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Zhang C, Yusuf SM, Farag S, Wade RG, Wormald JCR. Protocol for a systematic review and network meta-analysis of the use of prophylactic antibiotics in hand trauma surgery. Syst Rev 2024; 13:157. [PMID: 38877569 PMCID: PMC11177469 DOI: 10.1186/s13643-024-02573-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 05/28/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND The use of prophylactic antibiotics in surgery is contentious. With the rise in antimicrobial resistance, evidence-based antibiotic use should be followed. This systematic review and network meta-analysis will assess the effectiveness of different antibiotics on the prevention of surgical site infection (SSI) following hand trauma surgery. METHODS AND ANALYSIS The databases Embase, MEDLINE, CINAHL and CENTRAL, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform will be searched. Abstracts will be screened by two persons independently to identify eligible studies. This systematic review will include both randomised and non-randomised prospective comparative studies in participants with hand and/or wrist injuries requiring surgery; bite injuries will be excluded. The network meta-analysis will compare the use of different prophylactic antibiotics against each other, placebo and/or no antibiotics on the development of SSI within 30 days of surgery (or 90 days if there is an implanted device). The Cochrane risk-of-bias tool 2 will be used to assess the risk of methodological bias in randomised controlled trials, and the Newcastle-Ottowa scale (NOS) will be used to assess the risk of bias in non-randomised studies. A random-effects network meta-analysis will be conducted along with subgroup analyses looking at antibiotic timing, injury type, and operation location. Sensitivity analyses including only low risk-of-bias studies will be conducted, and the confidence in the results will be assessed using Confidence in Network Meta-Analysis (CINEMA). DISCUSSION This systematic review and network meta-analysis aims to provide an up-to-date synthesis of the studies assessing the use of antibiotics following hand and wrist trauma to enable evidence-based peri-operative prescribing. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42023429618.
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Affiliation(s)
- Chen Zhang
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, Oxfordshire, OX3 9DU, UK.
| | - Suraya Mohamed Yusuf
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, Oxfordshire, OX3 9DU, UK
| | - Soma Farag
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, Oxfordshire, OX3 9DU, UK
| | | | - Justin Conrad Rosen Wormald
- Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, Oxford Trauma and Emergency Care, Nuffield University of Oxford, Oxford, OX3 9DU, UK
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Dahmus ES, Foster BK, Callahan CR, Schroer JM, Frank KE, Dwyer CL, Jacob GC, Grandizio LC. Foregoing Preoperative Antibiotics in Clean, Implant-Based Hand Surgery Does Not Increase Postoperative Infectious Risks. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:338-343. [PMID: 38817759 PMCID: PMC11133795 DOI: 10.1016/j.jhsg.2024.01.013] [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: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 06/01/2024] Open
Abstract
Purpose Although data support foregoing preoperative antibiotics for outpatient, soft-tissue procedures, there is a paucity of evidence regarding antibiotics for implant-based hand procedures. The purpose of this investigation was to assess early postoperative infectious concerns for patients undergoing implant-based hand surgery, regardless of preoperative antibiotic use. Methods A retrospective cohort analysis was performed consisting of all patients undergoing implant-based hand procedures between January 2015 and October 2021. Primary outcomes included antibiotic prescription or reoperation for infection within 90 days of surgery. Demographics (age, gender, body mass index, diabetes, and smoking status) and hand surgery procedure type were recorded. To account for differences in baseline characteristics between patients who did and did not receive preoperative antibiotics, covariate balancing was performed with subsequent weighted logistic regression models constructed to estimate the effect of no receipt of preoperative antibiotics on the need for postoperative antibiotics. In a separate logistic regression analysis, patients' baseline characteristics were evaluated together as predictors of postoperative antibiotic prescription. Results One thousand eight hundred sixty-two unique procedures were reviewed with 1,394 meeting criteria. Two hundred thirty-six patients (16.9%) were not prescribed preoperative antibiotics. Overall, 54 (3.87%) and 69 (4.95%) patients received antibiotics within 30 and 90 days of surgery, respectively. One patient (0.07%) underwent reoperation. There were no differences in the rates of 30- and 90-day postoperative antibiotic prescriptions between the two groups. After covariant balancing of risk factors, patients not prescribed preoperative antibiotics did not display significantly higher odds of requiring postoperative antibiotics at 30 or 90 days. Logistic regression models showed male gender, temporary Kirschner wire fixation, and elevated body mass index were associated with increased postoperative antibiotics at 30 and 90 days. Conclusions For implant-based hand procedures, there was no increased risk in postoperative antibiotic prescription or reoperation for patients who did not receive preoperative antibiotics. Type of study/level of evidence Therapeutic III.
