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Heiman E, Delaune J, Hong IS, Lamb M, Fisher M, Molino B, Moreau S, Devivo M, Liporace FA, Yoon RS, Jankowski JM. Maximizing Adherence and Minimizing Time to Antibiotics: A Multidisciplinary Institutional Trauma Bay Protocol for Single Antibiotic Prophylaxis in Open Fractures. J Orthop Trauma 2024; 38:313-319. [PMID: 38478500 DOI: 10.1097/bot.0000000000002805] [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] [Accepted: 03/07/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVES To determine if a multidisciplinary institutional protocol can optimize the time to antibiotic (Abx) administration for open fractures (openFx) and improve compliance with the administration of Abx prophylaxis during trauma activation. METHODS DESIGN Retrospective pre-post study design. SETTING Single Level II Trauma Center. PATIENT SELECTION CRITERIA All patients who triggered a trauma activation with suspected openFx and were treated according to the institutional single antibiotic regimen were eligible for inclusion. Patients were excluded if fractures did not involve the appendicular skeleton. Patients treated before implementation of a standardized institutional protocol where premixed IV bags of antibiotics were stocked in automated dispensing systems within ED trauma bays (January 2021-October 2022) were defined as the "pre" group and those treated following implementation the "post" group. OUTCOME MEASURES AND COMPARISONS The primary outcome was time from trauma bay arrival to antibiotic aministration, measured in minutes, with comparisons made between preprotocol and postprotocol implementation. Secondary outcomes for comparison included rates (%) of time to Abx <60 minutes, allergic reactions, acute kidney injury, ototoxicity, surgical site infection, multi-drug-resistant organisms identified in blood or biopsy cultures in cases requiring reoperation, and Clostridium difficile infection in the gastrointestinal system, confirmed by stool test results, within 30 days. RESULTS Twenty-four patients (mean age 39.5 ± 16.3 years) met the criteria after protocol implementation compared with 72 patients (mean age 34.3 ± 14.8 years) before implementation. Implementation of the institutional protocol resulted in a significant reduction in the time to Abx administration for openFx from 87.9 ± 104.6 minutes to 22.2 ± 12.8 minutes in the postprotocol group ( P < 0.001). In addition, only 53% in the preprotocol group received Abx within 60 minutes compared with 96% in postprotocol group ( P < 0.001). Post hoc power analysis revealed that the study was powered at 92% (effect size = 0.72) to detect a significant difference between the preprotocol and postprotocol groups. CONCLUSION This study provides evidence that a multidisciplinary institutional protocol for the administration of Abx prophylaxis can be an effective strategy for optimizing the time to Abx administration in cases of suspected openFx. This protocol may be implemented in other trauma centers to optimize time to Abx administration for openFx. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Erick Heiman
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ
| | - Joss Delaune
- Department of Pharmacy, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ; and
| | - Ian S Hong
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ
| | - Matthew Lamb
- Department of Pharmacy, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ; and
| | - Marissa Fisher
- Trauma Surgery and Surgical Critical Care, Department of General Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ
| | - Bruno Molino
- Trauma Surgery and Surgical Critical Care, Department of General Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ
| | - Sandy Moreau
- Department of Pharmacy, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ; and
| | - Maria Devivo
- Department of Pharmacy, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ; and
| | - Frank A Liporace
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ
| | - Richard S Yoon
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ
| | - Jaclyn M Jankowski
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ
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Mehta DD, Leucht P. Prevention and treatment of osteomyelitis after open tibia fractures. OTA Int 2024; 7:e309. [PMID: 38840709 PMCID: PMC11149744 DOI: 10.1097/oi9.0000000000000309] [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: 11/27/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 06/07/2024]
Abstract
Infection and chronic post-traumatic osteomyelitis of the tibia after open fracture are complex problems that cause significant morbidity and threaten the viability of a limb. Therefore, it is of utmost importance for the orthopaedic surgeon to understand both patient and treatment factors that modify the risk of developing these disastrous complications. Infection risk is largely based on severity of open injury in addition to inherent patient factors. Orthopaedic surgeons can work to mitigate this risk with prompt antibiotic administration, thorough and complete debridement, expedient fracture stabilization, and early wound closure. In the case osteomyelitis does occur, the surgeon should use a systematic multidisciplinary approach for eradication.
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Affiliation(s)
- Devan D. Mehta
- Department of Orthopedic Surgery, NYU Grossman School of Medicine—NYU Langone Orthopedic Hospital, New York, NY
| | - Philipp Leucht
- Department of Orthopedic Surgery, NYU Grossman School of Medicine—NYU Langone Orthopedic Hospital, New York, NY
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Eikani C, Hoyt A, Cho E, Levack AE. The State of Local Antibiotic Use in Orthopedic Trauma. Orthop Clin North Am 2024; 55:207-216. [PMID: 38403367 DOI: 10.1016/j.ocl.2023.07.003] [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: 02/27/2024]
Abstract
Fracture-related infections are a challenging complication in orthopedic trauma that often necessitates multiple surgeries. Early administration of systemic antibiotics and surgical intervention remains the gold standard of care, but despite these measures, treatment failures can be as high as 35%. For these reasons, the introduction of local antibiotics at the site of at-risk fractures has increased over the past decade. This review looks at the various measures being used clinically including local antibiotic powder, polymethylmethacrylate, biodegradable substances, antibiotic-coated implants, and novel methods such as hydrogels and nanoparticles that have the potential for use in the future.
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Affiliation(s)
- Carlo Eikani
- Loyola University Stritch School of Medicine; Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, 2160 South 1st Avenue, Maguire Suite 1700, Maywood, IL, USA.
