intercompartment transfer constants (k12: 1.3 ± 0.98 h-1, k21: 0.6 ± 0.45 h-1). No statistical relationships were observed between blood products, volume of blood products, and cefazolin clearance or Vc (R2: 0.0004-0.21, p = 0.08-0.95). Using a 5,000-patient Monte Carlo simulation, 2 g with repeated dosing every 2 h until end of surgery was required to achieve 93.2% probability of 100% free time above the minimum inhibitory concentration (MIC) (fT > MIC) at the ECOFF value for Staphylococcus aureus (2 mg/L). Conclusions: In these 15 trauma patients receiving blood transfusion, no relationship with blood volume resuscitation and cefazolin pharmacokinetics was observed. On the basis of this pharmacokinetic model, frequent cefazolin doses are required to maintain 100% fT > MIC.
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Affiliation(s)
- Aliaa Fouad
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Angela Berry
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Jonathan Gates
- Division of Acute Care Surgery, Hartford Hospital, Hartford, Connecticut, USA
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Jane J Keating
- Division of Acute Care Surgery, Hartford Hospital, Hartford, Connecticut, USA
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut, USA
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Robinson TW, Gautreaux CE, Lee YLL, Mbaka M, Kinnard CM, Bright AC, Williams AY, Polite NM, Capasso TJ, Simmons JD, Butts CC. Monotherapy Antibiotic Prophylaxis of Lower Extremity Long Bone Type III Open Fractures. Am Surg 2024; 90:2068-2069. [PMID: 38551626 DOI: 10.1177/00031348241241657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Gustilo type III open fractures involve extensive soft tissue damage and wound contamination that pose significant infection risks. The historical standard for antibiotic prophylaxis has been cefazolin and gentamicin. We conducted a retrospective cohort study of lower extremity type III open fractures treated with ceftriaxone alone for prophylaxis. Eighty-six patients were identified. Nearly all (98%) were managed with appropriate antibiotics, but only 55 (64%) received prophylaxis within 1 hour. Overall, there were 12 infections. This infection rate was not statistically different than the reported literature (14% vs 19%, P = .20). The infection rate between those who received antibiotics within 1 hour was not statistically different from those who got it beyond 1 hour (15% vs 13%, P = .98). In conclusion, the use of ceftriaxone as monotherapy for antibiotic prophylaxis in lower extremity type III open fractures is not statistically different than the use of historic prophylactic regimens.
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Affiliation(s)
- Thomas W Robinson
- Division of Trauma, Acute Care Surgery, and Burns, Department of Surgery, Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
| | - Corinne E Gautreaux
- Division of Trauma, Acute Care Surgery, and Burns, Department of Surgery, Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
| | - Yann-Leei L Lee
- Division of Trauma, Acute Care Surgery, and Burns, Department of Surgery, Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
| | - Maryann Mbaka
- Division of Trauma, Acute Care Surgery, and Burns, Department of Surgery, Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
| | - Christopher M Kinnard
- Division of Trauma, Acute Care Surgery, and Burns, Department of Surgery, Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
| | - Andrew C Bright
- Division of Trauma, Acute Care Surgery, and Burns, Department of Surgery, Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
| | - Ashley Y Williams
- Division of Trauma, Acute Care Surgery, and Burns, Department of Surgery, Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
| | - Nathan M Polite
- Division of Trauma, Acute Care Surgery, and Burns, Department of Surgery, Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
| | - Thomas J Capasso
- Division of Trauma, Acute Care Surgery, and Burns, Department of Surgery, Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
| | - Jon D Simmons
- Division of Trauma, Acute Care Surgery, and Burns, Department of Surgery, Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
| | - Charles C Butts
- Division of Trauma, Acute Care Surgery, and Burns, Department of Surgery, Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
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Marchiori JGT, Nunes APF. TIME UNTIL THE START OF ANTIBIOTIC PROPHYLAXIS AND THE RISK OF OPEN FRACTURE INFECTION: A SYSTEMATIC REVIEW. ACTA ORTOPEDICA BRASILEIRA 2024; 32:e263176. [PMID: 38933354 PMCID: PMC11197951 DOI: 10.1590/1413-785220243202e263176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/05/2022] [Indexed: 06/28/2024]
Abstract
Open fractures are highly incident injuries closely related to the modern life, in which accidents caused by motor vehicles or other machines impart high energy to bone tissue. Individual morbidity is represented by the functional impairment resultant of infection, nonunion, or vicious healing. In terms of public health, there are huge costs involved with the treatment of these fractures, particularly with their complications. One of the critical issues in managing open fractures is the use of antibiotics (ATB), including decisions about which specific agents to administer, duration of use, and ideal timing of the first prophylactic dose. Although recent guidelines have recommended starting antibiotic prophylaxis as soon as possible, such a recommendation appears to stem from insufficient evidence. In light of this, we conducted a systematic review, including studies that addressed the impact of the time to first antibiotic and the risk of infectious outcomes. Fourteen studies were selected, of which only four found that the early initiation of treatment with antibiotics is able to prevent infection. All studies had important risks of bias. The results indicate that this question remains open, and further prospective and methodologically sound studies are necessary in order to guide practices and health policies related to this matter. Level of Evidence II; Therapeutic Studies Investigating the Results Level of Treatment.
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Affiliation(s)
| | - Ana Paula Ferreira Nunes
- Universidade Federal do Espírito Santo (UFES), Department of Pathology, Postgraduate Program in Infectious Diseases, Health Sciences Center, Vitória, ES, Brazil
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Hunt TJ, Powlan FJ, Renfro KN, Polmear M, Macias RA, Dunn JC, Wells ME. Common Finger Injuries: Treatment Guidelines for Emergency and Primary Care Providers. Mil Med 2024; 189:988-994. [PMID: 36734106 DOI: 10.1093/milmed/usad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/10/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Finger and hand injuries are among the most common musculoskeletal conditions presenting to emergency departments and primary care providers. Many rural and community hospitals may not have immediate access to an orthopedic surgeon on-site. Furthermore, military treatment facilities, both within the continental United States and in austere deployment environments, face similar challenges. Therefore, knowing how to treat basic finger and hand injuries is paramount for patient care. MATERIALS AND METHODS The Armed Forces Health Surveillance Branch operates the Defense Medical Surveillance System, a database that serves as the central repository of medical surveillance data for the armed forces. The Defense Medical Surveillance System was queried for ICD-10 codes associated with finger injuries from 2015 to 2019 among active duty service members across the major branches of the military. RESULTS The most commonly reported finger injuries were open wounds to fingers without damage to nails, metacarpal fractures, phalanx fractures, and finger subluxation/dislocation. Emergency departments were the most commonly reported treatment facility type accounting for 35% of initial finger injuries, followed by 32.2% at orthopedic surgery clinics, 22.2% at family medicine clinics, and 10.8% at urgent care centers. CONCLUSIONS Finger injuries are common in the military setting and presenting directly to an orthopedic surgeon does not appear the norm. Fingertip injuries, fractures within the hand, and finger dislocations can often be managed without the need for a subspecialist. By following simple guidelines with attention to "red flags," primary care providers can manage most of these injuries with short-term follow-up with orthopedics.
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Affiliation(s)
- Tyler J Hunt
- Jack Hughston Memorial Hospital, Phenix City, AL 36867, USA
| | - Franklin J Powlan
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX 79905, USA
| | - Kayleigh N Renfro
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX 79905, USA
| | - Michael Polmear
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX 79905, USA
| | - Reuben A Macias
- Blanchfield Army Community Hospital, Fort Campbell, KY 42223, USA
| | - John C Dunn
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Matthew E Wells
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX 79905, USA
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The Bioburden Associated with Severe Open Tibial Fracture Wounds at the Time of Definitive Closure or Coverage: The BIOBURDEN Study. J Bone Joint Surg Am 2024; 106:858-868. [PMID: 38489393 DOI: 10.2106/jbjs.23.00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND Infection is common following high-energy open tibial fractures. Understanding the wound bioburden may be critical to infection risk reduction strategies. This study was designed to identify the bioburden profile of high-energy open tibial fractures at the time of definitive wound closure or coverage and determine the relationship to subsequent deep infection. METHODS This multicenter prospective study enrolled 646 patients with high-energy open tibial fractures requiring a second debridement surgery and delayed wound closure or coverage. Wound samples were obtained at the time of definitive closure or coverage and were cultured in a central laboratory. Cultures were also subsequently obtained from patients who underwent a fracture-site reoperation. RESULTS Two hundred and six (32%) of the wounds had a positive culture at the time of closure or coverage. A single genus was identified in 154 (75%) of these positive cultures and multiple genera, in 52 (25%). Gram-positive cocci (GPCs) were identified in 98 (47%) of the positive cultures. Staphylococci were identified in 64 (31%) of the cultures, and 53 (83%) of these were coagulase-negative (CONS). Enterococci were identified in 26 (13%) of the cultures. Gram-negative rods (GNRs) were identified in 100 (49%) of the cultures; the most frequent GNR genera identified were Enterobacter (39, 19%) and Pseudomonas (21, 10%). Positive cultures were subsequently obtained from 154 (50%) of 310 revision surgeries. A single genus was identified in 85 (55%) of the 154 and multiple genera, in 69. GPCs were identified in 134 (87%) of the 154 positive cultures, staphylococci were identified in 94 (61%), and GNRs were identified in 100 (65%). CONCLUSIONS The bioburden in high-energy open tibial fractures at delayed closure or coverage was often characterized by pathogens of multiple genera and of genera that are nonresponsive to typically employed antibiotic prophylaxis. Awareness of the final wound bioburden might inform strategies to lower the infection rate. LEVEL OF EVIDENCE Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Del Pilar Zarazaga M, Tinti MG, Litterio NJ, Himelfarb MA, Andrés-Larrea MIS, Rubio-Langre S, Serrano-Rodríguez JM, Lorenzutti AM. Dose regimen optimization of cephalothin for surgical prophylaxis against Staphylococcus aureus and coagulase negative staphylococci in dogs by pharmacokinetic/pharmacodynamic modeling. Res Vet Sci 2024; 171:105202. [PMID: 38492279 DOI: 10.1016/j.rvsc.2024.105202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/13/2024] [Accepted: 02/26/2024] [Indexed: 03/18/2024]
Abstract
First generation cephalosporins such cephalothin of cefazolin are indicated for antimicrobial prophylaxis for clean and clean contaminated surgical procedures because its antimicrobial spectrum, relative low toxicity and cost. Anesthesia and surgery could alter the pharmacokinetic behavior of different drugs administered perioperative by many mechanisms that affect distribution, metabolism or excretion processes. Intravenous administration of the antimicrobial within 30 and 60 min before incision is recommended in order to reach therapeutic serum and tissue concentrations and redosing is recommended if the duration of the procedure exceeds two half-life of the antimicrobial. To the author's knowledge there are no pharmacokinetic studies of cephalothin in dogs under anesthesia/surgery conditions. The aim of this study was (1) to evaluate the pharmacokinetics of cephalothin in anesthetized dogs undergoing ovariohysterectomy by a nonlinear mixed-effects model and to determine the effect of anesthesia/surgery and other individual covariates on its pharmacokinetic behavior; (2) to determine the MIC and conduct a pharmacodynamic modeling of time kill curves assay of cephalothin against isolates of Staphylococcus spp. isolated from the skin of dogs; (3) to conduct a PK/PD analysis by integration of the obtained nonlinear mixed-effects models in order to evaluate the antimicrobial effect of changing concentrations on simulated bacterial count; and (4) to determine the PK/PD endpoints and PK/PDco values in order to predict the optimal dose regimen of cephalothin for antimicrobial prophylaxis in dogs. Anesthesia/surgery significantly reduced cephalothin clearance by 18.78%. Based on the results of this study, a cephalothin dose regimen of 25 mg/kg q6h by intravenous administration showed to be effective against Staphylococcus spp. isolates with MIC values ≤2 μg/mL and could be recommended for antimicrobial prophylaxis for clean surgery in healthy dogs.
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Affiliation(s)
- María Del Pilar Zarazaga
- Facultad de Ciencias Agropecuarias, IRNASUS CONICET-Universidad Católica de Córdoba, Argentina; Farmacología Clínica y Toxicología, Carrera de Veterinaria, Instituto Académico y Pedagógico de Ciencias Básicas y Aplicadas, Universidad Nacional de Villa María, Argentina.
| | - Mariano Guillermo Tinti
- Facultad de Ciencias Agropecuarias, IRNASUS CONICET-Universidad Católica de Córdoba, Argentina.
| | - Nicolás Javier Litterio
- Facultad de Ciencias Agropecuarias, IRNASUS CONICET-Universidad Católica de Córdoba, Argentina.
| | | | | | - Sonia Rubio-Langre
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Universidad Complutense de Madrid, Spain.
| | - Juan Manuel Serrano-Rodríguez
- Pharmacology Area, Department of Nursing, Pharmacology and Physiotherapy, Faculty of Veterinary Medicine, University of Córdoba, Spain.
