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Albavera-Gutierrez RR, Espinosa-Ramos MA, Rebolledo-Bello E, Paredes-Herrera FJ, Carballo-Lucero D, Valencia-Ledezma OE, Castro-Fuentes CA. Prevalence of Staphylococcus aureus Infections in the Implantation of Orthopedic Devices in a Third-Level Hospital: An Observational Cohort Study. Pathogens 2024; 13:620. [PMID: 39204221 PMCID: PMC11357249 DOI: 10.3390/pathogens13080620] [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: 06/17/2024] [Revised: 07/19/2024] [Accepted: 07/24/2024] [Indexed: 09/03/2024] Open
Abstract
Using orthopedic devices or prosthetic joints to treat various conditions is expected in a Traumatology and Orthopedics Unit. Recently, the materials used to build these different devices have evolved; however, pathogens can still infect these materials. Additionally, the immune system has limitations when defending against these pathogens, which results in bacterial infections like Staphylococcus aureus, Methicillin-susceptible Staphylococcus aureus (MSSA) and Methicillin-resistant Staphylococcus aureus (MRSA). A total of 276 patients who attended the Traumatology and Orthopedics Unit of our hospital from 1 June 2018 to 1 June 2019, were included in the present study. Our study analyzed the incidence of S. aureus and other bacterial pathogens in the surgical sites of patients with orthopedic implants, as well as the most used types of implants and implant materials. The specimens obtained from the surgical sites of the patients were cultured in anaerobic and aerobic media for subsequent identification using their phenotypic characteristics. Subsequently, antibiotic susceptibility tests were performed to establish the appropriate treatment. The primary pathogens identified were Staphylococcus aureus (26.4%), followed by Escherichia coli (21.0%) and Staphylococcus epidermidis (15.8%). The most commonly used implants were plates (41.7%), followed by endomedullary nails (20%), Kirschner wires (14.1%), and fixators (10.1%). As for the anatomical regions of the implants, the most frequent sites were the legs, followed by the thighs, wrists, and ankles. The pathogens were more susceptible to ciprofloxacin (95%), clindamycin (89%), and cefotaxime (86%). S. aureus is the primary infectious agent in our hospital, with an incidence of 26.4% after the placement of orthopedic implants. Although its incidence was lower compared to other tertiary hospitals, it is necessary to improve aseptic techniques in such a way as to reduce the incidence of this pathogen further.
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Affiliation(s)
- Roberto Renan Albavera-Gutierrez
- Traumatology and Orthopedics Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico; (R.R.A.-G.); (M.A.E.-R.); (E.R.-B.); (F.J.P.-H.); (D.C.-L.)
| | - Manuel A. Espinosa-Ramos
- Traumatology and Orthopedics Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico; (R.R.A.-G.); (M.A.E.-R.); (E.R.-B.); (F.J.P.-H.); (D.C.-L.)
| | - Ernesto Rebolledo-Bello
- Traumatology and Orthopedics Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico; (R.R.A.-G.); (M.A.E.-R.); (E.R.-B.); (F.J.P.-H.); (D.C.-L.)
| | - Francisco Javier Paredes-Herrera
- Traumatology and Orthopedics Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico; (R.R.A.-G.); (M.A.E.-R.); (E.R.-B.); (F.J.P.-H.); (D.C.-L.)
| | - Daniel Carballo-Lucero
- Traumatology and Orthopedics Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico; (R.R.A.-G.); (M.A.E.-R.); (E.R.-B.); (F.J.P.-H.); (D.C.-L.)