| | - Aaron Hoyt
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, 2160 South 1st Avenue, Maguire Suite 1700, Maywood, IL, USA
| | - Elizabeth Cho
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, 2160 South 1st Avenue, Maguire Suite 1700, Maywood, IL, USA
| | - Ashley E Levack
- Loyola University Stritch School of Medicine; Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, 2160 South 1st Avenue, Maguire Suite 1700, Maywood, IL, USA
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Uçkay I, Bomberg H, Risch M, Müller D, Betz M, Farshad M. Broad-spectrum antibiotic prophylaxis in tumor and infected orthopedic surgery-the prospective-randomized, microbiologist-blinded, stratified, superiority trials: BAPTIST Trials. Trials 2024; 25:69. [PMID: 38243311 PMCID: PMC10799415 DOI: 10.1186/s13063-023-07605-5] [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: 10/27/2022] [Accepted: 08/26/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND The perioperative antibiotic prophylaxis with 1st or 2nd generation cephalosporins is evidence-based in orthopedic surgery. There are, however, situations with a high risk of prophylaxis-resistant surgical site infections (SSI). METHODS We perform a superiority randomized controlled trial with a 10% margin and a power of 90% in favor of the broad-spectrum prophylaxis. We will randomize orthopedic interventions with a high risk for SSI due to selection of resistant pathogens (open fractures, surgery under therapeutic antibiotics, orthopedic tumor surgery, spine surgery with American Society of Anesthesiologists (ASA) score ≥ 3 points) in a prospective-alternating scheme (1:1, standard prophylaxis with cefuroxime versus a broad-spectrum prophylaxis of a combined single-shot of vancomycin 1 g and gentamicin 5 mg/kg parenterally). The primary outcome is "remission" at 6 weeks for most orthopedic surgeries or at 1 year for surgeries with implant. Secondary outcomes are the risk for prophylaxis-resistant SSI pathogens, revision surgery for any reason, change of antibiotic therapy during the treatment of infection, adverse events, and the postoperative healthcare-associated infections other than SSI within 6 weeks (e.g., urine infections or pneumonia). With event-free surgeries to 95% in the broad-spectrum versus 85% in the standard prophylaxis arm, we need 2 × 207 orthopedic surgeries. DISCUSSION In selected patients with a high risk for infections due to selection of prophylaxis-resistant SSI, a broad-spectrum combination with vancomycin and gentamycin might prevent SSIs (and other postoperative infections) better than the prophylaxis with cefuroxime. TRIAL REGISTRATION ClinicalTrial.gov NCT05502380. Registered on 12 August 2022. Protocol version: 2 (3 June 2022).
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Affiliation(s)
- Ilker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
- Infection Control, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Hagen Bomberg
- Department of Anesthesiology, Intensive Care and Pain Medicine, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Markus Risch
- Department of Anesthesiology, Intensive Care and Pain Medicine, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Daniel Müller
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Michael Betz
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
- Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Abbasi MY, Wiwattanawongsa K, Chaijamorn W, Charoensareerat T, Doungngern T. What is the right gentamicin dose for multiple trauma patients? A Monte Carlo simulation exploration study. Int J Crit Illn Inj Sci 2023; 13:118-124. [PMID: 38023581 PMCID: PMC10664035 DOI: 10.4103/ijciis.ijciis_14_23] [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: 03/13/2023] [Revised: 06/12/2023] [Accepted: 06/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background The appropriate dose of gentamicin is important to prevent and treat infections. The study aimed to determine the optimal dose of gentamicin to achieve the probability of pharmacokinetic/pharmacodynamic (PK) targets for efficacy and safety in multiple trauma patients. Methods PK parameters of gentamicin in multiple trauma patients were gathered to develop a one-compartment PK model for prediction. The Monte Carlo simulation method was performed. The 24-h area under the concentration time curve to the minimum inhibitory concentration ratio (AUC24h/MIC) ≥50 was defined for the infection prevention target. AUC24h/MIC ≥110 or the maximum serum concentration to MIC ratio ≥8-10 was for the treatment of serious Gram-negative infection target. The risk of nephrotoxicity was the minimum serum concentration ≥2 mg/L. The optimal dose of gentamicin was determined when the efficacy target was >90% and the risk of nephrotoxicity was lowest. Results The optimal gentamicin dose to prevent infection when the MIC was <1 mg/L was 6-7 mg/kg/day. A higher dose of gentamicin up to 10 mg/kg/day could not reach the target for treating serious Gram-negative infection when the expected MIC was ≥1 mg/L. The probability of nephrotoxicity was minimal at 0.2-4% with gentamicin doses of 5-10 mg/kg/day for 3 days. Conclusions Once daily gentamicin doses of 6-7 mg/kg are recommended to prevent infections in patients with multiple trauma. Gentamicin monotherapy could not be recommended for serious infections. Further clinical studies are required to confirm our results.
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Affiliation(s)
- Mohammad Yaseen Abbasi
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince Songkla University, Hat Yai, Songkhla, Thailand
| | - Kamonthip Wiwattanawongsa
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince Songkla University, Hat Yai, Songkhla, Thailand
| | - Weerachai Chaijamorn
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Pathum Wan, Bangkok, Thailand
| | | | - Thitima Doungngern
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince Songkla University, Hat Yai, Songkhla, Thailand
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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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Suzuki T, Inui T, Sakai M, Ishii K, Kurozumi T, Watanabe Y. Type III Gustilo-Anderson open fracture does not justify routine prophylactic Gram-negative antibiotic coverage. Sci Rep 2023; 13:7085. [PMID: 37127796 PMCID: PMC10151338 DOI: 10.1038/s41598-023-34142-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/25/2023] [Indexed: 05/03/2023] Open
Abstract
Postoperative surgical site infection (SSI) is common in open long bone fractures, so early administration of prophylactic antibiotics is critical to prevent SSI. However, the necessity of initial broad-spectrum coverage for Gram-positive and -negative pathogens remains unclear. The purpose of this study was to clarify the effectiveness of prophylactic broad-spectrum antibiotics in a large, national-wide sample. We reviewed an open fracture database of prospectively collected data from 111 institutions managed by our society. A retrospective cohort study was designed to compare the rates of deep SSI between narrow- and broad-spectrum antibiotics, which were initiated within three hours after injury. A total of 1041 type III fractures were evaluated at three months after injury. Overall deep SSI rates did not differ significantly between the narrow-spectrum group (43/538, 8.0%) and broad-spectrum group (49/503, 9.8%) (p = 0.320). During propensity score-matched analysis, 425 pairs were analyzed. After matching, no significant difference in the SSI rate was seen between the narrow- and broad-spectrum groups, with 42 SSIs (9.9%) and 40 SSIs (9.4%), respectively (p = 0.816). The probability of deep SSI was not reduced by broad-spectrum antibiotics compared with narrow-spectrum antibiotics in type III open long bone fractures.