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Conombo B, Guertin JR, Hoch JS, Grimshaw J, Bérubé M, Malo C, Berthelot S, Lauzier F, Stelfox HT, Turgeon AF, Archambault P, Belcaid A, Moore L. Implementation of an audit and feedback module targeting low-value clinical practices in a provincial trauma quality assurance program: a cost-effectiveness study. BMC Health Serv Res 2024; 24:479. [PMID: 38632593 PMCID: PMC11025277 DOI: 10.1186/s12913-024-10969-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 04/09/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Audit and Feedback (A&F) interventions based on quality indicators have been shown to lead to significant improvements in compliance with evidence-based care including de-adoption of low-value practices (LVPs). Our primary aim was to evaluate the cost-effectiveness of adding a hypothetical A&F module targeting LVPs for trauma admissions to an existing quality assurance intervention targeting high-value care and risk-adjusted outcomes. A secondary aim was to assess how certain A&F characteristics might influence its cost-effectiveness. METHODS We conducted a cost-effectiveness analysis using a probabilistic static decision analytic model in the Québec trauma care continuum. We considered the Québec Ministry of Health perspective. Our economic evaluation compared a hypothetical scenario in which the A&F module targeting LVPs is implemented in a Canadian provincial trauma quality assurance program to a status quo scenario in which the A&F module is not implemented. In scenarios analyses we assessed the impact of A&F characteristics on its cost-effectiveness. Results are presented in terms of incremental costs per LVP avoided. RESULTS Results suggest that the implementation of A&F module (Cost = $1,480,850; Number of LVPs = 6,005) is associated with higher costs and higher effectiveness compared to status quo (Cost = $1,124,661; Number of LVPs = 8,228). The A&F module would cost $160 per LVP avoided compared to status quo. The A&F module becomes more cost-effective with the addition of facilitation visits; more frequent evaluation; and when only high-volume trauma centers are considered. CONCLUSION A&F module targeting LVPs is associated with higher costs and higher effectiveness than status quo and has the potential to be cost-effective if the decision-makers' willingness-to-pay is at least $160 per LVP avoided. This likely represents an underestimate of true ICER due to underestimated costs or missed opportunity costs. Results suggest that virtual facilitation visits, frequent evaluation, and implementing the module in high-volume centers can improve cost-effectiveness.
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Affiliation(s)
- Blanchard Conombo
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
| | - Jason R Guertin
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
| | - Jeffrey S Hoch
- Division of Health Policy and Management, Department of Public Health Sciences, University of California at Davis, Davis, CA, USA
| | - Jeremy Grimshaw
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Christian Malo
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Québec, Canada
- Centre de Recherche Intégrée Pour Un Système Apprenant en Santé Et Services Sociaux, Centre Intégré de Santé Et de Services Sociaux de Chaudière-Appalaches, Lévis, Québec, Canada
| | - François Lauzier
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Québec, Canada
- VITAM-Centre de Recherche en Santé Durable, Québec City, Québec, Canada
| | - Amina Belcaid
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada.
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Ghali AN, Venugopal V, Montgomery N, Cornaghie M, Ghilzai U, Batiste A, Mitchell S, Dawson J. Infectious profiles in civilian gunshot associated long bone fractures. INTERNATIONAL ORTHOPAEDICS 2024; 48:31-36. [PMID: 37336798 DOI: 10.1007/s00264-023-05870-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/14/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE There is a paucity of literature on infections in civilian gunshot associated with long bone fractures with the reported rates ranging from 0-15.7%.This study aimed to investigate the rates of infection associated with long bone fractures caused by civilian gunshots. The specific objectives were to determine if certain extremities were at a higher risk for infection and to identify the types of bacteria present in these infections by analyzing culture isolates. METHODS We conducted a retrospective review of consecutive patients aged 18-64 who sustained gunshot-associated long bone fractures at an urban Level I trauma centre from 2010 to 2017. Patient selection was based done through a institutional trauma centre database using international classification of diseases (ICD) 9 and 10 codes. We included patients who underwent surgical treatment, specifically fracture fixation, at our institution and excluded patients with fractures involving the pelvis, spine, foot, and hand. A total of 384 gunshot-associated long bone fractures in 347 patients were identified for analysis. Relevant patient-, injury-, and treatment-related variables were extracted from clinical records and radiographic reviews. Outcomes of interest included bony union, repeat operative procedures, and the development of deep infection. RESULTS 347 patients with 384 long bone fractures were included. 32 fractures in 32 patients developed an infection for an incidence of 9.3% of patients and 8.3% of fractures. Gram-positive bacteria were present in 23/32 (72.0%) culture isolates, gram-negative bacteria in 10/32 (31.3%) culture isolates, and six infections were polymicrobial. Staphylococcus 16/32 (50.0%) and Enterobacter 6/32 (18.8%) species were the most common isolates. Of the Staphylococcus species, 5/16 (31.3%) were MRSA. Lower extremity fractures had a greater risk for infection compared to the upper extremity (11.7% vs 3.7% p < 0.01) and fractures that developed an infection had a larger average zone of comminution (63.9 mm vs 48.5 mm p < 0.05). CONCLUSION This study investigated the rates of infection associated with long bone fractures caused by civilian gunshots. The overall infection rate observed in our series aligns with existing literature. Gram-positive bacteria were the predominant isolates, with a notable incidence of MRSA in our patient population, highlighting the need for considering empiric coverage. Additionally, gram-negative organisms were found in a significant proportion of infections, and a notable percentage of infections were polymicrobial. Our findings emphasize the importance of carefully assessing highly comminuted lower extremity fractures and implementing appropriate antibiotic coverage and operative debridement for patients with gunshot-related long bone fractures. While current prophylaxis algorithms for open fractures lack specific inclusion of gunshot wounds, we propose incorporating these injuries to reduce the incidence of infections associated with such fractures.
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Affiliation(s)
- Abdullah N Ghali
- Department of Orthopaedics, Baylor College of Medicine, Houston, TX, USA.
| | - Vivek Venugopal
- Department of Orthopaedics, Baylor College of Medicine, Houston, TX, USA
| | - Nicole Montgomery
- Department of Orthopaedics, Baylor College of Medicine, Houston, TX, USA
| | - Meg Cornaghie
- Department of Orthopaedics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Umar Ghilzai
- Department of Orthopaedics, Baylor College of Medicine, Houston, TX, USA
| | - Alexis Batiste
- Department of Orthopaedics, Baylor College of Medicine, Houston, TX, USA
| | - Scott Mitchell
- Department of Orthopaedics, Baylor College of Medicine, Houston, TX, USA
| | - Jack Dawson
- Department of Orthopaedics, Baylor College of Medicine, Houston, TX, USA
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Nichols DS, Newsum N, Satteson E, Miao G, Struk A, Horodyski M, Matthias R. Open hand fractures: a prospective analysis of functional outcomes and risk factors for infection after initial management in the emergency department. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3449-3459. [PMID: 37191885 DOI: 10.1007/s00590-023-03549-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE Open hand fractures are common orthopaedic injuries, historically managed with early debridement in the operating room. Recent studies suggest immediate operative treatment may not be necessary but have been limited by poor follow-up and lack of functional outcomes. This study sought to prospectively evaluate these injuries treated initially in the emergency department (ED), without immediate operative intervention, to determine long-term infectious and functional outcomes using the Michigan Hand Outcomes Questionnaire (MHQ). METHODS Adult patients with open hand fractures managed initially in the ED at a Level-I trauma center were considered for inclusion (2012-2016). Follow-up and MHQ administration occurred at 6 weeks, 12 weeks, 6 months, and 1 year. Logistic regression and Kruskal-Wallis testing were used for analysis. RESULTS Eighty-one patients (110 fractures) were included. Most had Gustilo Type III injuries (65%). Injury mechanisms most commonly included saw/cut (40%) and crush (28%). Nearly half of all patients (46%) had additional injuries involving a nailbed or tendon. Fifteen percent of patients had surgery within 30 days. The average follow-up was 8.9 months, with 68% of patients completing at least 12 months. Eleven patients (14%) developed an infection, of which 4 (5%) required surgery. Subsequent surgery and laceration size were associated with increased odds of infection, and at one-year, functional outcomes were not significantly different regardless of fracture classification, injury mechanism, or surgery. CONCLUSIONS Initial ED management of open hand fractures results in reasonable infection rates compared to similar literature and functional recovery demonstrated by MHQ score improvements over time.
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Affiliation(s)
- David Spencer Nichols
- University of Florida College of Medicine, P.O. Box 100138, Gainesville, FL, 32610, USA
| | - Nicholas Newsum
- Department of Orthopedic Surgery, University of Florida, 3450 Hull Road, Third Floor, Room 3341, Gainesville, FL, 32607, USA
| | - Ellen Satteson
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida, P.O. Box 100138, Gainesville, FL, 32610, USA
| | - Guanhong Miao
- Department of Biostatistics, University of Florida, 2004 Mowry Rd. 5th Floor, Gainesville, FL, 32603, USA
| | - Aimee Struk
- Department of Orthopedic Surgery, University of Florida, 3450 Hull Road, Third Floor, Room 3341, Gainesville, FL, 32607, USA
| | - MaryBeth Horodyski
- Department of Orthopedic Surgery, University of Florida, 3450 Hull Road, Third Floor, Room 3341, Gainesville, FL, 32607, USA
| | - Robert Matthias
- Department of Orthopedic Surgery, University of Florida, 3450 Hull Road, Third Floor, Room 3341, Gainesville, FL, 32607, USA.
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Bärtl S, Walter N, Lang S, Hitzenbichler F, Rupp M, Alt V. [Antibiotic use for prophylaxis and empirical therapy of fracture-related infections in Germany : A survey of 44 hospitals]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:707-714. [PMID: 35750887 PMCID: PMC10450009 DOI: 10.1007/s00113-022-01200-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Antibiotics play an important role in the prophylaxis and treatment of infections in orthopedic trauma surgery; however, there seems to be remarkable differences in the clinical antibiotic practice between hospitals, particularly for open fractures and for the empirical therapy of fracture-related infections (FRI). METHODS Therefore, we intended to evaluate the current clinical praxis in university and workers' compensation hospitals in Germany with a questionnaire on prophylaxis and empirical treatment of FRI. The results were compared with the resistance profile of 86 FRI patients in order to analyze the hypothetical effectiveness of the empirical treatment. RESULTS A total of 44 hospitals (62.0%) responded. A homogeneous antibiotic prophylaxis (95.5% of all hospitals) with cephalosporins was reported for perioperative prophylaxis of internal fixation of closed fractures. For open fractures, eight different monotherapy and combination treatment concepts were reported. In empirical treatment of FRI, 12 different therapeutic concepts were reported, including aminopenicillins/beta lactamase inhibitors (BLI) (31.8%), cephalosporins (31.8%), and ampicillin/sulbactam + vancomycin (9.1%). In terms of the hypothetical effectiveness of these antibiotic regimes, low sensitivity rates of 65.1% and 74.4% for cephalosporins and aminopenicillins/BLI, respectively, were found. For the combination vancomycin + meropenem, the highest hypothetical sensitivity (91.9%) was detected. DISCUSSION Based on the existing, institution-specific pathogen spectrum, the combination therapy including meropenem and vancomycin seems to be of value but should be restricted to patients with multiple revision procedures or a septic course of infection in order to prevent the selection of highly resistant pathogens.