| | - Omar Esteban Valencia-Ledezma
- Research Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico;
| | - Carlos Alberto Castro-Fuentes
- Research Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico;
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Messori M, Touloupakis G, Gilli A, Theodorakis E, Pozzi P, Ghirardelli S, Antonini G. The risk of infection in open distal tibial fracture: the DANGER score. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2965-2970. [PMID: 36917286 DOI: 10.1007/s00590-023-03517-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/02/2023] [Indexed: 03/15/2023]
Abstract
INTRODUCTION Open fractures of the distal tibia can be functionally devastating, and they remain one of the most challenging injuries treated by trauma surgeons usually burdened with a high rate of complications, including surgical site infections (SSI). Our aim is to analyze the most significant risk factors of SSI and propose a new scoring system-called the DANGER scale-potentially able to predict reliably and quantify the infection risk in distal tibia open fractures. METHODS We identified six variables summarized in the acronym DANGER where D stands for Diabetes, A for Antibiotic, N for Nature of trauma (high- or low-energy trauma), G represents Grade of fracture following the AO/OTA classification, E indicates Exposure of the fracture according to the Gustilo-Anderson classification, and R represents Relative risk of patient, including use of tobacco, alcoholism, and psychiatric disorders. Therefore, total score ranged from 1 to 14, with a lower score indicating less risk to develop SSI. RESULTS A total of 103 patients with open distal tibial fractures were enrolled, 12 patients (11.6%) developed SSI. Regarding DANGER score, a rating of 8.2 was calculated in SSI group and 4.8 in non-SSI group. Based on Fisher's test, diabetes (odds = 31.8 p < 0.05), grade of articular involvement (p < 0.05), severity of open fracture (p < 0.05), and dangerous behavior such as use of tobacco, alcoholism, and psychiatric disorders (p < 0.05) were significantly correlated with infection. Significant difference between total DANGER scores in SSI and non-SSI groups was found (p < 0.001). ROC curve was calculated founding a potential threshold of 7.5 (p < 0.001). CONCLUSION Based on the above well-accepted risk factors, DANGER scale represents an advantageous and practical tool in order to readily estimate the risk of surgical site infection of open distal tibial fractures.
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Affiliation(s)
- Matteo Messori
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy.
- University of Milan, 20122, Milan, Italy.
| | - Georgios Touloupakis
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
- University of Milan, 20122, Milan, Italy
| | - Antonio Gilli
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
- University of Milan, 20122, Milan, Italy
| | - Emmanouil Theodorakis
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
- University of Milan, 20122, Milan, Italy
| | - Pierrenzo Pozzi
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
- University of Milan, 20122, Milan, Italy
| | - Stefano Ghirardelli
- Women's College Hospital, University Toronto Orthopedic Sports Medicine, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Guido Antonini
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy
- University of Milan, 20122, Milan, Italy
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Lee C, Mayer E, Bernthal N, Wenke J, O'Toole RV. Orthopaedic infections: what have we learned? OTA Int 2023; 6:e250. [PMID: 37168032 PMCID: PMC10166335 DOI: 10.1097/oi9.0000000000000250] [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: 09/20/2022] [Accepted: 12/22/2022] [Indexed: 05/13/2023]
Abstract
Orthopaedic infections remain challenging complications to treat, with profound economic impact in addition to patient morbidity. The overall estimates of infection after orthopaedic surgery with internal devices has been estimated at 5%, with hospital costs eight times that of those without fracture-related infections and with significantly poorer functional and pain interference PROMIS scores. Orthopaedic infection interventions have been focused on prevention and treatment options. The creation of new modalities for orthopaedic infection treatment can benefit from the understanding of the temporal relationship between bacterial colonization and host-cell integration, a concept referred to as "the race for the surface." Regarding prevention, host modulation and antibiotic powder use have been explored as viable options to lower infection rates. Orthopaedic infection treatment has additionally continued to evolve, with PO antibiotics demonstrating equivalent efficacy to IV antibiotics for the treatment of orthopaedic infections in recent studies. In conclusion, orthopaedic infections remain difficult clinical dilemmas, although evolving prevention and treatment modalities continue to emerge.
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Affiliation(s)
- Christopher Lee
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
- Corresponding author. Address: Christopher Lee, MD, University of California Los Angeles Department of Orthopaedic Surgery, 10833 Le Conte Ave, Los Angeles, CA 90095. E-mail:
| | - Erik Mayer
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Nicholas Bernthal
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Joseph Wenke
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch at Galveston, Galveston, TX; and
| | - Robert V. O'Toole
- Department of Orthopaedic Surgery, University of Maryland, Baltimore, MD
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Wang H, Liu Y, Shi Z, Wang D, Zhang H, Diao S, Xu X, Waheed MZ, Lu T, Zhou J. Intrawound application of vancomycin reduces the proportion of fracture-related infections in high-risk tibial plateau fractures. Injury 2023; 54:1088-1094. [PMID: 36740472 DOI: 10.1016/j.injury.2023.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Despite the improvements in surgical techniques and the use of prophylactic intravenous antibiotics, the fracture-related infection (FRI) incidence after high-risk tibial plateau fractures remains high. This study aimed to evaluate the clinical effect of the intrawound application of vancomycin on the FRI after high-risk tibial plateau fracture surgery. METHODS A total of 243 patients who underwent high-risk tibial plateau fracture surgery from May 2013 to June 2021 were retrospectively reviewed. Of these, 233 cases were enrolled. Considering the preoperative patient condition, surgeons applied vancomycin powder directly into the surgical site before wound closure in 105 cases (intrawound application of vancomycin powder with preoperative intravenous cephalosporin). The remaining 128 cases served as the control group (preoperative intravenous cephalosporin alone). Clinical data and surgical details were recorded. The Cox proportional hazards regression analysis was used to assess risk factors for FRI. The Kaplan-Meier method and the log rank test illustrated the infection status of patients based on the application of intrawound vancomycin. The primary outcome was an FRI within one year. Secondary outcomes included bacterial culture and vancomycin-related complications. RESULTS Our study demonstrated a significant difference in the incidence of FRI between the vancomycin group and the control group (3.8% versus 10.9%; p=0.041). Multivariable Cox regression showed the intrawound application of vancomycin powder decreased the rate of FRI. There were no complications related to intrawound vancomycin observed during follow-up. The presence of Gram-positive FRI was higher in the control group compared with the vancomycin group. CONCLUSIONS Intrawound application of vancomycin was associated with a significant lower rate of FRI after high-risk tibial plateau fracture surgery compared to the control group.