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Affiliation(s)
- Takashi Suzuki
- Trauma and Reconstruction Center, Teikyo University Hospital, Tokyo, Japan.
| | - Takahiro Inui
- Trauma and Reconstruction Center, Teikyo University Hospital, Tokyo, Japan
| | - Miyoshi Sakai
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan
| | - Keisuke Ishii
- Trauma and Reconstruction Center, Teikyo University Hospital, Tokyo, Japan
| | - Taketo Kurozumi
- Trauma Center, Federation of National Public Service Personnel Mutual Aid Associations, Toranomon Hospital, Tokyo, Japan
| | - Yoshinobu Watanabe
- Trauma and Reconstruction Center, Teikyo University Hospital, Tokyo, Japan
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8
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Risk of Acute Kidney Injury and Fracture-Related Infection After Antibiotic Prophylaxis With Piperacillin-Tazobactam in Open Fractures. J Orthop Trauma 2023; 37:e73-e79. [PMID: 36001947 DOI: 10.1097/bot.0000000000002473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the effects of prophylactic piperacillin-tazobactam (PT) on inpatient acute kidney injury (AKI) and fracture-related infection (FRI) in patients with open fractures. SETTING The study was conducted at a Level 1 trauma center. PATIENTS We reviewed 358 Gustilo-Anderson type II and III open fractures at our institution from January 2013 to December 2017. INTERVENTION Administration of PT (the PT group) or antibiotics other than PT (the historical control group) during the first 48 hours of arrival for open fracture antibiotic prophylaxis. MAIN OUTCOME MEASUREMENTS The main outcome measurements were rates of inpatient AKI and FRI within six months after definitive fixation. RESULTS There were 176 patients in the PT group and 182 patients in the historical control group. The PT group had worse American Society of Anesthesiologists class ( P = 0.004) and injury severity scores ( P < 0.001), a higher average number of debridements before closure/coverage ( P = 0.043), and higher rates of gross soil contamination ( P = 0.049) and staged procedures ( P = 0.008) compared with the historical control group.There was no difference in the rate of AKI between the PT and historical control groups (5.7% vs. 2.7%, P = 0.166) nor when stratified by Gustilo-Anderson fracture classification (type II: 5.8% vs. 3.6%, P = 0.702; type III: 5.6% vs. 2.0%, P = 0.283). There was no significant difference in the rate of FRI between the PT and historical control groups (23.6% vs. 19.6%, P = 0.469). CONCLUSION The use of PT in prophylactic antimicrobial treatment in patients with Gustilo-Anderson type II and III open fractures does not increase the rate of AKI or FRI. We believe PT can be used as an effective monotherapy in these patients without an increased risk of renal injury, but future investigations are necessary. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Flores MJ, Brown KE, Morshed S, Shearer DW. Evidence for Local Antibiotics in the Prevention of Infection in Orthopaedic Trauma. J Clin Med 2022; 11:jcm11247461. [PMID: 36556077 PMCID: PMC9782030 DOI: 10.3390/jcm11247461] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/18/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
Prevention of fracture-related infection (FRI) remains a substantial challenge in orthopaedic trauma care. There is evolving evidence to support the use of local antibiotics for both the prevention and treatment of musculoskeletal infection. Local antibiotics can achieve higher local tissue concentrations with a lower risk of systemic complications compared to intravenously administered antibiotics. These antibiotics may be administered in powder or liquid form without carrier, or if sustained release is desired, using a carrier. Polymethylmethacrylate (PMMA), ceramics, and hydrogels are examples of antibiotic carriers. Unlike PMMA, ceramics and hydrogels have the advantage of not requiring a second surgery for removal. The VANCO trial supported the use of powdered vancomycin in high-risk fracture cases for the reduction of Gram-positive infections; although, data is limited. Future studies will evaluate the use of aminoglycoside antibiotics to address Gram-negative infection prevention. While theoretical concerns exist with the use of local antibiotics, available studies suggest local antibiotics are safe with a low-risk of adverse effects.
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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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Collopy K, Zimmerman L, Westmoreland AM, Powers WF. Prehospital Administration of Cefazolin in Trauma Patients. Air Med J 2022; 41:447-450. [PMID: 36153141 DOI: 10.1016/j.amj.2022.06.001] [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: 03/31/2022] [Revised: 05/31/2022] [Accepted: 06/07/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE A lack of research has become a barrier to the common use of prehospital antibiotics. The objective of this study is to further the limited research of prehospital antibiotics through evaluating the clinical impact, safety, and reliability of prehospital cefazolin administration in trauma patients. METHODS We completed a retrospective evaluation of adult trauma patients who were transported by a single air and ground critical care transport program between January 1, 2014, and June 30 2017. Two hundred eighty-two patients received prehospital cefazolin for deep wounds or open fractures before their arrival at a single level 2 trauma center during the study period. Patient demographics, mechanism of injury, injury type, infection rate, and identification of allergic reactions to cefazolin were also collected. RESULTS Of 278 patients in the final analysis, 35.3% (n = 98) were diagnosed with an open fracture and 58.6% (n = 163) had a deep tissue injury. Eighty-two percent of prehospital open fracture diagnoses were confirmed in the emergency department. The overall infection rate was 6%; 31.3% of patients received a second dose of cefazolin in the emergency department during the study period. No patients receiving prehospital cefazolin had allergic or anaphylactic reactions. The overadministration rate was 5% (n = 14). CONCLUSION Prehospital providers reliably identified open fractures, and prehospital cefazolin administration was not associated with anaphylactic reactions. This study population's infection rate of open fractures caused by traumatic injury was found to be 6%, and there was a low inappropriate administration rate.
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Affiliation(s)
- Kevin Collopy
- AirLink/VitaLink Critical Care Transport, Novant Health New Hanover Regional Medical Center, Wilmington, NC.