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Affiliation(s)
- Susanne Bärtl
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Nike Walter
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Siegmund Lang
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Florian Hitzenbichler
- Abteilung für Krankenhaushygiene und Infektiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Markus Rupp
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
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Berner JE, Ali SR, Will PA, Tejos R, Nanchahal J, Jain A. Standardising the management of open extremity fractures: a scoping review of national guidelines. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:1463-1471. [PMID: 35819519 PMCID: PMC10276057 DOI: 10.1007/s00590-022-03324-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 06/20/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Open extremity fractures can be life-changing events. Clinical guidelines on the management of these injuries aim to standardise the care of patients by presenting evidence-based recommendations. We performed a scoping systematic review to identify all national clinical practice guidelines published to date. MATERIALS AND METHODS A PRISMA-compliant scoping systematic review was designed to identify all national or federal guidelines for the management of open fractures, with no limitations for language or publication date. EMBASE and MEDLINE database were searched. Article screening and full-text review was performed in a blinded fashion in parallel by two authors. RESULTS Following elimination of duplicates, 376 individual publications were identified and reviewed. In total, 12 clinical guidelines were identified, authored by groups in the UK, USA, the Netherlands, Finland, and Malawi. Two of these focused exclusively on antibiotic prophylaxis and one on combat-related injuries, with the remaining nine presented wide-scope recommendations with significant content overlap. DISCUSSION Clinical practice guidelines serve clinicians in providing evidence-based and cost-effective care. We only identified one open fractures guideline developed in a low- or middle-income country, from Malawi. Even though the development of these guidelines can be time and resource intensive, the benefits may outweigh the costs by standardising the care offered to patients in different healthcare settings. International collaboration may be an alternative for adapting guidelines to match local resources and healthcare systems for use across national borders.
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Affiliation(s)
- Juan Enrique Berner
- Kellogg College, University of Oxford, Oxford, UK.
- Plastic Surgery Department, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd., E1 1FR, London, UK.
| | - Stephen R Ali
- Reconstructive Surgery and Regenerative Medicine Research Group, Institute of Life Sciences, Swansea University Medical School, Swansea, UK
- Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK
| | - Patrick A Will
- BG Klinik Ludwigshafen, Ludwigshafen Am Rhein, Germany
- Ruprecht Karl University of Heidelberg, Heidelberg, Germany
| | - Rodrigo Tejos
- Sección de Cirugía Plástica y Reconstructiva. Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jagdeep Nanchahal
- The Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Abhilash Jain
- Imperial College Healthcare NHS Trust, London, UK
- Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Via GG, Brueggeman DA, Murray VA, Froehle AW, Burdette SD, Prayson MJ. Use of single agent Cefotetan for Gustilo-Anderson type III open fracture prophylaxis. Injury 2023; 54:110914. [PMID: 37441857 DOI: 10.1016/j.injury.2023.110914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/23/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION The prophylactic intravenous antibiotic regimen for Gustilo-Anderson Type III open fractures traditionally consists of cefazolin with an aminoglycoside plus penicillin for gross contamination. Cefotetan, a second-generation cephalosporin, offers a wide spectrum of activity against both aerobes and anaerobes as well as against Gram-positive and Gram-negative bacteria. Cefotetan has not been previously established within orthopedic surgery as a prophylactic intravenous agent. PATIENTS AND METHODS Cefotetan monotherapeutic prophylaxis versus any other antibiotic regimen (standard/literature-supported and otherwise) was studied for patient encounters between September 2010 and December 2019 within a single Level 1 regional trauma center. Patient comorbidities, preoperative fracture characteristics, and in-hospital/operative metrics (including length of stay [LOS], number of antibiotic doses, and antibiotic costs [US$]) were included for analysis. Postoperative outcomes up to 1 year included rates of surgical site infection (SSI), deep infection necessitating return to the operating room (OR), non-union, prescribed outpatient antibiotics, hospital readmissions, and related returns to the emergency department (ED). Sensitivity analyses were also conducted to include standard/literature-supported antibiotic regimens as a nested random factor within the non-cefotetan cohort. RESULTS The nested variable accounting for standard/literature-supported antibiotic regimens had no significant effect in any model for any outcome (for each, P ≥ 0.302). Thus, 1-year data for 138 Type III open fractures were included, accounting for only the binary effect of cefotetan (n = 42) versus non-cefotetan cohorts. The cohorts did not differ significantly at baseline. The cefotetan cohort received fewer in-house dose/day antibiotics (P < 0.001), was less likely to receive outpatient antibiotics in the following year (P = 0.023), had decreased return to the OR (35.7% versus 54.2%, P = 0.045), and demonstrated non-union rates of 16.7% versus 28.1% (P = 0.151). When adjusted for length of stay (LOS), the dose/day total costs for antibiotics were $8.71/day more expensive for the cefotetan cohort (P = 0.002). Type III open fractures incurred overall rates of SSI reaching 16.7% in the cefotetan cohort and 14.7% for non-cefotetan (P = 0.773). Deep infections necessitating return to the OR were 9.5% and 11.6%, respectively (P = 0.719). CONCLUSION Cefotetan alone may provide superior antibiotic stewardship with similar infectious sequalae compared to more traditional antibiotic prophylaxis regimens for Gustilo-Anderson Type III open long bone fractures. LEVEL OF EVIDENCE Level III Retrospective Cohort Study.
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Affiliation(s)
- Garrhett G Via
- Wright State University Department of Orthopaedic Surgery, 30 E. Apple St., Ste 2200, Dayton, Ohio 45409 United States of America.
| | - David A Brueggeman
- Wright State University Department of Orthopaedic Surgery, 30 E. Apple St., Ste 2200, Dayton, Ohio 45409 United States of America
| | - Victoria A Murray
- Wright State University Department of Orthopaedic Surgery, 30 E. Apple St., Ste 2200, Dayton, Ohio 45409 United States of America
| | - Andrew W Froehle
- Wright State University Department of Orthopaedic Surgery, 30 E. Apple St., Ste 2200, Dayton, Ohio 45409 United States of America
| | - Steven D Burdette
- Wright State University Department of Infectious Disease, 30 E. Apple St., Ste 6258, Dayton, Ohio 45409 United States of America
| | - Michael J Prayson
- Wright State University Department of Orthopaedic Surgery, 30 E. Apple St., Ste 2200, Dayton, Ohio 45409 United States of America
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Open tibial shaft fractures: treatment patterns in sub-Saharan Africa. OTA Int 2023; 6:e228. [PMID: 36919118 PMCID: PMC10005832 DOI: 10.1097/oi9.0000000000000228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 10/17/2022] [Indexed: 06/18/2023]
Abstract
Objective Open tibial shaft fractures are a leading cause of disability worldwide, particularly in low and middle-income countries (LMICs). Guidelines for these injuries have been developed in many high-income countries, but treatment patterns across Africa are less well-documented. Methods A survey was distributed to orthopaedic service providers across sub-Saharan Africa. Information gathered included surgeon and practice setting demographics and treatment preferences for open tibial shaft fractures across 3 domains: initial debridement, antibiotic administration, and fracture stabilization. Responses were grouped according to country income level and were compared between LMICs and upper middle-income countries (UMICs). Results Responses from 261 survey participants from 31 countries were analyzed, with 80% of respondents practicing in LMICs. Most respondents were male practicing orthopaedic surgeons at a tertiary referral hospital. For all respondents, initial debridement occurred most frequently in the operating room (OR) within the first 24 hours, but LMIC surgeons more frequently reported delays due to equipment availability, treatment cost, and OR availability. Compared with their UMIC counterparts, LMIC surgeons less frequently confirmed tetanus vaccination status and more frequently used extended courses of postoperative antibiotics. LMIC surgeons reported lower rates of using internal fixation, particularly for high-grade and late-presenting fractures. Conclusions This study describes management characteristics of open tibial shaft fractures in sub-Saharan Africa. Notably, there were reported differences in wound management, antibiotic administration, and fracture stabilization between LMICs and UMICs. These findings suggest opportunities for standardization where evidence is available and further research where it is lacking. Level of Evidence VI-Cross-Sectional Study.
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15
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Fonkoue L, Tissingh EK, Muluem OK, Kong D, Ngongang O, Tambekou U, Handy D, Cornu O, McNally M. Predictive factors for fracture-related infection in open tibial fractures in a Sub-Saharan African setting. Injury 2023:110816. [PMID: 37246113 DOI: 10.1016/j.injury.2023.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/30/2023]
Abstract
INTRODUCTION The management of open tibial fractures (OTF) is challenging in low and middle-income countries (LMICs) where appropriate human resources and infrastructure (including equipment, implants and surgical supplies) are not readily available and medical care is not readily accessible. OTF are not rarely associated with a subsequent fracture-related infection (FRI), which is one of the most devastating and difficult to cure complications in orthopaedic trauma care. The aim of this study was to determine the rate and the predictive factors of FRI in OTF in a limited-resource setting of sub-Saharan Africa. METHODS Patients with OTF who underwent surgery from July 2015 to December 2020 and followed-up for at least 12 months in a tertiary care teaching hospital in Yaoundé (Cameroon) were retrospectively investigated. Diagnosis of FRI was based on the confirmatory criteria of the International FRI Consensus definition. All patients with bone infections, occurring at any time point during follow-up, were included. Logistic regression was used to determine the predictive factors for FRI. RESULTS One hundred and five patients with OTF were studied. With a mean follow-up period of 29.5 ± 16.6 months, 33 patients (31.4%) presented with FRI. Gustilo-Anderson type of OTF, compliance with antibiotics, blood transfusion, time to first washing of the wounds and method of bone fixation were factors associated with the occurrence of FRI. In multivariable logistic regression, 6-hours delay to first washing of the wounds (OR=8.07, 95% CI: 1.43-45.31, p = 0.01), and compliance with antibiotics (OR=11.33, 95%CI: 1.11-115.6, p = 0.04) were the only independent predictors of FRI. CONCLUSION The overall rate of FRI in open tibial fracture is still high in the sub-Saharan African context. For similar low-resources settings, this study supports the recommendations (1) to perform a very early washing-dressing-splinting of OTF on admission of the patient, (2) to administer antibiotics early, and (3) to perform surgery as soon as reasonably possible, once appropriate personnel, equipment, implants and surgical supplies are available.
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Affiliation(s)
- Loïc Fonkoue
- Department of Orthopedics and Trauma, Yaoundé General Hospital, Yaoundé, Cameroon; Department of surgery and specialties, University of Yaoundé 1, Yaoundé PO Box 5408, Cameroon; Department of Orthopedics and Trauma, Yaoundé Emergency Center, Yaoundé, Cameroon.
| | - Elizabeth K Tissingh
- Royal National Orthopedic Hospital NHS TRUST, United Kingdom of Great Britain and Northern Ireland. United Kingdom; King's Global Health Partnerships, School of Life Course and Population Sciences, King's College London, United Kingdom of Great Britain and Northern Ireland, London, United Kingdom
| | - Olivier Kennedy Muluem
- Department of Orthopedics and Trauma, Yaoundé General Hospital, Yaoundé, Cameroon; Department of surgery and specialties, University of Yaoundé 1, Yaoundé PO Box 5408, Cameroon
| | - Denis Kong
- Department of surgery and specialties, University of Yaoundé 1, Yaoundé PO Box 5408, Cameroon
| | - Olivier Ngongang
- Department of Orthopedics and Trauma, Yaoundé Emergency Center, Yaoundé, Cameroon
| | - Urich Tambekou
- Department of Orthopedics and Trauma, Yaoundé Emergency Center, Yaoundé, Cameroon
| | - Daniel Handy
- Department of surgery and specialties, University of Yaoundé 1, Yaoundé PO Box 5408, Cameroon
| | - Olivier Cornu
- Department of Orthopedics and Trauma, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Martin McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, United Kingdom of Great Britain and Northern Ireland, Oxford, United Kingdom
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Risk Factors for Surgical Site Infections in Elective Orthopedic Foot and Ankle Surgery: The Role of Diabetes Mellitus. J Clin Med 2023; 12:jcm12041608. [PMID: 36836144 PMCID: PMC9963651 DOI: 10.3390/jcm12041608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023] Open
Abstract
Surgical site infection (SSI) after elective orthopedic foot and ankle surgery is uncommon and may be higher in selected patient groups. Our main aim was to investigate the risk factors for SSI in elective orthopedic foot surgery and the microbiological results of SSI in diabetic and non-diabetic patients, in a tertiary foot center between 2014 and 2022. Overall, 6138 elective surgeries were performed with an SSI risk of 1.88%. The main independent associations with SSI in a multivariate logistic regression analysis were an ASA score of 3-4 points, odds ratio (OR) 1.87 (95% confidence interval (CI) 1.20-2.90), internal, OR 2.33 (95% CI 1.56-3.49), and external material, OR 3.08 (95% CI 1.56-6.07), and more than two previous surgeries, OR 2.86 (95% CI 1.93-4.22). Diabetes mellitus showed an increased risk in the univariate analysis, OR 3.94 (95% CI 2.59-5.99), and in the group comparisons (three-fold risk). In the subgroup of diabetic foot patients, a pre-existing diabetic foot ulcer increased the risk for SSI, OR 2.99 (95% CI 1.21-7.41), compared to non-ulcered diabetic patients. In general, gram-positive cocci were the predominant pathogens in SSI. In contrast, polymicrobial infections with gram-negative bacilli were more common in contaminated foot surgeries. In the latter group, the perioperative antibiotic prophylaxis by second-generation cephalosporins did not cover 31% of future SSI pathogens. Additionally, selected groups of patients revealed differences in the microbiology of the SSI. Prospective studies are required to determine the importance of these findings for optimal perioperative antibiotic prophylactic measures.