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Affiliation(s)
- Hanzhou Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Yang Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Zongxin Shi
- Department of Orthopedic Surgery, Beijing Liangxiang Hospital, Beijing 102446, PR China
| | - Dong Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Hui Zhang
- Department of Orthopedic Surgery, Beijing Liangxiang Hospital, Beijing 102446, PR China
| | - Shuo Diao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Xiaopei Xu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Muhammad Zeeshan Waheed
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Tianchao Lu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China
| | - Junlin Zhou
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing 100020, PR China.
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Do Intrawound Antibiotics Reduce the Incidence of Surgical Site Infections in Pelvic and Lower-Limb Trauma Surgery? A Systematic Review and Meta-analysis. J Orthop Trauma 2022; 36:e418-e424. [PMID: 35616630 DOI: 10.1097/bot.0000000000002422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To analyze the efficacy of intraoperative topical antibiotics in reducing the incidence of postoperative surgical site infections in pelvic and lower-limb trauma orthopaedic surgery. DATA SOURCES A search of Ovid MEDLINE, PubMed, and Embase was conducted for English language studies published from 1946 through September 3, 2021, using relevant keywords. STUDY SELECTION Included studies were randomized controlled trials, cohort studies, or case-control studies reporting on the rate of surgical site infections in adult patients (age 16 and older) who underwent surgical fixation of lower-limb or pelvic traumatic fractures, including both open and closed fractures, with topical intraoperative antibiotics applied to the surgical site before wound closure. DATA EXTRACTION Studies were evaluated using the Joanna Briggs Institute Critical Appraisal Checklist for analytical cross-sectional studies. The risk of bias was assessed using the ROBINS-I and Cochrane risk-of-bias tools. DATA SYNTHESIS A meta-analysis was conducted using the inverse variance method and random-effects model to assess effect significance and study heterogeneity. CONCLUSIONS Seven studies were included in the systematic review. Results of the meta-analysis suggested a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intraoperative antibiotic powder compared with those managed with intravenous antibiotics alone (odds ratio 0.77, 95% confidence interval 0.52-1.13), although the results did not reach statistical significance. Further powered studies including randomized controlled trials would be of great value to validate the results suggested in this study and inform best practice intraoperative antibiotic prophylaxis in pelvic and lower-limb trauma surgery. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Edmiston CE, Leaper DJ. Prevention of Orthopedic Prosthetic Infections Using Evidence-Based Surgical Site Infection Care Bundles: A Narrative Review. Surg Infect (Larchmt) 2022; 23:645-655. [PMID: 35925775 DOI: 10.1089/sur.2022.146] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The number of primary/revision total joint replacements (TJR) are expected to increase substantially with an aging population and increasing prevalence of comorbid conditions. The 30-day re-admission rate, in all orthopedic specialties, is 5.4% (range, 4.8%-6.0%). A recent publication has documented that the surgical site infection (SSI) infection rate associated with revision total knee (rTKR, 15.6%) and revision total hip (rTHR, 8.6%) arthroplasties are four to seven times the rate of the primary procedures (2.1%-2.2%). These orthopedic infections prolong hospital stays, double re-admissions, and increase healthcare costs by a factor of 300%. Methods: A search of PubMed/MEDLINE, EMBASE and the Cochrane Library publications, which reported the infection risk after TKR and THR, was undertaken (January 1, 1995 to December 31, 2021). The search also included documentation of evidence-based practices that lead to improved post-operative outcomes. Results: The evidence-based approach to reducing the risk of SSI was grouped into pre-operative, peri-operative, and post-operative periods. Surgical care bundles have existed within other surgical disciplines for more than 20 years, although their use is relatively new in peri-operative orthopedic surgical care. Pre-admission chlorhexidine gluconate (CHG) showers/cleansing, staphylococcal decolonization, maintenance of normothermia, wound irrigation, antimicrobial suture wound closure, and post-operative wound care has been shown to improve clinical outcome in randomized controlled studies and meta-analyses. Conclusions: Evidence-based infection prevention care bundles have improved clinical outcomes in all surgical disciplines. The significant post-operative morbidity, mortality, and healthcare cost, associated with SSIs after TJR can be reduced by introduction of evidence-based pre-operative, intra-operative, and post-operative interventions.