| | - Lisa Zimmerman
- Department of Pharmacy, Novant Health New Hanover Regional Medical Center, Wilmington, NC
| | | | - William F Powers
- AirLink/VitaLink Critical Care Transport, Novant Health New Hanover Regional Medical Center, Wilmington, NC; Department of Surgery, Novant Health New Hanover Regional Medical Center, Wilmington, NC
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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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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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Li J, Wong RMY, Chung YL, Leung SSY, Chow SKH, Ip M, Cheung WH. Fracture-related infection in osteoporotic bone causes more severe infection and further delays healing. Bone Joint Res 2022; 11:49-60. [PMID: 35100815 PMCID: PMC8882324 DOI: 10.1302/2046-3758.112.bjr-2021-0299.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims With the ageing population, fragility fractures have become one of the most common conditions. The objective of this study was to investigate whether microbiological outcomes and fracture-healing in osteoporotic bone is worse than normal bone with fracture-related infection (FRI). Methods A total of 120 six-month-old Sprague-Dawley (SD) rats were randomized to six groups: Sham, sham + infection (Sham-Inf), sham with infection + antibiotics (Sham-Inf-A), ovariectomized (OVX), OVX + infection (OVX-Inf), and OVX + infection + antibiotics (OVX-Inf-A). Open femoral diaphysis fractures with Kirschner wire fixation were performed. Staphylococcus aureus at 4 × 104 colony-forming units (CFU)/ml was inoculated. Rats were euthanized at four and eight weeks post-surgery. Radiography, micro-CT, haematoxylin-eosin, mechanical testing, immunohistochemistry (IHC), gram staining, agar plating, crystal violet staining, and scanning electron microscopy were performed. Results Agar plating analysis revealed a higher bacterial load in bone (p = 0.002), and gram staining showed higher cortical bone colonization (p = 0.039) in OVX-Inf compared to Sham-Inf. OVX-Inf showed significantly increased callus area (p = 0.013), but decreased high-density bone volume (p = 0.023) compared to Sham-Inf. IHC staining showed a significantly increased expression of TNF-α in OVX-Inf compared to OVX (p = 0.049). Significantly reduced bacterial load on bone (p = 0.001), enhanced ultimate load (p = 0.001), and energy to failure were observed in Sham-Inf-A compared to Sham-Inf (p = 0.028), but not in OVX-Inf-A compared to OVX-Inf. Conclusion In osteoporotic bone with FRI, infection was more severe with more bone lysis and higher bacterial load, and fracture-healing was further delayed. Systemic antibiotics significantly reduced bacterial load and enhanced callus quality and strength in normal bone with FRI, but not in osteoporotic bone. Cite this article: Bone Joint Res 2022;11(2):49–60.
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Affiliation(s)
- Jie Li
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Ronald Man Yeung Wong
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Yik Lok Chung
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | | | - Simon Kwoon-Ho Chow
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Margaret Ip
- Department of Microbiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Wing-Hoi Cheung
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
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15
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Kim EK, Donnelley CA, Tiee M, Roberts HJ, Von Kaeppler E, Shearer D, Morshed S. Prophylactic Topical Antibiotics in Fracture Repair and Spinal Fusion. Adv Orthop 2021; 2021:1949877. [PMID: 34691783 PMCID: PMC8531801 DOI: 10.1155/2021/1949877] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/09/2021] [Accepted: 09/11/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The objective of this systematic review with meta-analysis is to determine whether prophylactic local antibiotics prevent surgical site infections (SSIs) in instrumented spinal fusions and traumatic fracture repair. A secondary objective is to investigate the effect of vancomycin, a common local antibiotic of choice, on the microbiology of SSIs. METHODS An electronic search of PubMed, EMBASE, and Web of Science databases and major orthopedic surgery conferences was conducted to identify studies that (1) were instrumented spinal fusions or fracture repair and (2) had a treatment group that received prophylactic local antibiotics. Both randomized controlled trials (RCTs) and comparative observational studies were included. Meta-analysis was performed separately for randomized and nonrandomized studies with subgroup analysis by study design and antibiotic. RESULTS Our review includes 44 articles (30 instrumented spinal fusions and 14 fracture repairs). Intrawound antibiotics significantly decreased the risk of developing SSIs in RCTs of fracture repair (RR 0.61, 95% CI: 0.40-0.93, I 2 = 32.5%) but not RCTs of instrumented spinal fusion. Among observational studies, topical antibiotics significantly reduced the risk of SSIs in instrumented spinal fusions (OR 0.34, 95% CI: 0.27-0.43, I 2 = 52.4%) and in fracture repair (OR 0.49, 95% CI: 0.37-0.65, I 2 = 43.8%). Vancomycin powder decreased the risk of Gram-positive SSIs (OR 0.37, 95% CI: 0.27-0.51, I 2 = 0.0%) and had no effect on Gram-negative SSIs (OR 0.95, 95% CI: 0.62-1.44, I 2 = 0.0%). CONCLUSIONS Prophylactic intrawound antibiotic administration decreases the risk of SSIs in fracture surgical fixation in randomized studies. Therapeutic efficacy in instrumented spinal fusion was seen in only nonrandomized studies. Vancomycin appears to be an effective agent against Gram-positive pathogens. There is no evidence that local vancomycin powder is associated with an increased risk for Gram-negative infection.
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Affiliation(s)
- Eric K. Kim
- University of California San Francisco, School of Medicine, San Francisco, California, USA
| | - Claire A. Donnelley
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedics, University of California, San Francisco, California, USA
| | - Madeline Tiee
- University of California San Francisco, School of Medicine, San Francisco, California, USA
| | - Heather J. Roberts
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, California, USA
| | - Ericka Von Kaeppler
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedics, University of California, San Francisco, California, USA
| | - David Shearer
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, California, USA
| | - Saam Morshed
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, California, USA
- University of California San Francisco, Department of Epidemiology and Biostatistics, San Francisco, California, USA
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16
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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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18
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Mener A, Staley C, Boissonneault A, Reisman W, Schenker M, Hernandez-Irizarry R. Infection after Open Long Bone Fractures: Can we Improve on Prophylaxis? J Surg Res 2021; 268:33-39. [PMID: 34280663 DOI: 10.1016/j.jss.2021.05.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 03/14/2021] [Accepted: 05/26/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Current standards recommend antibiotic prophylaxis administered after open fracture injury. The purpose of this study was to assess culture results in patients with open fracture-associated infections, hypothesizing that cultures obtained do not vary by Gustilo-Anderson (GA) classification. METHODS We examined cultured bacterial species from patients with open long bone fractures that underwent irrigation and debridement at a Level 1 trauma center (2008-2016), evaluating our current and two hypothetical antibiotic protocols to assess whether they provided appropriate coverage. The antibiotic protocols included protocols 1 (cefazolin, with gentamicin added for type III fractures), 2 (vancomycin and cefepime) and 3 (ceftriaxone). RESULTS GA classification was not associated with bacterial gram stain (P = 0.161), nor was it predictive of mono- versus polymicrobial infection (P = 0.094). Of 42 culture-positive infections, 31 were type III and 11 were type I or II fractures. 27% of the infections for type I or II fractures were caused by organisms targeted by protocol 1 (OR 0.18, 95% CI 0.04-0.82; P = 0.027). There was no difference in coverage by fracture type among protocol 2 (P = 0.771) or protocol 3 (P = 0.891). For type III fractures, protocol 2 provided 94% appropriate coverage compared to 68% and 61% coverage by protocols 1 and 3, respectively. CONCLUSION For open fractures complicated by infection, isolated bacterial organisms do not correlate with GA open fracture classification, suggesting that hypothetical protocol 2 should be used for all fracture types. Protocol 2's broad coverage, across all GA fracture types, may prevent infection by organisms not covered by current antibiotic prophylaxis.