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Buckman SA, Forrester JD, Bessoff KE, Parli SE, Evans HL, Huston JM. Surgical Infection Society Guidelines: 2022 Updated Guidelines for Antibiotic Use in Open Extremity Fractures. Surg Infect (Larchmt) 2022; 23:817-828. [DOI: 10.1089/sur.2022.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Sara A. Buckman
- Division of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Joseph D. Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Kovi E. Bessoff
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Sara E. Parli
- Department of Pharmacy Services, University of Kentucky, Lexington, Kentucky, USA
| | - Heather L. Evans
- Division of General and Acute Care Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jared M. Huston
- Departments of Surgery and Science Education, Zucker School of Medicine, Northwell Health, Manhasset, New York, USA
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Analysis of the Validity of Perioperative Antibiotic Prophylaxis in Maxillofacial Surgery. J Clin Med 2022; 11:jcm11195812. [PMID: 36233680 PMCID: PMC9573060 DOI: 10.3390/jcm11195812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 09/23/2022] [Accepted: 09/27/2022] [Indexed: 11/29/2022] Open
Abstract
Perioperative antibiotic prophylaxis is the standard in surgical departments. The type of operation, the duration of the procedure, the degree of microbiological purity of the operating field and the current clinical condition of the patient determine its administration. The aim of this study was to validate the antibiotic prophylaxis used in a Maxillofacial Surgery Department for a group of trauma and non-trauma patients. To that end, an observational prospective cohort study was carried out. The study was conducted on a group of 83 patients of the Department of Cranio-Maxillo-Facial Surgery who were divided into a group of trauma patients (n = 43) and one of non-trauma patients (n = 40). In both groups, the classic microbiological tests were carried out, and the results were analyzed in relation to: the study group, age, sex, duration of surgery, type of surgical access. Most bacterial strains were isolated at the initial stage of the operation. Gram (+) cocci were isolated more often in the trauma group and Gram (-) rods in the non-trauma group. Significantly more often, strains of fungi were noted in the initial stage of the procedure in the trauma group. We conclude that the use of perioperative antibiotic prophylaxis in the Maxillofacial Surgery Departments is justified.
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Salomon B, Griffard J, Patel J, Wideman M, Mcgee T, Corbitt N, Rowe AS, Price C, Heidel R, McKnight CL. Efficacy of Cefazolin versus Ceftriaxone for Extremity Open Fracture Management at a Level 1 Trauma Center. Surg Infect (Larchmt) 2022; 23:675-681. [PMID: 35925762 DOI: 10.1089/sur.2022.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Antibiotic agents have been shown to improve outcomes in open extremity fractures. The first-generation cephalosporins, which are used most often, are often under-dosed based on weight and recommended frequency. Ceftriaxone offers a broader coverage and a decreased frequency of administration. Our institution began utilizing ceftriaxone for open fracture management in 2017 to address those concerns. Objective: To examine the efficacy of cefazolin versus ceftriaxone for open fracture management of extremity trauma. Patients and Methods: Retrospective study from 2015-2019 of patients who sustained open extremity fractures. Patients were stratified by antibiotic administered and Gustilo-Anderson grade. Outcomes included non-union/malunion, superficial surgical site infection (SSI), deep SSI, osteomyelitis, re-operation after index hospital visit, re-admission due to prior injury, limb loss, and death. Subgroup analysis stratified each antibiotic group by Gustilo-Anderson grade 1 or 2 and grade 3. Results: Data was collected from 2015 to 2019. Of the 1,149 patients, 619 patients met inclusion criteria. Three hundred fifty-five patients received cefazolin and 264 patients received ceftriaxone. There were no statistically significant differences between groups on specified outcomes. No statistically significant differences existed during subgroup analysis for the specified outcomes. Multivariable analysis demonstrated increased Gustilo-Anderson grade increased risk of infectious outcome. Conclusions: Ceftriaxone is a safe and effective alternative for open fracture extremity management that offers the advantage of 24-hour dosing and single antibiotic coverage for grade 3 open fractures. It does not increase infectious complications and offers benefits of resource efficiency.
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Affiliation(s)
- Brett Salomon
- Department of Surgery, University of Tennessee at Knoxville Graduate School of Medicine, Knoxville, Tennessee, USA
| | - Jared Griffard
- Department of Surgery, University of Tennessee at Knoxville Graduate School of Medicine, Knoxville, Tennessee, USA
| | - Jay Patel
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Matthew Wideman
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Trevor Mcgee
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nolan Corbitt
- Tickle College of Engineering, University of Tennessee, Knoxville, Knoxville, Tennessee, USA
| | - A Shaun Rowe
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Knoxville, Tennessee, USA
| | - Chelsea Price
- Office of Biostatistics and Research Consultation, University of Tennessee at Knoxville Graduate School of Medicine, Knoxville, Tennessee, USA
| | - Robert Heidel
- Department of Surgery and Division of Biostatistics, University of Tennessee Medical Center at Knoxville, Knoxville, Tennessee, USA
| | - C Lindsay McKnight
- Department of Surgery and Division of Trauma and Critical Care Surgery, University of Tennessee at Knoxville Graduate School of Medicine, Knoxville, Tennessee, USA
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20
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Forrester JD, Bukur M, Dvorak JE, Faliks B, Hindin D, Kartiko S, Kheirbek T, Lin L, Manasa M, Martin TJ, Miskimins R, Patel B, Pieracci FM, Ritter KA, Schubl SD, Tung J, Huston JM. Surgical Infection Society: Chest Wall Injury Society Recommendations for Antibiotic Use during Surgical Stabilization of Traumatic Rib or Sternal Fractures to Reduce Risk of Implant Infection. Surg Infect (Larchmt) 2022; 23:321-331. [PMID: 35522129 DOI: 10.1089/sur.2022.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Surgical stabilization of rib fractures is recommended in patients with flail chest or multiple displaced rib fractures with physiologic compromise. Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involve open reduction and internal fixation of fractures with a plate construct to restore anatomic alignment. Most plate constructs are composed of titanium and presence of this foreign, non-absorbable material presents opportunity for implant infection. Although implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity often requiring prolonged antibiotic therapy, debridement, and potentially implant removal. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for antibiotic use during and after surgical stabilization of traumatic rib and sternal fractures. Clinical scenarios included patients with concomitant infectious processes (sepsis, pneumonia, empyema, cellulitis) or sources of contamination (open chest, gross contamination) incurred as a result of their trauma and present at the time of their surgical stabilization. PubMed, Embase, and Cochrane databases were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: For patients undergoing SSRF or SSSF in the absence of pre-existing infectious process, there is insufficient evidence to suggest existing peri-operative guidelines or recommendations are inadequate. For patients undergoing SSRF or SSSF in the presence of sepsis, pneumonia, or an empyema, there is insufficient evidence to provide recommendations on duration and choice of antibiotic. This decision may be informed by existing guidelines for the concomitant infection. For patients undergoing SSRF or SSSF with an open or contaminated chest there is insufficient evidence to provide specific antibiotic recommendations. Conclusions: This guideline document summarizes the current Surgical Infection Society and Chest Wall Injury Society recommendations regarding antibiotic use during and after surgical stabilization of traumatic rib or sternal fractures. Limited evidence exists in the chest wall surgical stabilization literature and further studies should be performed to delineate risk of implant infection among patients undergoing SSSRF or SSSF with concomitant infectious processes.
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Affiliation(s)
- Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Marko Bukur
- Division of Acute Care Surgery, Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Justin E Dvorak
- Division of Trauma, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Bradley Faliks
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - David Hindin
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Susan Kartiko
- Center for Trauma and Critical Care, Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Tareq Kheirbek
- Department of Surgery, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Leo Lin
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Morgan Manasa
- Department of General Surgery, University of California, Irvine, Irvine, California, USA
| | - Thomas J Martin
- Department of Surgery, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Richard Miskimins
- Division of Acute Care Surgery, Department of Surgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Bhavik Patel
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Kaitlin A Ritter
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Sebastian D Schubl
- Department of General Surgery, University of California, Irvine, Irvine, California, USA
| | - Jamie Tung
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Jared M Huston
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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21
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Moore L, Bérubé M, Tardif PA, Lauzier F, Turgeon A, Cameron P, Champion H, Yanchar N, Lecky F, Kortbeek J, Evans D, Mercier É, Archambault P, Lamontagne F, Gabbe B, Paquet J, Razek T, Stelfox HT. Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care. JAMA Surg 2022; 157:507-514. [PMID: 35476055 PMCID: PMC9047751 DOI: 10.1001/jamasurg.2022.0812] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators. Objective To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care. Design, Setting, and Participants This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners. Main Outcomes and Measures Panelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability. Results Of 49 eligible experts approached, 46 (94%; 18 experts [39%] aged ≥50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery). Conclusions and Relevance In this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Mélanie Bérubé
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.,Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - François Lauzier
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Alexis Turgeon
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Howard Champion
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom.,Trauma Audit and Research Network, Salford, United Kingdom
| | - John Kortbeek
- Department of Surgery, University of Calgary, Calgary, Canada
| | - David Evans
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Éric Mercier
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Transfert des Connaissances et Évaluation des Technologies et Modes d'Intervention en Santé, Centre de Recherche du CHU de Québec - Université Laval (Hôpital St François d'Assise), Université Laval, Québec City, Québec, Canada
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jérôme Paquet
- Division of Neurosurgery, Department of Surgery, Université Laval, Québec, Québec, Canada
| | - Tarek Razek
- Department of Trauma Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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22
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Takahara S, Tokura T, Nishida R, Uefuji A, Ichimura K, Nishihara H, Aoki K, Takayama H, Nakagawa N, Harada T. Ampicillin/sulbactam versus cefazolin plus aminoglycosides for antimicrobial prophylaxis in management of Gustilo type IIIA open fractures: A retrospective cohort study. Injury 2022; 53:1517-1522. [PMID: 35090733 DOI: 10.1016/j.injury.2022.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 01/15/2022] [Accepted: 01/17/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The antibiotic regimens for prophylaxis in the management of open fractures remain controversial. Although the use of aminoglycosides is widely accepted for treatment of Gustilo type III open fractures, aminoglycosides are often avoided in patients with risk factors. This study aimed to compare efficacy and safety of two regimens, cephazolin plus aminoglycoside (amikacin or gentamicin) and ampicillin/sulbactam (ABPC/SBT), in patients with Gustilo type IIIA open fractures. METHODS A total of 95 Gustilo type IIIA fractures in 90 patients were retrospectively reviewed in this study. The cohort was categorized into two groups that were treated in accordance with the institutional prescribed regimen in different periods: (1) cefazolin plus aminoglycoside (January 1, 2014-September 30, 2017) and (2) ABPC/SBT monotherapy (October 1, 2017-September 30, 2020). Cefazolin was used at 1-2 g every 8 h, aminoglycoside (amikacin or gentamicin) was used daily depending on body weight, and ABPC/SBT was used at 3 g every 8 h The antibiotic administration was continued within 3 days or until successful soft tissue coverage was achieved. The infection rate and the incidence of acute kidney injury (AKI) in both groups were assessed. RESULTS ABPC/SBT was used in 34 patients (36 fractures), and 56 patients (59 fractures) received cefazolin plus aminoglycoside for antibiotic prophylaxis. Infection developed in 2 of 36 fractures in ABPC/SBT group and 4 of 59 fractures in the cefazolin plus aminoglycoside group (p > 0.99). The average serum creatinine levels on admission, baseline, and peak during the hospital stay were not significantly different between the two groups. One case of AKI was identified in each group, indicating that incidence rate of AKI was not significantly different between the two groups. CONCLUSION We demonstrated the non-inferiority of ABPC/SBT therapy over cefazolin plus aminoglycoside regimen for type IIIA open fractures. The ABPC/SBT regimen may be an alternative option for managing Gustilo type IIIA open fractures. Further prospective studies with larger samples are needed to verify these results.