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Affiliation(s)
- Charles E Edmiston
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin USA
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O'Hara NN, Carullo J, Joshi M, Banoub M, Claeys KC, Sprague S, Slobogean GP, O'Toole RV. Does cumulative topical antibiotic powder use increase the risk of drug induced acute kidney injury in fracture patients? Bone Jt Open 2022; 3:284-290. [PMID: 35363046 PMCID: PMC9044090 DOI: 10.1302/2633-1462.34.bjo-2022-0009.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIMS There is increasing evidence to support the use of topical antibiotics to prevent surgical site infections. Although previous research suggests a minimal nephrotoxic risk with a single dose of vancomycin powder, fracture patients often require multiple procedures and receive additional doses of topical antibiotics. We aimed to determine if cumulative doses of intrawound vancomycin or tobramycin powder for infection prophylaxis increased the risk of drug-induced acute kidney injury (AKI) among fracture patients. METHODS This cohort study was a secondary analysis of single-centre Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma (PREP-IT) trial data. We included patients with a surgically treated appendicular fracture. The primary outcome was drug-induced AKI. The odds of AKI per gram of vancomycin or tobramycin powder were calculated using Bayesian regression models, which adjusted for measured confounders and accounted for the interactive effects of vancomycin and tobramycin. RESULTS Of the 782 included patients (mean age 48 years (SD 20); 59% male), 83% (n = 648) received at least one vancomycin dose (cumulative range 1 to 12 g). Overall, 45% of the sample received at least one tobramycin dose (cumulative range 1.2 to 9.6 g). Drug-induced AKI occurred in ten patients (1.2%). No association was found between the cumulative dose of vancomycin and drug-induced AKI (odds ratio (OR) 1.08 (95% credible interval (CrI) 0.52 to 2.14)). Additional doses of tobramycin were associated with a three-fold increase in the adjusted odds of drug-induced AKI (OR 3.66 (95% CrI 1.71 to 8.49)). Specifically, the risk of drug-induced AKI rose substantially after 4.8 g of tobramycin powder (7.5% (95% CrI 1.0 to 35.3)). CONCLUSION Cumulative doses of vancomycin were not associated with an increased risk of drug-induced AKI among fracture patients. While the risk of drug-induced AKI remains less than 4% with three or fewer 1.2 g tobramycin doses, the estimated risk increases substantially to 8% after four cumulative doses. Level of evidence: Therapeutic Level III Cite this article: Bone Jt Open 2022;3(4):284-290.
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Affiliation(s)
- Nathan N. O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jessica Carullo
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Manjari Joshi
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mary Banoub
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Kimberly C. Claeys
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sheila Sprague
- Department of Surgery, McMaster University, Hamilton, Canada
| | - Gerard P. Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Robert V. O'Toole
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - PREP-IT Investigators
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
- Department of Surgery, McMaster University, Hamilton, Canada
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Carlini AR, Joshi M, Qadir R, Castillo RC, O'Toole RV. In Response. J Orthop Trauma 2021; 35:e437-e438. [PMID: 34653110 DOI: 10.1097/bot.0000000000002223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Anthony R Carlini
- Johns Hopkins Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public, Health, Baltimore, MD
| | - Manjari Joshi
- R Adams Cowley Shock Trauma Center, Division of Infectious Disease, University of Maryland School of Medicine, Baltimore, MD
| | - Rabah Qadir
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Renan C Castillo
- Johns Hopkins Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public, Health, Baltimore, MD
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
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