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Affiliation(s)
- Amanda Mener
- Emory University School of Medicine, Atlanta, GA
| | | | - Adam Boissonneault
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - William Reisman
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Mara Schenker
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
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Lin CA, O'Hara NN, Sprague S, O'Toole RV, Joshi M, Harris AD, Warner SJ, Johal H, Natoli RM, Hagen JE, Jeray KJ, Fowler JT, Phelps KD, Pilson HT, Gitajn IL, Bhandari M, Slobogean GP. Low Adherence to Recommended Guidelines for Open Fracture Antibiotic Prophylaxis. J Bone Joint Surg Am 2021; 103:609-617. [PMID: 33411466 DOI: 10.2106/jbjs.20.01229] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prompt administration of antibiotics is a critical component of open fracture treatment. Traditional antibiotic recommendations have been a first-generation cephalosporin for Gustilo Type-I and Type-II open fractures, with the addition of an aminoglycoside for Type-III fractures and penicillin for soil contamination. However, concerns over changing bacterial patterns and the side effects of aminoglycosides have led to interest in other regimens. The purpose of the present study was to describe the adherence to current prophylactic antibiotic guidelines. METHODS We evaluated the antibiotic-prescribing practices of 24 centers in the U.S. and Canada that were participating in 2 randomized controlled trials of skin-preparation solutions for open fractures. A total of 1,234 patients were evaluated. RESULTS All patients received antibiotics on the day of admission. The most commonly prescribed antibiotic regimen was cefazolin monotherapy (53.6%). Among patients with Type-I and Type-II fractures, there was 61.1% compliance with cefazolin monotherapy. In contrast, only 17.2% of patients with Type-III fractures received the recommended cefazolin and aminoglycoside therapy, with an additional 6.7% receiving piperacillin/tazobactam. CONCLUSIONS There is moderate adherence to the traditional antibiotic treatment guidelines for Gustilo Type-I and Type-II fractures and low adherence for Type-III fractures. Given the divergence between current practice patterns and prior recommendations, high-quality studies are needed to determine the most appropriate prophylactic protocol.
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Affiliation(s)
- Carol A Lin
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Nathan N O'Hara
- University of Maryland School of Medicine, Baltimore, Maryland
| | | | | | - Manjari Joshi
- University of Maryland School of Medicine, Baltimore, Maryland
| | | | | | | | - Roman M Natoli
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | | | | | - Holly T Pilson
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - I Leah Gitajn
- Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire
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The evidence base for 2017 BOAST-4 guidance on open fracture management: Are we due an update? J Clin Orthop Trauma 2021; 17:233-238. [PMID: 33898242 PMCID: PMC8050850 DOI: 10.1016/j.jcot.2021.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Open fracture management in the United Kingdom and several other countries is guided by the British Orthopaedic Association's Standards for Trauma Number 4 (BOAST-4). This is updated periodically and is based on the best available evidence at the time. The aim of this study is to evaluate the evidence base forming this guidance and to highlight new developments since the last version in 2017. METHODS Searches have been performed using the PubMed, Embase and Medline databases for time periods a) before December 31, 2017 and from 01/01/2018-01/02/2021. Results have been summarized and discussed. DISCUSSION Several contentious issues remain within the 2017 guideline. Antibiotic guidance, the use of antibiotic impregnated PMMA beads and intramedullary devices, irrigation in the emergency department, time to theatre and the use of negative pressure dressings and guidance regarding the management of paediatric injuries have all demonstrated no clear consensus. CONCLUSION The advent of the BOAST-4 guideline has been of huge benefit, however the refinement and improvement of this work remains ongoing. There remains a need for further study into these contentious issues previously listed.
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21
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Current concepts in the prevention, diagnosis and treatment of fracture-related infection (FRI). EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:957-966. [PMID: 33778904 DOI: 10.1007/s00590-021-02956-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/21/2021] [Indexed: 12/24/2022]
Abstract
Fracture-related infection (FRI) is one of the most challenging complications following operative management of fractures. It can have profound implications for the patient, can be associated with considerable morbidity and often lead to impaired outcomes. There are significant healthcare-related costs. In recent years, there has been significant progress towards developing preventative strategies. Furthermore, diagnostic algorithms and management protocols have recently been reported. Lack of a strong evidence base has previously hindered efforts to implement these and develop established standards of care. There are multiple aspects of care that need to be considered and a multi-disciplinary approach is recommended. In this narrative review, we present the most up-to-date recommendations in the prevention, diagnosis and management of FRI.
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Prada C, Marcano-Fernández FA, Schemitsch EH, Bzovsky S, Jeray K, Petrisor B, Bhandari M, Sprague S. Timing and Management of Surgical Site Infections in Patients With Open Fracture Wounds: A Fluid Lavage of Open Wounds Cohort Secondary Analysis. J Orthop Trauma 2021; 35:128-135. [PMID: 33105456 DOI: 10.1097/bot.0000000000001912] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Many studies report on the incidence or prevalence of fracture-related surgical site infections (SSIs) after open fractures; however, few studies report on their timing and management outcomes. To address this gap, we used data from the Fluid Lavage of Open Wounds trial to determine timing of diagnosis, management, and resolution of SSIs. METHODS All participants included in this analysis had an SSI after an open fracture. Participants were assigned to a group based on the type of SSI as follows: (1) those who developed a superficial SSI and (2) those who had either a deep or organ/space SSI. Descriptive statistics characterized the type, timing, and management of each SSI. RESULTS Of the 2445 participants in the Fluid Lavage of Open Wounds trial, 325 (13.3%) had an SSI. Superficial SSIs were diagnosed significantly earlier [26.5 days, interquartile range (IQR) 12-48] than deep or organ/space SSIs (53 days, IQR 15-119). Of the 325 patients with SSIs, 174 required operative management and 151 were treated nonoperatively. For SSIs managed operatively, median time for infection resolution was 73 days (IQR 28-165), and on average, 1.73 surgeries (95% confidence interval 1.58-1.88) were needed during the 12 months follow-up. There were 24 cases whose SSIs were not resolved at the time of the final follow-up visit (12 months). CONCLUSIONS Based on this study's findings and in contradistinction to the Centers for Disease Control and Prevention guidelines, after an open fracture, superficial SSIs were diagnosed at one month and deep/organ/space SSIs at 2 months. This information can allow for earlier infection detection. In addition, the knowledge that approximately 50% of the SSIs in our study required a reoperation and 3 months at a minimum to resolve will assist orthopaedic surgeons when counseling their patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Carlos Prada