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Affiliation(s)
- Shunsuke Takahara
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan.
| | - Takeo Tokura
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Ryota Nishida
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Atsuo Uefuji
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Katsuhito Ichimura
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Hirotaka Nishihara
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Kenji Aoki
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Hiroyuki Takayama
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Natsuko Nakagawa
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
| | - Toshihiko Harada
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo 675-8555, Japan
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23
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Type of antibiotic but not the duration of prophylaxis correlates with rates of fracture-related infection. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:987-992. [PMID: 35262777 PMCID: PMC8905276 DOI: 10.1007/s00590-022-03246-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 10/30/2022]
Abstract
PURPOSE The issue of optimal prophylactic antibiotic administration for closed and open fracture surgeries remains controversial. The purpose of this study was to assess the role of type and duration longer than 48 h of antibiotic prophylaxis on the rates of fracture-related infection (FRI). METHODS This is a single-center, prospective observational cohort study carried out with patients undergoing surgery for implants insertion to fracture stability. Risk estimates were calculated on the variables associated with factors for FRI and reported as a prevalence ratio (PR) with respect to the 95% confidence interval (CI). RESULTS Overall, 132 patients were analyzed. The global rate of FRI was 15.9% (21/132), with open and closed fractures accounting for 30.5% (11/36) and 10.4% (10/96), respectively. The FRI rates in patients undergoing orthopedic surgery for fracture stabilization who received prophylactic antibiotic for up to and longer than 48 h were 8.9% and 26.4%, respectively. This difference did not reach statistical significance (prevalence ratio [PR] = 2.6, 95% confidence interval [95% CI]: 0.9-7.3. p = 0.063). CONCLUSIONS Duration of antibiotic prophylaxis for surgical orthopedic fractures was not correlated with rates of FRI.
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24
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Opri F, Bianchini S, Nicoletti L, Monaco S, Opri R, Di Pietro M, Carrara E, Rigotti E, Auriti C, Caminiti C, Donà D, Lancella L, Lo Vecchio A, Pizzi S, Principi N, Simonini A, Tesoro S, Venturini E, Villani A, Staiano A, Marchesini Reggiani L, Esposito S. Surgical Antimicrobial Prophylaxis in Patients of Neonatal and Pediatric Age Undergoing Orthopedic and Hand Surgery: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:antibiotics11030289. [PMID: 35326754 PMCID: PMC8944525 DOI: 10.3390/antibiotics11030289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/15/2022] [Accepted: 02/20/2022] [Indexed: 01/29/2023] Open
Abstract
Surgical site infections (SSIs) represent a potential complication in any type of surgery and can occur up to one year after the procedure in the case of implant placement. In the field of orthopedic and hand surgery, the rate of SSIs is a relevant issue, considering the need for the placement of synthesis devices and the type of some interventions (e.g., exposed fractures). This work aims to provide guidance on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing orthopedic and hand surgery in order to standardize the management of patients and to reduce, on the one hand, the risk of SSI and, on the other, the development of antimicrobial resistance. The following scenarios were considered: (1) bloodless fracture reduction; (2) reduction of unexposed fracture and grade I and II exposed fracture; (3) reduction of grade III exposed fracture or traumatic amputation; (4) cruel fracture reduction with percutaneous synthesis; (5) non-traumatic amputation; (6) emergency intact skin trauma surgery and elective surgery without synthetic media placement; (7) elective orthopedic surgery with prosthetic and/or synthetic media placement and spinal surgery; (8) clean elective hand surgery with and without bone involvement, without use of synthetic means; (9) surgery of the hand on an elective basis with bone involvement and/or with use of synthetic means. This manuscript has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies and represents, in our opinion, the most complete and up-to-date collection of recommendations regarding the behavior to be adopted in the peri-operative setting in neonatal and pediatric orthopedic and hand surgery. The specific scenarios developed are aimed at guiding the healthcare professional in practice to ensure the better and standardized management of neonatal and pediatric patients, together with an easy consultation.
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Affiliation(s)
- Francesca Opri
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37124 Verona, Italy; (F.O.); (R.O.); (M.D.P.); (E.R.)
| | - Sonia Bianchini
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
| | - Laura Nicoletti
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
| | - Sara Monaco
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
| | - Roberta Opri
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37124 Verona, Italy; (F.O.); (R.O.); (M.D.P.); (E.R.)
| | - Marilia Di Pietro
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37124 Verona, Italy; (F.O.); (R.O.); (M.D.P.); (E.R.)
| | - Elena Carrara
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, 37134 Verona, Italy;
| | - Erika Rigotti
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37124 Verona, Italy; (F.O.); (R.O.); (M.D.P.); (E.R.)
| | - Cinzia Auriti
- Neonatology and Neonatal Intensive Care Unit, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, 43126 Parma, Italy;
| | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, 35100 Padua, Italy;
| | - Laura Lancella
- Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (L.L.); (A.V.)
| | - Andrea Lo Vecchio
- Department of Translational Medical Science, Section of Pediatrics, University of Naples “Federico II”, 80138 Naples, Italy; (A.L.V.); (A.S.)
| | - Simone Pizzi
- Pediatric Anesthesia and Intensive Care Unit, Salesi Children’s Hospital, 60123 Ancona, Italy; (S.P.); (A.S.)
| | | | - Alessandro Simonini
- Pediatric Anesthesia and Intensive Care Unit, Salesi Children’s Hospital, 60123 Ancona, Italy; (S.P.); (A.S.)
| | - Simonetta Tesoro
- Division of Anesthesia, Analgesia, and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, 06129 Perugia, Italy;
| | - Eisabetta Venturini
- Pediatric Infectious Disease Unit, Meyer Children’s Hospital, 50139 Florence, Italy;
| | - Alberto Villani
- Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (L.L.); (A.V.)
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples “Federico II”, 80138 Naples, Italy; (A.L.V.); (A.S.)
| | | | - Susanna Esposito
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
- Correspondence: ; Tel.: +39-0521-903524
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25
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Constantine RS, Le EL, Gehring MB, Ohmes L, Iorio ML. Risk Factors for Infection After Distal Radius Fracture Fixation: Analysis of Impact on Cost of Care. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:123-127. [PMID: 35601524 PMCID: PMC9120794 DOI: 10.1016/j.jhsg.2021.12.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/28/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose Infection after distal radius fracture fixation can be a devastating complication, leading to potential hardware removal, prolonged antibiotic courses, multiple office visits, and increased costs. This study aimed to identify potential risk factors for infectious complications after distal radius fracture fixation and assess the impacts on cost. Methods This study used the PearlDiver national database, encompassing 53 million unique patients from January 1, 2010, to March 31, 2020. The cohort included patients undergoing distal radius fracture fixation. The endpoint was postoperative infection within 180 days of fixation. Two-sample t test was used to compare rates of infection between open and percutaneous fracture fixation techniques. A propensity-matched cohort was created using patient age, gender, and open fracture. Logistic regression analyses defined independent risk factors for developing a postoperative infection among all patients and within the matched cohorts. A Mann-Whitney U test was used to compare costs of care with and without infection. Results The database included 87,169 patients who underwent distal radius fracture fixation. Postoperative infections were identified in 781 patients (0.9%). There was a significant difference in rates of postoperative infection with percutaneous fixation (1.3%) versus open fixation (0.8%). Logistic regression analysis identified male gender, open fracture, lung disease, chronic kidney disease, diabetes, hypertension, liver disease, obesity, and tobacco to be independent risk factors for developing a postoperative infection. Logistic regression analysis of the propensity-matched cohorts identified tobacco use as a significant risk factor. The average cost of care for patients undergoing fracture fixation without an infection was $6,383, versus $23,355 for those with an infection, which was significantly different. Conclusions Multiple risk factors for postoperative infection were identified. Cost is significantly increased after postoperative infection, by almost 4-fold. Attempts to correct or optimize modifiable risk factors may lead to substantial cost savings, and potentially decreased rates of infection. Type of study/level of evidence Prognostic III.
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Affiliation(s)
- Ryan S. Constantine
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Elliot L.H. Le
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Michael B. Gehring
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Lucas Ohmes
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Matthew L. Iorio
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
- Corresponding author: Matthew L. Iorio, MD, Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, 12631 E. 17th Ave, C309 (Room 6414), Aurora, CO 80045.
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26
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Yu G, Ren H, Xiao A, Liu J, Li M, Zhang N. Wound infection in elbow fractures: Incidence and new management protocol. Int Wound J 2021; 19:1409-1417. [PMID: 34935285 PMCID: PMC9493212 DOI: 10.1111/iwj.13734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/27/2021] [Accepted: 12/01/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Guiyong Yu
- Department of Rehabilitation, Hengshui People's Hospital, Hengshui, China
| | - Hong Ren
- Department of Rehabilitation, Hengshui People's Hospital, Hengshui, China
| | - Aiwei Xiao
- Department of Rehabilitation, Hengshui People's Hospital, Hengshui, China
| | - Juan Liu
- Department of Rehabilitation, Hengshui People's Hospital, Hengshui, China
| | - Mei Li
- Department of Rehabilitation, Hengshui People's Hospital, Hengshui, China
| | - Ning Zhang
- Department of Orthopedic Surgery, Hengshui People's Hospital, Hengshui, China
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27
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Ioannou P, Karakonstantis S, Schouten J, Kostyanev T, Charani E, Vlahovic-Palcevski V, Kofteridis DP. Indications for medical antibiotic prophylaxis and potential targets for antimicrobial stewardship intervention: a narrative review. Clin Microbiol Infect 2021; 28:362-370. [PMID: 34653572 DOI: 10.1016/j.cmi.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Most of the antimicrobial stewardship (AMS) literature has focused on antimicrobial consumption for the treatment of infections, for the prophylaxis of surgical site infection and for the prevention of endocarditis. The role of AMS for medical antibiotic prophylaxis (AP) has not been adequately addressed. AIMS To identify targets for AMS interventions for medical AP in adult patients. SOURCES Targeted searches were conducted in PubMed. CONTENT The various indications for medical AP and relevant evidence from practice guidelines are outlined. The following were identified as potential targets for AMS interventions: (a) addressing under-utilization of antibiotic-sparing strategies (e.g. for recurrent urinary tract infections, recurrent soft-tissue infections, recurrent exacerbations associated with bronchiectasis or chronic obstructive pulmonary disease), (b) reducing unnecessary AP beyond recommended indications (e.g. for acute pancreatitis, bite wounds, or urinary catheter manipulations), (c) reducing the use of AP with a broader spectrum than necessary, (d) reducing the use of AP for longer than the recommended duration (e.g. AP for prevention of osteomyelitis in open fractures or AP in high-risk neutropenia), (e) evaluating the role of antibiotic cycling to prevent the emergence of resistance during prolonged AP (e.g. in recurrent urinary tract infections or prophylaxis for spontaneous bacterial peritonitis), and (f) addressing research gaps regarding appropriate indications or antibiotic regimens for medical prophylaxis. IMPLICATIONS This review summarizes current trends in AP and proposes targets for AMS interventions.
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Affiliation(s)
- Petros Ioannou
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Stamatis Karakonstantis
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Jeroen Schouten
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Tomislav Kostyanev
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Esmita Charani
- Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
| | - Vera Vlahovic-Palcevski
- Department of Clinical Pharmacology, University Hospital Rijeka / Medical Faculty and Faculty of Health Studies, University of Rijeka, Rijeka, Croatia
| | - Diamantis P Kofteridis
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, Crete, Greece.
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O'Connell CR, Kooda KJ, Sawyer MD, Wise KB, Mara KC, Skrupky LP. Evaluation of Piperacillin-Tazobactam for Antibiotic Prophylaxis in Traumatic Grade III Open Fractures. Surg Infect (Larchmt) 2021; 23:41-46. [PMID: 34612703 DOI: 10.1089/sur.2021.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Broad-spectrum antibiotic agents are sometimes utilized for prophylaxis of Gustilo grade III open fractures. However, this practice is not recommended by current guidelines, and it is unknown how patient outcomes are impacted. This study aimed to determine if prophylaxis with piperacillin-tazobactam (PT) results in different rates of infection versus guideline-concordant therapy (GCT). Patients and Methods: This was a single-center, retrospective cohort study of adult trauma patients with Gustilo grade III open long bone fractures admitted between January 2008 and August 2018. The primary outcome of infection (superficial or deep) at six weeks and secondary outcomes of delayed union, nonunion, Clostridioides difficile, and development of resistant organisms were abstracted from medical records. Guideline-concordant therapy was defined as a first-generation cephalosporin with or without an aminoglycoside. Univariable and multivariable analyses controlling for injury severity score (ISS) were performed. Results: One hundred twenty patients were included; 97 (81%) received PT, 23 (19%) received GCT. Common injury mechanisms were motor vehicle/motorcycle accident (57%) and falls (17%), and a majority involved a lower extremity (65%). Baseline characteristics were similar except higher median ISS in PT (14; interquartile range [IQR], 9-22) versus GCT (9; IQR, 9-14). Guideline-concordant therapy was given for a median of four (range, 2-8) days and PT for six (range, 3-11) days (p = 0.078). On univariable analysis, PT patients had more infections at six weeks (23.7% vs. 4.3%; p = 0.042), but multivariable analysis demonstrated no difference (odds ratio [OR], 5.81; 95% confidence interval [CI], 0.73-46.25; p = 0.096). Patients receiving prophylaxis with PT had a longer median length of stay at 16 days (range, 10-22) versus nine days (range, 4-16). No statistically significant differences in delayed union, non-union, Clostridioides difficile, or development of resistant organisms were observed. Conclusions: Broad-spectrum antibiotic prophylaxis with PT did not improve infection rates compared to GCT, suggesting it may not be warranted.