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Francesc A Marcano-Fernández
- Orthopaedic Department, Parc Taulí Hospital Universitari, Institut D'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Emil H Schemitsch
- Department of Surgery, University of Western Ontario, London, ON, Canada
| | - Sofia Bzovsky
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Kyle Jeray
- Department of Orthopaedic Surgery, Greenville Health System, Greenville, SC; and
| | - Brad Petrisor
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sheila Sprague
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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How Successful Is Antibiotic Treatment for Superficial Surgical Site Infections After Open Fracture? A Fluid Lavage of Open Wounds (FLOW) Cohort Secondary Analysis. Clin Orthop Relat Res 2020; 478:2846-2855. [PMID: 32412929 PMCID: PMC7899390 DOI: 10.1097/corr.0000000000001293] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although many studies report the incidence and prevalence of surgical site infections (SSIs) after open fractures, there is limited information on the treatment and subsequent outcomes of superficial SSIs in patients with open fractures. Additionally, clinical studies describing the factors that are associated with persistent infection after nonoperative treatment with antibiotics for patients with superficial SSIs are lacking. QUESTIONS/PURPOSES Therefore, we asked: (1) What proportion of patients with superficial SSIs after open fracture treatment developed persistent infection after nonoperative treatment (that is, treatment with antibiotics alone)? (2) What risk factors are associated with SSIs that do not resolve with nonoperative (antibiotic) treatment? As a secondary objective, we planned to analyze the microbiological information about participants wound cultures, when these were available, and the proportion of positive cultures for patients whose SSIs were not resolved by antibiotics alone. METHODS This is a secondary analysis of the Fluid Lavage of Open Wounds (FLOW) trial dataset. The FLOW trial included 2445 patients with operatively managed open fractures. FLOW participants who had a nonoperatively managed superficial SSI diagnosed in the 12 months post-fracture were included in this analysis. Superficial SSIs were diagnosed in 168 participants within 12 months of their fracture. Of these, 83% (139) had their superficial SSI treated with antibiotics alone. Participants were grouped into two categories: (1) 97 participants whose treatment with antibiotics alone resolved the superficial SSI and (2) 42 participants whose treatment with antibiotics alone did not resolve the SSI (defined as undergoing surgical management or the SSI being unresolved at latest follow-up [12-months post-fracture for the FLOW trial]). Of the participants whose treatment with antibiotics alone resolved the SSI, 92% (89 of 97) had complete follow-up, 6% (6 of 97) were lost to follow-up before 12 months, 1% (1 of 97) withdrew consent from the study before 12 months, and 1% (1 of 97) experienced mortality before 12 months. Of the participants whose treatment with antibiotics alone did not resolve the SSI, 90% (38 of 42) had complete follow-up, 7% (3 of 42) were lost to follow-up before 12 months, and 2% (1 of 42) withdrew consent from the study before 12 months. A logistic binary regression analysis was conducted to identify factors associated with persistent infection despite superficial SSI antibiotic treatment. Based on biologic rationale and previous evidence, we identified a priori 13 potential factors (corresponding to 14 levels) to be included in the regression model. RESULTS The antibiotic treatment resolved the superficial SSI in 70% (97 of 139) of patients and did not resolve the SSI in 30% (42 of 139). After controlling for potential confounding variables, such as age, fracture severity, and time from injury to initial surgical irrigation and débridement, superficial SSIs diagnosed later in follow-up were associated with antibiotics not resolving the SSI (odds ratio 1.05 [95% CI 1.004 to 1.009] for every week of follow-up; p = 0.03). Sex, fracture pattern, and wound size were not associated with antibiotics not resolving the SSI. CONCLUSIONS Our secondary analysis of prospectively collected FLOW data suggests that antibiotics alone can be an appropriate treatment option when treating superficial SSIs after an open fracture wound, especially when promptly diagnosed. Further research with longer follow-up time is needed to better identify the natural history of superficial SSIs and possibly some dormant or subclinical infections to help clinicians in the treatment decision-making process. LEVEL OF EVIDENCE Level III, therapeutic study.
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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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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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Retrospective analysis of risk factors for deep infection in lower limb Gustilo-Anderson type III fractures. J Orthop Traumatol 2020; 21:10. [PMID: 32683562 PMCID: PMC7368875 DOI: 10.1186/s10195-020-00549-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 05/07/2020] [Indexed: 11/10/2022] Open
Abstract
Background Open fractures are among the most severe injuries observed in orthopedic patients. Treating open fractures is difficult because such patients with infections may require multiple operations and amputations. Furthermore, only a few studies have focused on antibiotic prophylaxis in open fractures and evaluated how to cover lost soft tissue to increase the success rate of reconstruction. We evaluated the risk factors for deep infection in lower limb Gustilo–Anderson (G–A) type III fractures. Materials and methods This retrospective study investigated patients who underwent surgical procedures for lower limb G–A type III fractures between January 2007 and January 2017 at our institution. We enrolled 110 patients with 114 lower limb G–A type III fractures (77 G–A type IIIA fractures and 37 G–A type IIIB fractures) who were followed up for at least 2 years. We compared patients presenting infections with those without infections by assessing the following factors: severe contamination, diabetes, smoking, Injury Severity Scale, segmental fracture, location of fracture, G–A classification, damage control surgery, methods of surgery, timing of fixation, combination of antibiotics used, duration of antibiotic prophylaxis, timing of wound closure, and soft-tissue reconstruction failure. Results Eighteen fractures presented deep infections. Compared with patients without infections, patients developing infections differed significantly in terms of severe contamination (P < 0.01), G–A classification (P < 0.01), duration of antibiotic prophylaxis (P < 0.01), timing of wound closure (P < 0.01), and incidence of soft-tissue reconstruction failure (P < 0.01). Skin grafting was associated with significantly higher failure rates than muscle and free flap reconstructions (P = 0.04). Treatment with antibiotics was significantly longer in patients with drug-resistant bacterial infections than in those without infections (P < 0.01). Conclusion Early flaps rather than skin grafting should be used to cover G–A type IIIB fractures, because skin grafting resulted in the highest failure rate among soft-tissue reconstructions in open fractures. Longer duration of antibiotic use had a significant impact not only on deep infection rates but also on the presence of drug-resistant bacteria. These findings suggest that prolonged use of antibiotics should be avoided in cases of open fractures. Level of evidence Level IV retrospective observational study.