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Affiliation(s)
- Casey R O'Connell
- Department of Pharmacy Services, Mayo Clinic Hospital-Rochester, Rochester, Minnesota, USA
| | - Kirstin J Kooda
- Department of Pharmacy Services, Mayo Clinic Hospital-Rochester, Rochester, Minnesota, USA
| | - Mark D Sawyer
- Department of Surgery, Mayo Clinic Hospital-Rochester, Rochester, Minnesota, USA
| | - Kevin B Wise
- Department of Surgery, Mayo Clinic Hospital-Rochester, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic Hospital-Rochester, Rochester, Minnesota, USA
| | - Lee P Skrupky
- Department of Pharmacy Services, Mayo Clinic Hospital-Rochester, Rochester, Minnesota, USA
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Sagi HC, Patzakis MJ. Evolution in the Acute Management of Open Fracture Treatment? Part 1. J Orthop Trauma 2021; 35:449-456. [PMID: 34415869 DOI: 10.1097/bot.0000000000002094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Despite decades of advancement in wound debridement, prophylactic antibiotic therapy, fracture stabilization, and soft tissue reconstruction, infection remains a serious complication after open fracture. Inconclusive historical data and new challenges with resistant organisms and antimicrobial stewardship having created a difficult environment within which to develop sound, evidence-based treatment protocols that can be applied universally. The first part of this 2-part series will synthesize the historical perspective along with the current concepts surrounding bacteriology and antibiotic use/stewardship. Part 2 will analyze and summarize the current literature regarding the management of open fracture and prevention of subsequent infection.Numerous authors from Hippocrates to Larrey noted that superior results were obtained with an early aggressive debridement of necrotic tissue after wounding.1-7 Historically, the usual outcome after open fracture was infection, sepsis, amputation, and death before the introduction of antibiotics.8-11 As recently as the first half of the 20th century, surgeons argued that if an appropriate debridement was performed, antibiotics were not necessary and advocated against their routine use over concern for resistant organisms.The current period of open fracture treatment (starting in the 1970s) heralded a more scientific era with critical evaluation of antibiotics, surgical debridement, and the development of standardized evidence-based protocols. This era began with 3 classic articles by Patzakis and Gustilo that, to this day, remain central to the discussion of infection prevention after open fractures.12-14. LEVEL OF EVIDENCE Therapeutic Level V. See Instructions for Authors for a Complete description of levels of evidence.
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Affiliation(s)
- Henry C Sagi
- Department of Orthopaedic Surgery and Sports Medicine, Univeristy of Cincinnati Medical Center, Cincinnati, OH; and
| | - Michael J Patzakis
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA
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National Metrics Improved Timeliness of Antibiotic Administration for Open Extremity Fractures. J Orthop Trauma 2021; 35:437-441. [PMID: 33278206 DOI: 10.1097/bot.0000000000002027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Antibiotics have been shown to be an essential component in the treatment of open extremity fractures. The American College of Surgeons' Trauma Quality Improvement Program, based on a committee of physician leaders including orthopaedic trauma surgeons, publishes best-practice guidelines for the management of open fractures. Accordingly, it established the tracking of antibiotic timing as a metric with a plan to use that metric before trauma center site reviews. Our hypothesis was that this physician-led effort at the national level would provide the necessary incentive to effect change within our institution. METHODS A retrospective review of all patients treated at our institution for open extremity fractures was performed over 3 periods separated by 2 quality initiatives. The first initiative was an institution-driven effort to increase awareness and educate specific departments about the importance of prompt antibiotic administration. The second initiative was the tracking of antibiotic order and administration times with quarterly audits following newly published guidelines. RESULTS Neither antibiotic order placement within 1 hour nor administration within 1 hour improved after our first institution-specific initiative. Both outcome measures significantly improved after the second quality initiative, as did median times from arrival to antibiotic order and administration. CONCLUSIONS Metrics developed and measured by a physician-led national organization led to practice changes at our hospital. Tracking of antibiotic timing for open fracture treatment was more effective than institutional education of healthcare providers alone. This study suggests that nationally published guidelines, developed and measured by physician leaders, will be found to be relevant by other physicians and can be a powerful tool to drive change.
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Pottecher J, Lefort H, Adam P, Barbier O, Bouzat P, Charbit J, Galinski M, Garrigue D, Gauss T, Georg Y, Hamada S, Harrois A, Kedzierewicz R, Pasquier P, Prunet B, Roger C, Tazarourte K, Travers S, Velly L, Gil-Jardiné C, Quintard H. Guidelines for the acute care of severe limb trauma patients. Anaesth Crit Care Pain Med 2021; 40:100862. [PMID: 34059492 DOI: 10.1016/j.accpm.2021.100862] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOAL To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre. DESIGN A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded. METHODS The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.
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Affiliation(s)
- Julien Pottecher
- Service d'Anesthésie-Réanimation & Médecine Péri-Opératoire, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098 Strasbourg Cedex, France; Université de Strasbourg, FMTS, France.
| | - Hugues Lefort
- Structure des urgences, Hôpital d'Instruction des Armées Legouest, BP 9000, 57077 Metz Cédex 03, France
| | - Philippe Adam
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 Avenue Molière, 67098 Strasbourg Cedex, France
| | - Olivier Barbier
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital d'Instruction des Armées Sainte Anne, 2 boulevard Sainte Anne, 83000 Toulon, France; Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France
| | - Pierre Bouzat
- Université Grenoble Alpes, Pôle Anesthésie-Réanimation, Centre Hospitalo-Universitaire Grenoble-Alpes, Grenoble, France
| | - Jonathan Charbit
- Soins critiques DAR Lapeyronie, CHU Montpellier, France; Réseau OcciTRAUMA, Réseau Régional Occitanie de prise en charge des traumatisés sévères, France
| | - Michel Galinski
- Pôle urgences adultes - SAMU 33, Hôpital Pellegrin, CHU de Bordeaux 3300 Bordeaux, France; INSERM U1219, ISPED, Bordeaux Population Health Research Center INSERM U1219-"Injury Epidemiology Transport Occupation" Team, F-33076 Bordeaux Cedex, France
| | - Delphine Garrigue
- Pôle d'Anesthésie Réanimation, Pôle de l'Urgence, CHU Lille, F-59000 Lille, France
| | - Tobias Gauss
- Service d'Anesthésie-Réanimation, Hôpital Beaujon, DMU PARABOL, AP-HP Nord, Clichy, France; Université de Paris, Paris, France
| | - Yannick Georg
- Service de Chirurgie Vasculaire et Transplantation Rénale, Hôpitaux Universitaire de Strasbourg, Strasbourg, France
| | - Sophie Hamada
- Département d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou, APHP, Université de Paris, Paris, France
| | - Anatole Harrois
- Département d'anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Saclay, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, France
| | - Romain Kedzierewicz
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Bureau de Médecine d'Urgence, Division Santé, Brigade de Sapeurs-Pompiers de Paris, 1 place Jules Renard, 75017 Paris, France
| | - Pierre Pasquier
- Département anesthésie-réanimation, Hôpital d'instruction des armées Percy, Clamart, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Bertrand Prunet
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Claire Roger
- Service de Réanimation Chirurgicale, Pôle Anesthésie Réanimation Douleur Urgence, CHU Carémeau, 30000 Nîmes, France
| | - Karim Tazarourte
- Service SAMU-Urgences, CHU Edouard Herriot, Hospices civils de Lyon, Lyon, France; Université Lyon 1 Hesper EA 7425, Lyon, France
| | - Stéphane Travers
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; 1ère Chefferie du Service de Santé, Villacoublay, France
| | - Lionel Velly
- Service d'Anesthésie Réanimation, CHU Timone Adultes, 264 rue St Pierre 13005 Marseille, France; MeCA, Institut de Neurosciences de la Timone - UMR 7289, Aix Marseille Université, Marseille, France
| | - Cédric Gil-Jardiné
- Pôle Urgences adultes SAMU-SMUR, CHU Bordeaux, Bordeaux Population Health - INSERM U1219 Université de Bordeaux, Equipe IETO, Bordeaux, France
| | - Hervé Quintard
- Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
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Sim WP, Ng HJH, Liang BZ, Rajaratnam V. Can Open Hand Injuries Wait for Their Surgery in a Tertiary Hospital? J Hand Microsurg 2021; 13:157-163. [PMID: 34511832 PMCID: PMC8426081 DOI: 10.1055/s-0041-1725220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Objective Open hand injuries are routinely admitted and planned for surgery acutely, competing with other surgical emergencies. This retrospective study aims to evaluate if a delay in timing to surgery for open hand injuries led to an increased rate of infection. Materials and Methods All patients who sustained open hand injuries and underwent semi-emergent day surgery from January 1, 2015 to December 31, 2016 were included. Outcome of postoperative infection was analyzed against demographic data, injury details, and delay from trauma to therapy. Results There were 232 cases (91% males) included, with 92.0% performed under local anesthesia. Deep seated postoperative infection was seen in 1.3%, which was not significantly associated with delay to surgery. Conclusion We had comparable infection rates as compared with published literature. Delayed timing of surgical treatment in open hand injuries was not associated with increased rates of deep-seated infection. Managing open hand injuries as semi-emergent surgeries may be acceptable given the low infection rates.
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Affiliation(s)
- Wei Ping Sim
- Hand and Reconstructive Microsurgery Service, Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Hannah Jia Hui Ng
- Hand and Reconstructive Microsurgery Service, Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Benjamin Zhiren Liang
- Hand and Reconstructive Microsurgery Service, Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Vaikunthan Rajaratnam
- Hand and Reconstructive Microsurgery Service, Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
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Impact of duration of perioperative antibiotic prophylaxis on development of fracture-related infection in open fractures. Arch Orthop Trauma Surg 2021; 141:235-243. [PMID: 32409906 DOI: 10.1007/s00402-020-03474-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Infection is a common complication of open fractures potentially leading to nonunion, functional loss, and even amputation. Perioperative antibiotic prophylaxis (PAP) is standard practice for infection prevention in the management of open fractures. However, optimal duration of PAP remains controversial. The objectives were to assess whether PAP duration is independently associated with infection in open fractures and if administration of PAP beyond the commonly-recommended limit of 72 h has any effect on the infection rate. MATERIALS AND METHODS Over a 14-year period from 2003 to 2017, 530 skeletally-mature patients with operatively-treated, non-pathologic, long-bone open fractures were treated at one institution. Twenty-eight patients were excluded because of death or loss to follow-up and the remaining 502 patients (with 559 open fractures) who completed a 24-month follow-up were included in this retrospective study. The outcome was fracture-related infection (FRI), defined by the criteria of a recent consensus definition. A logistic generalized estimating equations regression model was conducted, including PAP duration and variables selected by a least absolute shrinkage and selection operator (LASSO) method, to assess the association between PAP duration and FRI. Propensity score analysis using a 72-h cut-off was performed to further cope with confounding. RESULTS PAP duration, adjusted for the LASSO selected predictors, was independently associated with FRI (OR: 1.11 [95%CI, 1.04-1.19] for every one-day increase in PAP duration, p = 0.003). PAP duration longer than 72 h did not significantly increase the odds for FRI compared to shorter durations (p = 0.06, analysis adjusted for propensity score). CONCLUSIONS This study found no evidence that administration of prophylactic antibiotics beyond 72 h in patients with long-bone open fractures is warranted. Analyses adjusted for known confounders even revealed a higher risk for FRI for longer PAP. However, this effect cannot necessarily be considered as causal and further research is needed.