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28
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Rupp M, Popp D, Alt V. Prevention of infection in open fractures: Where are the pendulums now? Injury 2020; 51 Suppl 2:S57-S63. [PMID: 31679836 DOI: 10.1016/j.injury.2019.10.074] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/07/2019] [Accepted: 10/22/2019] [Indexed: 02/02/2023]
Abstract
Soft tissue management and fracture fixation including initial external fixation in Gustilo-Anderson type II and type III open fractures are cornerstones in the treatment but details on timing and type of wound closure, irrigation and debridement, systemic and local antibiotics, antimicrobial-coated implants and the use of Bone Morphogenetic Protein-2 remain controversial. This article looks at current clinical evidence of these items for the management of open fractures. Timing of debridement and wound closure remains critical. Early debridement by an experienced team within 24 h seems adequate while gross contamination, a devascularized limb, a multi-injured patient and compartment syndrome require immediate surgical intervention. Wound closure during the first surgery was shown to result in reduced rates for infections and nonunion. If soft-tissue reconstruction is needed, it should be performed within the first 7 days. Regarding types of irrigation fluid, antiseptic and antibacterial solutions did not prove to be superior to saline. High pressure irrigation has not been demonstrated to be beneficial whereas antibiotic administration as soon as possible has been proven to be favorable. Administration of more than 72 h was not superior to shorter systemic antibiotic intervals. For Gustilo-Anderson type I and II, broad spectrum antibiotic therapy is reasonable. Additional aminoglycosides for broader coverage are recommended in Gustilo-Anderson type III fractures. There is newer literature on the beneficial effects of the use of local antibiotics, e.g. by antibiotic beads. Coating of internal fixation devices is a modern approach to improve infection prophylaxis and gentamicin-coated implants have been demonstrated to be safe in clinical application. Vacuum assisted closure (VAC) could not evidence negative pressure wound therapy to reduce infection risk, improve self-rated disability or quality of life in open fractures, however, enhance treatment costs. Recombinant human bone morphogenetic proteins (rhBMP)-2 showed promising data in Gustilo-Anderson type III open tibial shaft fractures with lower rates of invasive secondary procedures. In conclusion, there is evidence for thorough debridement and irrigation with saline, early soft tissue coverage and the use of systemic and local antibiotics. Except for a short-term soft tissue coverage VAC seems not to be beneficial and rhBMP-2 is an additional tool in Gustilo-Anderson type III open fractures.
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Affiliation(s)
- Markus Rupp
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Daniel Popp
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.
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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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You DZ, Schneider PS. Surgical timing for open fractures: Middle of the night or the light of day, which fractures, what time? OTA Int 2020; 3:e067. [PMID: 33937687 PMCID: PMC8081492 DOI: 10.1097/oi9.0000000000000067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/15/2019] [Indexed: 11/25/2022]
Abstract
Controversy exists over the optimal management of open fractures as new clinical studies question open fracture management dogma. Open fractures are complex injuries requiring the orthopaedic surgeon to consider both the bone injury as well as associated soft tissue injury. Early intravenous antibiotics and tetanus prophylaxis remain instrumental in infection prevention. However, the “six-hour rule” for initial open fracture debridement and revascularization has come into question. New evidence supports initial debridement within 24 hours with the appropriate surgical team. Additionally, orthopaedic surgeons and vascular surgeons should collaborate on the sequence of management of open fractures with associated vascular injury. Whereas debates on the optimal irrigation pressure and solution have been answered by multicenter randomized controlled trials, further research is required to determine the optimal irrigation volume and timing of wound closure. With advances in management of open fractures, the utility of well-known classification systems including the Gustilo-Anderson classification and Mangled Extremity Severity Score need to be re-evaluated in favor of up-to-date classification systems which better guide management and predict prognosis.
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Affiliation(s)
- Daniel Z You
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Canada
| | - Prism S Schneider
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
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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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Miller EA, Iannuzzi NP, Kennedy SA. Management of the Mangled Upper Extremity: A Critical Analysis Review. JBJS Rev 2019; 6:e11. [PMID: 29688909 DOI: 10.2106/jbjs.rvw.17.00131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Erin A Miller
- Division of Plastic Surgery, Department of Surgery (E.A.M.), and Department of Orthopaedics and Sports Medicine (N.P.I. and S.A.K.), University of Washington, Seattle, Washington
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Shawar SK, Ly TV, Li J, Shirk MB, Reichert EM. Piperacillin/Tazobactam versus Tobramycin-Based Antibiotic Prophylaxis for Type III Open Fractures. Surg Infect (Larchmt) 2019; 21:23-28. [PMID: 31381489 DOI: 10.1089/sur.2019.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Type III open fractures are associated with an infection rate as high as 50%. The optimal antibiotic for open fracture prophylaxis remains unclear, and the literature comparing the safety and efficacy of different antibiotic regimens is limited. The aim of this study was to compare the composite adverse events (AEs) in patients before and after a change in prophylactic antibiotic management for these injuries from a tobramycin- to a piperacillin/tazobactam-based regimen. Methods: This was a retrospective single-center cohort study of patients with Type III open fractures admitted from January 2010 to December 2016. Patients were included if they received either tobramycin plus cefazolin or clindamycin or piperacillin/tazobactam for fracture prophylaxis. The primary outcome was the rate of composite AEs, which included nephrotoxicity, surgical site infection (SSI), and hospital re-admission with surgical intervention. Secondary outcomes included the rate of SSI within 30 and 60 days after injury. Data were analyzed using the Student t-, Mann-Whitney U, and Fisher exact tests. Results: Eighty-five patients were included. There were 29 events in the tobramycin group compared with three in the piperacillin/tazobactam group. At 30 days, SSI had occurred in 17 patients (27.5%) in the tobramycin group and 1 patient (4.3%) in the piperacillin/tazobactam group (p = 0.033). At 60 days, SSI had occurred in three additional patients in the tobramycin group (p = 0.009). Conclusion: There was no difference in the composite AEs in the piperacillin/tazobactam compared with the tobramycin group. However, SSI within 30 and 60 days was significantly more common with tobramycin.
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Affiliation(s)
- Suhair K Shawar
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Thuan V Ly
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Junan Li
- The Ohio State University College of Pharmacy, Columbus, Ohio
| | - Mary Beth Shirk
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio.,The Ohio State University College of Pharmacy, Columbus, Ohio
| | - Erin M Reichert
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Abstract
Upper extremity gunshot wounds result in notable morbidity for the orthopaedic trauma patient. Critical neurovascular structures are particularly at risk. The fractures are often comminuted and may be associated with a variable degree of soft-tissue injury. The literature lacks consensus regarding antibiotic selection and duration, and indications for surgical débridement. Bullets and/or bullet fragments should be removed in cases of plumbism, intra-articular location, nerve impingement, location within a vessel, and location in a subcutaneous position within the hand and/or wrist. Gunshot fractures generally do not follow common fracture patterns seen in blunt injuries, and the complexity of certain gunshot fractures can often be a challenge for the treating orthopaedic surgeon. Common plate and screw constructs may not adequately stabilize these injuries, and innovative fixation techniques may be required. The treatment for bone defects varies by location and severity of injury, and typically requires staged treatment. Nerve injuries after gunshot wounds are common, but spontaneous nerve recovery is expected in most cases.
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Chang Y, Bhandari M, Zhu KL, Mirza RD, Ren M, Kennedy SA, Negm A, Bhatnagar N, Naji FN, Milovanovic L, Fei Y, Agarwal A, Kamran R, Cho SM, Schandelmaier S, Wang L, Jin L, Hu S, Zhao Y, Lopes LC, Wang M, Petrisor B, Ristevski B, Siemieniuk RA, Guyatt GH. Antibiotic Prophylaxis in the Management of Open Fractures. JBJS Rev 2019; 7:e1. [DOI: 10.2106/jbjs.rvw.17.00197] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
OBJECTIVES To determine the frequency and effect of under-dosing prophylactic weight-based antibiotics in patients with open tibial fractures. We hypothesized that patients who did not receive appropriate weight-based dosing of prophylactic antibiotics would have higher rates of infection. DESIGN Retrospective cohort study. SETTING Level 1 Trauma Center. PATIENTS/PARTICIPANTS Patients 18 years of age or older with high-grade (Gustilo-Anderson type IIIA or IIIB) open extraarticular tibial fractures over a 5-year period. MAIN OUTCOME The primary outcome was deep infection within one year of initial injury. Appropriate weight-based dosing of cefazolin was defined as: at least 1 g for patients <80 kg, 2 g for patients between 80 and 120 kg, and 3 g for patients >120 kg. RESULTS Sixty-three patients met the inclusion criteria; 21 (33%) were under-dosed with cefazolin at the time of initial presentation. Among the 20 patients who subsequently developed deep infection, only 55% were appropriately dosed with cefazolin; of the patients who did not develop deep infection, 72% were appropriately dosed with cefazolin (P = 0.18). Univariate analysis revealed that hypertension was associated with infection (P = 0.049). Multivariable logistic regression analysis of infection due to all organisms did not reveal a statistically significant reduction in the odds of infection with appropriate weight-based dosing of cefazolin [Odds ratio = 0.42 (95% confidence interval, 0.12-1.48), P = 0.177]. Five of 7 (71%) of the gram positive, non-methicillin-resistant Staphylococcus aureus, infections occurred in patients who were under-dosed with cefazolin. Five (23.8%) of 21 patients who were under-dosed with cefazolin had gram-positive, non-methicillin-resistant S. aureus infections, compared to 2 (4.8%) of 42 patients who were appropriately dosed (P = 0.036). CONCLUSIONS Under-dosing of weight-based antibiotics in the treatment of open fractures is common. Appropriate weight-based dosing of cefazolin for prophylaxis in high-grade open tibial fractures reduces the frequency of infection due to cefazolin-sensitive organisms. Interestingly, organisms not susceptible to cefazolin were responsible for the majority of infections. The effect of under-dosing of cefazolin and other weight-based antibiotics deserves further investigation in larger studies. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
Bone defects associated with open fractures require a careful approach and planning. At initial presentation, an emergent irrigation and debridement is required. Immediate definitive fixation is frequently safe, with the exception of those injuries that normally require staged management or very severe type IIIB and IIIC injuries. Traumatic wounds that can be approximated primarily should be closed at the time of initial presentation. Wounds that cannot be closed should have a negative pressure wound therapy dressing applied. The need for subsequent debridements remains a clinical judgment, but all nonviable tissue should be removed before definitive coverage. Cefazolin remains the standard of care for all open fractures, and type III injuries also require gram-negative coverage. Both induced membrane technique with staged bone grafting and distraction osteogenesis are excellent options for bony reconstruction. Soft tissue coverage within 1 week of injury seems critical.
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Affiliation(s)
- Paul Toogood
- Corresponding author: , phone 415-206-8812, fax 415-206-3733
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Carver DC, Kuehn SB, Weinlein JC. Role of Systemic and Local Antibiotics in the Treatment of Open Fractures. Orthop Clin North Am 2017; 48:137-153. [PMID: 28336038 DOI: 10.1016/j.ocl.2016.12.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The orthopedic community has learned much about the treatment of open fractures from the tremendous work of Ramon Gustilo, Michael Patzakis, and others; however, open fractures continue to be very difficult challenges. Type III open fractures continue to be associated with high infection rates. Some combination of systemic and local antibiotics may be most appropriate in these high-grade open fractures. Further research is still necessary in determining optimal systemic antibiotic regimens as well as the role of local antibiotics. Any new discoveries related to novel systemic antibiotics or local antibiotic carriers will need to be evaluated related to cost.
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Affiliation(s)
- David C Carver
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Sean B Kuehn
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - John C Weinlein
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, Memphis, TN, USA.
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Bevilacqua MP, Huang DJ, Wall BD, Lane SJ, Edwards CK, Hanson JA, Benitez D, Solomkin JS, Deming TJ. Amino Acid Block Copolymers with Broad Antimicrobial Activity and Barrier Properties. Macromol Biosci 2017; 17. [DOI: 10.1002/mabi.201600492] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/14/2017] [Indexed: 01/05/2023]
Affiliation(s)
| | - Daniel J. Huang
- Amicrobe, Inc. 3142 Tiger Run Court #101 Carlsbad CA 92010 USA
| | - Brian D. Wall
- Amicrobe, Inc. 3142 Tiger Run Court #101 Carlsbad CA 92010 USA
| | - Shalyn J. Lane
- Amicrobe, Inc. 3142 Tiger Run Court #101 Carlsbad CA 92010 USA
| | - Carl K. Edwards
- Amicrobe, Inc. 3142 Tiger Run Court #101 Carlsbad CA 92010 USA
| | | | - Diego Benitez
- Amicrobe, Inc. 3142 Tiger Run Court #101 Carlsbad CA 92010 USA
| | | | - Timothy J. Deming
- University of California, Los Angeles Bioengineering Department Chemistry and Biochemistry Department 5121, Engineering V Los Angeles CA 90095 USA
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