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Mele TS, Kaafarani HMA, Guidry CA, Loor MM, Machado-Aranda D, Mendoza AE, Morris-Stiff G, Rattan R, Schubl SD, Barie PS. Surgical Infection Society Research Priorities: A Narrative Review of Fourteen Years of Progress. Surg Infect (Larchmt) 2020; 22:568-582. [PMID: 33275862 DOI: 10.1089/sur.2020.309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: In 2006, the Surgical Infection Society (SIS) utilized a modified Delphi approach to define 15 specific priority research questions that remained unanswered in the field of surgical infections. The aim of the current study was to evaluate the scientific progress achieved during the ensuing period in answering each of the 15 research questions and to determine if additional research in these fields is warranted. Methods: For each of the questions, a literature search using the National Center for Biotechnology Information (NCBI) was performed by the Scientific Studies Committee of the SIS to identify studies that attempted to address each of the defined questions. This literature was analyzed and summarized. The data on each question were evaluated by a surgical infections expert to determine if the question was answered definitively or remains unanswered. Results: All 15 priority research questions were studied in the last 14 years; six questions (40%) were definitively answered and 9 questions (60%) remain unanswered in whole or in part, mainly because of the low quality of the studies available on this topic. Several of the 9 unanswered questions were deemed to remain research priorities in 2020 and warrant further investigation. These included, for example, the role of empiric antimicrobial agents in nosocomial infections, the use of inotropes/vasopressors versus volume loading to raise the mean arterial pressure, and the role of increased antimicrobial dosing and frequency in the obese patient. Conclusions: Several surgical infection-related research questions prioritized in 2006 remain unanswered. Further high-quality research is required to provide a definitive answer to many of these priority knowledge gaps. An updated research agenda by the SIS is warranted at this time to define research priorities for the future.
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Affiliation(s)
- Tina S Mele
- Divisions of General Surgery and Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher A Guidry
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michele M Loor
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David Machado-Aranda
- Division of Acute Care Surgery, Michigan Medicine and Ann Arbor Veterans' Affairs Health System, Ann Arbor, Michigan, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gareth Morris-Stiff
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio, USA
| | - Rishi Rattan
- Division of Trauma Surgery and Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine, California, USA
| | - Philip S Barie
- Division of Trauma Burns, Acute and Critical Care, Department of Surgery, and Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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McMurtrie T, Prather J, Cone R, Montgomery T, Patel C, McGwin G, Spitler C. Extended Antibiotic Coverage in the Management of Type II Open Fractures. Surg Infect (Larchmt) 2020; 22:662-667. [PMID: 33064633 DOI: 10.1089/sur.2020.300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Responsible antibiotic stewardship requires surgeons treating open fractures to use the narrowest appropriate antibiotic coverage possible to prevent infection. Because inter-observer agreement about the application of the Gustilo-Anderson open fracture classification is moderate at best, antibiotic selection can be overly aggressive. The purpose of this study was to evaluate the outcomes of Type II open fractures treated with gram-positive coverage only (GP) versus broad-spectrum antibiotic coverage (BS) with piperacillin-tazobactam (PT). Methods: A retrospective review of all Type II open fractures was performed at a single Level one trauma center over a 5-year period (2013-2017). All patients received prophylactic antibiotics on arrival on the basis of the best judgment of classification by the house officer on call. The final Gustilo-Anderson open fracture classification was assigned intra-operatively by the operating surgeon. Two groups were created, a GP antibiotic group (cefazolin and/or clindamycin) and a BS group (PT). A minimum of 3-month follow-up was required for inclusion. Patient demographics, cost of treatment, fracture-related infection (FRI) rates, and infecting bacteria were assessed. Results: The GP group contained 70 open fractures and the BS group contained 74 open fractures. Between the groups, there were no differences in age, sex, race, Body Mass Index, American Society of Anesthesiologists Class, or smoking status. There were no statistical differences in Injury Severity Score (ISS), fracture location, fixation method, or rates of staged management with external fixation. There was no difference in FRI rate between the GP and BS groups (8.6% versus 10.8%; p = 0.78). The bacteria responsible for FRI were similar in the GP and BS groups. The hospital charge for PT was 4.39 × the cost of cefazolin. Conclusions: The use of BS coverage in Type II open fractures does not result in a lower infection rate and adds significant cost to patient care. These data support the use of a GP-only antibiotic regimen for Type II open fractures.
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Affiliation(s)
- Thompson McMurtrie
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John Prather
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ryan Cone
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tyler Montgomery
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chirag Patel
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gerald McGwin
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Clay Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Early complications of antibiotic prophylaxis with cefazolin protocols versus piperacillin-tazobactam for open fractures: a retrospective comparative study. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kobata SI, Teixeira LEM, Fernandes SOA, Faraco AAG, Vidigal PVT, Araújo IDD. Prevention of bone infection after open fracture using a chitosan with ciprofloxacin implant in animal model. Acta Cir Bras 2020; 35:e202000803. [PMID: 32901680 PMCID: PMC7478494 DOI: 10.1590/s0102-865020200080000003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/06/2020] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate different concentrations of ciprofloxacin to prevent infection after open fracture contaminated with S. aureus in rats using absorbable local delivery system. METHODS Fifty-two Wistar rats were assigned to six groups. After 4 weeks, all animals underwent 99mTc-ceftizoxima scintigraphy evaluation, callus formation measurement and histological analysis. ANOVA, t-Student and Kruskal Wallis were used for quantitative variables statistical analysis, whereas qui square and exact Fisher were used for qualitative variables. RESULTS Treatment using 25% and 50% of ciprofloxacin incorporated at the fracture fixation device were effective in preventing bone infection compared to control group (p<0.05). Chitosan were not effective in preventing bone infection when used alone compared to control group (p>0.05). Histological findings demonstrated bone-healing delay with 50% of ciprofloxacin. No difference in callus formation were observed (p>0.05). CONCLUSION Local delivery treatment for contaminated open fracture using chitosan with ciprofloxacin is effective above 25%.
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Hand TL, Hand EO, Welborn A, Zelle BA. Gram-Negative Antibiotic Coverage in Gustilo-Anderson Type-III Open Fractures. J Bone Joint Surg Am 2020; 102:1468-1474. [PMID: 32310842 DOI: 10.2106/jbjs.19.01358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Thomas L Hand
- Department of Orthopaedics (T.L.H. and B.A.Z.) and the Pharmacotherapy Education and Research Center (E.O.H. and A.W.), UT Health San Antonio, San Antonio, Texas
| | - Elizabeth O Hand
- Department of Orthopaedics (T.L.H. and B.A.Z.) and the Pharmacotherapy Education and Research Center (E.O.H. and A.W.), UT Health San Antonio, San Antonio, Texas.,Department of Pharmacotherapy and Pharmacy Services, University Health System, San Antonio, Texas
| | - Amber Welborn
- Department of Orthopaedics (T.L.H. and B.A.Z.) and the Pharmacotherapy Education and Research Center (E.O.H. and A.W.), UT Health San Antonio, San Antonio, Texas
| | - Boris A Zelle
- Department of Orthopaedics (T.L.H. and B.A.Z.) and the Pharmacotherapy Education and Research Center (E.O.H. and A.W.), UT Health San Antonio, San Antonio, Texas
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Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017. J Trauma Acute Care Surg 2020; 88:e53-e76. [PMID: 32150031 DOI: 10.1097/ta.0000000000002407] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries. METHODS The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held. RESULTS The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb. CONCLUSION Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. LEVEL OF EVIDENCE Systematic review of predominantly level II studies, level II.
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Assunção ALFD, Oliveira de ST. Clínical Audit of Primary Treatment of Open Fractures: Antibiotic Treatment and Tetanus Prophylaxis. Rev Bras Ortop 2020; 55:284-292. [PMID: 32616972 PMCID: PMC7316547 DOI: 10.1055/s-0039-3402470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 03/28/2019] [Indexed: 11/25/2022] Open
Abstract
Objective To evaluate whether the conducts involving antimicrobial treatment and prophylaxis against tetanus have been performed according to the Clinical Protocol of the Institution. Methods Descriptive and retrospective study conducted in patients of both genders, > 18 years old admitted to a public hospital specialized in emergency and trauma, to treat primary open fracture. The data of interest were surveyed in medical records, drug prescriptions, report of patients admitted in the Surgical Block and tetanus prophylaxis requests. Results A total of 241 patients were selected, mostly male (81.7%), young adults (64.3%), victims of motorcycle accidents (53.5%). Infectious complications were present in 18.7% of the fractures, the mean time for the surgical approach was 4 hours and 12 minutes, and 91.7% of the patients had preoperative antimicrobial prescription. The main inadequacies identified were: period of prescription of antimicrobial treatment (63.5%); choice of the antimicrobial scheme (59.3%) and antimicrobial dose (58.0%). Only 14.1% of the patients were immunized against tetanus. Conclusion The greatest divergences with the Clinical Protocol were observed in the issues involving the antimicrobial regimen used, doses and time of prescription, as well as in tetanus prophylaxis.
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Obremskey WT, Metsemakers WJ, Schlatterer DR, Tetsworth K, Egol K, Kates S, McNally M. Musculoskeletal Infection in Orthopaedic Trauma: Assessment of the 2018 International Consensus Meeting on Musculoskeletal Infection. J Bone Joint Surg Am 2020; 102:e44. [PMID: 32118653 DOI: 10.2106/jbjs.19.01070] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fracture-related infections (FRIs) are among the most common complications following fracture fixation, and they have a huge economic and functional impact on patients. Because consensus guidelines with respect to prevention, diagnosis, and treatment of this major complication are scarce, delegates from different countries gathered in Philadelphia in July 2018 as part of the Second International Consensus Meeting (ICM) on Musculoskeletal Infection. This paper summarizes the discussion and recommendations from that consensus meeting, using the Delphi technique, with a focus on FRIs. A standardized definition that was based on diagnostic criteria was endorsed, which will hopefully improve reporting and research on FRIs in the future. Furthermore, this paper provides a grade of evidence (strong, moderate, limited, or consensus) for strategies and practices that prevent and treat infection. The grade of evidence is based on the quality of evidence as utilized by the American Academy of Orthopaedic Surgeons. The guidelines presented herein focus not only on the appropriate use of antibiotics, but also on practices for the timing of fracture fixation, soft-tissue coverage, and bone defect and hardware management. We hope that this summary as well as the full document by the International Consensus Group are utilized by those who are charged with musculoskeletal care internationally to optimize their management strategies for the prevention and treatment of FRIs.
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Affiliation(s)
- William T Obremskey
- Department of Orthopaedic Trauma, Vanderbilt Medical Center, Nashville, Tennessee
| | | | | | - Kevin Tetsworth
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Orthopaedic Research Centre of Australia, Brisbane, Queensland, Australia.,Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Kenneth Egol
- Department of Orthopedic Surgery, NYU School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Stephen Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Martin McNally
- Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
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Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. J Am Acad Orthop Surg 2020; 28:309-315. [PMID: 31851021 DOI: 10.5435/jaaos-d-18-00193] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Open fractures are often associated with high-energy trauma and have an increased risk of infection because of surrounding soft-tissue damage and the introduction of environmental contaminants that may communicate with the fracture site. The Gustilo-Anderson classification of open fractures has been used to guide prophylactic antibiotic therapy because different types of open fracture have been shown to have varying rates of surgical site infections with different combinations of pathogens. Prophylactic treatment with various classes of antibiotics, including penicillins and cephalosporins, aminoglycosides, and fluoroquinolones, has evolved over the past half century. More recently, broader spectrum agents including monobactams and glycopeptides have been used for additional coverage. Duration of antibiotic therapy remains variable between institutions, and antibiotic choice is not standardized. Coverage for nosocomial and multidrug-resistant organisms is an ongoing area of clinical research.
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Surgical nuances and placement of subgaleal drains for supratentorial procedures-a prospective analysis of efficacy and outcome in 150 craniotomies. Acta Neurochir (Wien) 2020; 162:729-736. [PMID: 31940095 PMCID: PMC7066100 DOI: 10.1007/s00701-019-04196-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 12/20/2019] [Indexed: 01/19/2023]
Abstract
Background For supratentorial craniotomy, surgical access, and closure technique, including placement of subgaleal drains, may vary considerably. The influence of surgical nuances on postoperative complications such as cerebrospinal fluid leakage or impaired wound healing overall remains largely unclear. With this study, we are reporting our experiences and the impact of our clinical routines on outcome in a prospectively collected data set. Method We prospectively observed 150 consecutive patients undergoing supratentorial craniotomy and recorded technical variables (type/length of incision, size of craniotomy, technique of dural and skin closure, type of dressing, and placement of subgaleal drains). Outcome variables (subgaleal hematoma/CSF collection, periorbital edema, impairment of wound healing, infection, and need for operative revision) were recorded at time of discharge and at late follow-up. Results Early subgaleal fluid collection was observed in 36.7% (2.8% at the late follow-up), and impaired wound healing was recorded in 3.3% of all cases, with an overall need for operative revision of 6.7%. Neither usage of dural sealants, lack of watertight dural closure, and presence of subgaleal drains, nor type of skin closure or dressing influenced outcome. Curved incisions, larger craniotomy, and tumor size, however, were associated with an increase in early CSF or hematoma collection (p < 0.0001, p = 0.001, p < 0.01 resp.), and larger craniotomy size was associated with longer persistence of subgaleal fluid collections (p < 0.05). Conclusions Based on our setting, individual surgical nuances such as the type of dural closure and the use of subgaleal drains resulted in a comparable complication rate and outcome. Subgaleal fluid collections were frequently observed after supratentorial procedures, irrespective of the closing technique employed, and resolve spontaneously in the majority of cases without significant sequelae. Our results are limited due to the observational nature in our single-center study and need to be validated by supportive prospective randomized design. Electronic supplementary material The online version of this article (10.1007/s00701-019-04196-6) contains supplementary material, which is available to authorized users.
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Quatman CE, Villarreal ME, Cochran A. Incisional Negative Pressure Wound Therapy Following Surgical Repair of Lower Extremity Fractures. JAMA 2020; 323:513-514. [PMID: 32044926 DOI: 10.1001/jama.2019.22531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Carmen E Quatman
- Department of Orthopedic Surgery, Ohio State University, Columbus
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Abstract
The "floating knee" is defined as fractures of the ipsilateral femur and tibia, which consists of a spectrum of injury, and may be in isolation or part of multiple system trauma for a given patient. A floating knee may compromise limb viability due to severe soft-tissue and vascular injury. Expeditious fracture reduction and patient resuscitation are crucial, while type and timing of provisional and definitive management is guided by the extent of injury to the involved extremity and associated systemic injuries. Numerous surgical techniques are available to treat the floating knee, including external fixation and internal fixation with plates or intramedullary nails. Fracture complexity and severity of soft-tissue injury present challenges, with articular injuries potentially more debilitating in the long term. Complications such as infection, deep vein thrombosis, knee stiffness, nonunion, malunion, and posttraumatic arthrosis after these injuries should be considered.
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Abstract
INTRODUCTION To evaluate the effects of a trauma performance improvement project involving standardized protocols for the administration of antibiotics in open fractures at a level one trauma center. This study specifically evaluated the protocol's efficacy for improving the timing of delivery and appropriate therapy administration and sought to identify factors that lead to the delay in antibiotic delivery. METHODS Retrospective comparative cohort study comparing patients with open fractures treated at our hospital between January 2013 and September 2015 (group 1) and between April 2016 and June 2017 (group 2). Group 1 was treated before implementation of the performance improvement project and group 2 was treated after implementation. RESULTS Group 1 consisted of 79 patients and group 2 consisted of 80 patients with open fractures. Each group was statistically similar in patient and injury factors. Group 1 received antibiotics at an average of 97 minutes after arrival to our hospital while group 2 patients received them at an average of 46 minutes (P < 0.0001). Average time from admission to initial evaluation improved from 10 to 3 minutes (P < 0.0001). Average time from evaluation to antibiotic order placement improved from 77 to 26 minutes (P < 0.0001). Average time from order entry to antibiotic administration showed no significant difference (12 versus 15 minutes, P = 0.25). Thirty-four percent (27/79) of group 1 patients and 84% (67/80) of group 2 patients received antibiotics within 1 hour of admission (P < 0.0001), while 91% and 99% received antibiotics within 3 hours, respectively (P = 0.03). DISCUSSION The described multifaceted performance improvement protocol was highly effective for producing a more coordinated, efficient, and timely process for administration of antibiotics to patients with open fractures at our hospital. This protocol may be adopted and implemented at other facilities. LEVEL OF EVIDENCE Therapeutic level III.
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Cefazolin Monotherapy Versus Cefazolin Plus Aminoglycosides for Antimicrobial Prophylaxis of Type III Open Fractures. Am J Ther 2019; 28:e284-e291. [PMID: 31789627 DOI: 10.1097/mjt.0000000000001121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are conflicting recommendations between organizations regarding aminoglycoside use for the prophylaxis of type III open fractures. STUDY QUESTION To compare cefazolin monotherapy versus cefazolin plus aminoglycoside therapy for prophylaxis of type III open fractures in trauma patients. STUDY DESIGN This was a multicenter, retrospective, cohort study conducted in 3 academic medical centers in the United States. Consecutive adult trauma patients with type III open fractures between January 2014 and September 2016 were included. Patients were divided into 2 groups: (1) cefazolin monotherapy versus (2) cefazolin plus aminoglycoside. MEASURES AND OUTCOMES The primary outcome measure was the occurrence of infection at the open fracture site. The secondary outcome measure was the occurrence of acute kidney injury. RESULTS There were 134 patients included in the study cohort. Of these, 39 received cefazolin monotherapy and 95 received cefazolin plus aminoglycoside. Overall, the mean age was 39 ± 15 years, 105 (78%) were male, and the most common fracture location was tibia/fibula (n = 74, 56%). Infection at the open fracture site occurred in 6 of 39 patients (15%) in the cefazolin monotherapy group and 15 of 95 patients (16%) in the cefazolin plus aminoglycoside group (P = 1.000). Acute kidney injury occurred in 0 of 39 (0%) in the cefazolin monotherapy group and 1 of 95 (1%) in the cefazolin plus aminoglycoside group (P = 1.000). CONCLUSIONS Cefazolin monotherapy may be appropriate for antimicrobial prophylaxis of type III open fractures in trauma patients.
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Lloyd BA, Murray CK, Shaikh F, Carson ML, Blyth DM, Schnaubelt ER, Whitman TJ, Tribble DR. Antimicrobial Prophylaxis with Combat-Related Open Soft-Tissue Injuries. Mil Med 2019; 183:e260-e265. [PMID: 29447384 DOI: 10.1093/milmed/usx125] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/08/2017] [Accepted: 11/30/2017] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION All Department of Defense (DoD) guidance documents recommend cefazolin or clindamycin as post-trauma antibiotic prophylaxis for open soft-tissue injuries. Although not advocated, some patients with open soft-tissue injuries also received expanded Gram-negative coverage (EGN) prophylaxis based on the judgment of front-line trauma providers. During the study period, revised guidelines in 2011/2012 re-emphasized recommendations for using cefazolin or clindamycin, and stewardship efforts in the DoD trauma community aimed to reduce the practice of adding EGN to guideline-recommended antibiotic prophylaxis. Our objective was to examine antibiotic utilization among wounded military personnel with open extremity soft-tissue injuries over a 5-yr period and assess the impact on infectious outcomes in patients who received EGN prophylaxis versus guideline-directed prophylaxis. METHODS The study population included military personnel with open extremity soft-tissue injuries sustained in Iraq and Afghanistan (2009-2014) who transferred to participating hospitals in the USA following medical evacuation. The analysis was restricted to patients who were hospitalized for at least seven days at a U.S. facility and excluded those who sustained open fractures. Post-trauma antibiotic prophylactic regimens were defined as narrow if they followed recommended guidance (e.g., IV cefazolin or clindamycin) or EGN coverage when the narrow regimen also included fluoroquinolones and/or aminoglycosides. Intravenous amoxicillin-clavulanate, which is commonly used at non-U.S. coalition theater hospitals, was also classified as narrow because it conformed to coalition antibiotic prophylaxis guidelines. This study was approved by the Infectious Disease Institutional Review Board of the Uniformed Services University of the Health Sciences. RESULTS A total of 287 wounded personnel with open soft-tissue injuries were assessed, of which 212 (74%) received narrow prophylaxis and 75 (26%) received EGN coverage (p < 0.001). Among patients in the narrow prophylaxis group, 81% were given cefazolin and/or clindamycin, while 19% received amoxicillin-clavulanate. In the EGN group, 88% and 12% received a fluoroquinolone and aminoglycoside, respectively. Use of EGN coverage significantly declined during the study period from 39% in 2009-2010 to 11% in 2013-2014 (p < 0.001). Approximately 3% of patients who received a narrow regimen developed an extremity skin and soft-tissue infection, while there were no skin and soft-tissue infections among patients in the EGN coverage group. Nonetheless, this was not a significant difference (p = 0.345). In addition, the proportion of non-extremity infections was not significantly different between narrow and EGN regimen groups (11% and 15%, respectively). There were also no significant differences between the narrow and EGN regimen groups related to duration of hospitalization (median of 19 versus 20 d). CONCLUSION Use of non-guideline directed EGN-based post-trauma antibiotic prophylaxis does not improve infectious outcomes nor does it shorten hospital stay.
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Affiliation(s)
- Bradley A Lloyd
- San Antonio Military Medical Center, 3551 Roger Brooke Drive #3600, Fort Sam Houston, TX
| | - Clinton K Murray
- San Antonio Military Medical Center, 3551 Roger Brooke Drive #3600, Fort Sam Houston, TX
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD
| | - Dana M Blyth
- San Antonio Military Medical Center, 3551 Roger Brooke Drive #3600, Fort Sam Houston, TX
| | | | - Timothy J Whitman
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
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Depcinski SC, Nguyen KH, Ender PT. Cefazolin and an aminoglycoside compared with cefazolin alone for the antimicrobial prophylaxis of type III open orthopedic fractures. Int J Crit Illn Inj Sci 2019; 9:127-131. [PMID: 31620351 PMCID: PMC6792399 DOI: 10.4103/ijciis.ijciis_7_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/13/2019] [Accepted: 08/05/2019] [Indexed: 12/16/2022] Open
Abstract
Context Uncertainty of antibiotic prophylaxis of type III open orthopedic fractures still exists. Controversy remains as using cefazolin as a single agent or the addition of an aminoglycoside for broader coverage to prevent infection. Aims The aim of the study was to determine if the combination of cefazolin and an aminoglycoside reduced infections compared with cefazolin alone. Subjects and Methods This was a retrospective study inclusive of patients with type III open fracture admitted between January 1, 2010, and August 31, 2014 at a level 1 trauma center, who were prophylactically treated with cefazolin alone or cefazolin and an aminoglycoside. Statistical Analysis Used All analyses were performed using Microsoft Excel 2010. Chi-square or Fisher's exact tests were used for categorical data and Wilcoxon rank-sum test for skewed continuous data. Logistic regression analysis was performed on all confounding variables with P < 0.1. Results A significantly higher percentage in the combination group developed infection (6/15 [40%] vs. 8/53 [15.1%], P = 0.035). There was a trend toward a higher odds of infection in the combination group (odds ratio: 2.99, 95% confidence interval: 0.79-11.33, P = 0.107). Infection rates due to multidrug-resistant bacteria were statistically higher with the combination group (3/15 [20%] vs. 1/53 [1.9%], P = 0.046). There were no statistically significant differences in 30-day mortality, 1-year readmission rates due to fracture complication, or length of hospital stay. Conclusions The results suggest that the addition of an aminoglycoside to cefazolin may not be necessary to prevent infection.
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Affiliation(s)
- Shawn C Depcinski
- Department of Pharmacy, St. Luke's University Health Network, PA, USA
| | | | - Peter T Ender
- Department of Medicine, Section of Infectious Diseases, St. Luke's University Health Network, Bethlehem, PA, USA
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Sabapathy SR, Venkatramani H, Mohan M. Initial Assessment, Debridement, and Decision Making in the Salvage of Severely Injured Lower Extremity. Indian J Plast Surg 2019; 52:10-16. [PMID: 31456608 PMCID: PMC6664836 DOI: 10.1055/s-0039-1689741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
An open fracture with extensive skin and soft tissue loss is considered as a severely injured lower extremity. Advances in rapid transport, resuscitation, skeletal fixation, and microsurgical techniques to cover large soft tissue and bone defects have made possible the salvage of these severely injured limbs. Salvage exercise is skill and resource intensive and could take a long time frame. The goal of management is to obtain painless independent weight bearing walking in a time frame and cost that the patient can afford. Decisions taken and the quality of care provided on day 1 determine the ultimate success. Inappropriate decisions and treatment lead to increased morbidity and secondary amputation. Infection is the commonest complication. Limb salvage scores are helpful to predict salvage and guide the sequence of treatment. Once the decision is taken for salvage, debridement, early skeletal fixation, and soft tissue cover are the key to success.
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Affiliation(s)
- S Raja Sabapathy
- Department of Plastic Surgery, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Hari Venkatramani
- Department of Plastic Surgery, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Monusha Mohan
- Department of Plastic Surgery, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
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