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Affiliation(s)
- Emma S. Dahmus
- Division of Plastic and Reconstructive Surgery, Geisinger Surgical Institute, Geisinger Medical Center, Danville, PA
| | - Brian K. Foster
- Geisinger Musculoskeletal Institute, Geisinger Medical Center, Danville, PA
| | | | | | - Katie E. Frank
- Department of Population Health Sciences, Geisinger Medical Center, Danville, PA
| | - C. Liam Dwyer
- Geisinger Musculoskeletal Institute, Geisinger Medical Center, Danville, PA
| | - Glen C. Jacob
- Geisinger Musculoskeletal Institute, Geisinger Wyoming Valley, Wilkes-Barre, PA
| | - Louis C. Grandizio
- Geisinger Musculoskeletal Institute, Geisinger Medical Center, Danville, PA
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McKay KM, Burchette R, Shi JM, Henry SL, Harness NG. Evidence-Based Antibiotic Prophylaxis in Clean Hand Surgeries: An Educational Intervention to Decrease Use. J Hand Surg Am 2023:S0363-5023(23)00208-3. [PMID: 37318406 DOI: 10.1016/j.jhsa.2023.04.014] [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: 06/05/2022] [Revised: 04/11/2023] [Accepted: 04/21/2023] [Indexed: 06/16/2023]
Abstract
PURPOSE Evidence for the use of prophylactic antibiotics in clean hand surgery is limited, yet surgeons continue to administer antibiotics to prevent postoperative infections. We sought to assess the effect of a program directed at reducing the use of antibiotic prophylaxis in carpal tunnel release surgery and elicit reasons for continued use. METHODS A surgeon leader implemented a program between September 1, 2018 and September 30, 2019 to reduce antibiotic prophylaxis in clean hand surgeries in a hospital system of 10 medical centers. It consisted of (1) an evidence-based educational session for all participating orthopedic and hand surgeons during which the elimination of the use of antibiotics in clean hand surgeries was requested and (2) a year-long, monthly antibiotic use audit and feedback cycle using carpal tunnel release (CTR) as a proxy for clean hand surgery. The rate of antibiotic use in the year of the intervention was compared to the rate prior to the intervention. Multivariable regression was used to determine patient-related risk factors for receiving antibiotics. Participating surgeons completed a survey to elucidate factors that contributed to continued use. RESULTS Antibiotic prophylaxis decreased from 1223/2379 (51%) in 2017-2018 to 531/2550 (21%) in 2018-2019. During the last month of evaluation, the rate decreased to 28/208 (14%). Logistic regression revealed a higher rate of antibiotic use during the period after the intervention among patients who had diabetes mellitus or who were operated upon by an older surgeon. The follow-up surgeon survey revealed a strong positive correlation between surgeon willingness to administer antibiotics and patient hemoglobin A1c and body mass index. CONCLUSIONS The rate of antibiotic use in carpal tunnel release decreased from 51% the year prior to 14% the final month of implementing a surgeon-led program to reduce antibiotic prophylaxis. Multiple barriers to the implementation of evidence-based practice were identified. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Kevin M McKay
- Department of Orthopedic Surgery, Loma Linda University Health, Loma Linda, CA.
| | - Raoul Burchette
- Kaiser Permanente Orange County - Anaheim Medical Center, Anaheim, CA
| | - Jiaxiao M Shi
- Kaiser Permanente Orange County - Anaheim Medical Center, Anaheim, CA
| | - Shayna L Henry
- Kaiser Permanente Orange County - Anaheim Medical Center, Anaheim, CA
| | - Neil G Harness
- Kaiser Permanente Orange County - Anaheim Medical Center, Anaheim, CA
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Antibiotic Prophylaxis for Distal Interphalangeal Joint Arthrodesis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4848. [PMID: 36891567 PMCID: PMC9988317 DOI: 10.1097/gox.0000000000004848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/04/2023] [Indexed: 03/08/2023]
Abstract
Prior evidence is clear that in clean, elective soft-tissue hand procedures less than 2 hours, antibiotic prophylaxis is not indicated. However, there is a lack of consensus regarding the boney procedures of the hand involving implanted hardware. Previous studies reviewing complications after distal interphalangeal (DIP) joint arthrodesis did not analyze whether patients receiving antibiotics before surgery had a significant difference in the infection rate. Methods A retrospective review of clean, elective DIP arthrodesis was conducted between September 2018 and September 2021. The subjects were aged 18 years and older and underwent elective DIP arthrodesis for the treatment of osteoarthritis or deformity of the DIP joint. All the procedures were performed using an intramedullary headless compression screw. The rates of postoperative infections and treatments required for infections were recorded and analyzed. Results Overall, 37 unique patients had at least one case of DIP arthrodesis that met the criteria for inclusion in our analysis. Twenty of the 37 patients did not receive antibiotic prophylaxis, and 17 of the 37 patients received antibiotic prophylaxis. Five of the 20 patients who did not receive antibiotics prophylactically developed infections, and none of the 17 patients who received antibiotics prophylactically developed an infection. Fisher exact test revealed a significant difference in the infection rates between the two groups (P < 0.05). There was no significant difference in infections with respect to smoking or diabetes status. Conclusion Antibiotic prophylaxis should be administered for clean, elective DIP arthrodesis, using an intramedullary screw.
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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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Applying Evidence to Inform Carpal Tunnel Syndrome Care. J Hand Surg Am 2021; 46:223-230.e2. [PMID: 33139119 DOI: 10.1016/j.jhsa.2020.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/03/2020] [Accepted: 09/20/2020] [Indexed: 02/02/2023]
Abstract
Carpal tunnel syndrome (CTS) is one of the most common problems treated by hand surgeons. As our understanding of the condition has improved and focus on quality and evidence-based care has evolved, management of CTS has shifted as well. Although for many patients the diagnosis and treatment plan are relatively straightforward, understanding how to decide what diagnostics are appropriate, how to avoid complications especially in high-risk patients, and even which surgical option to offer remains a challenge. As CTS research efforts broaden and available evidence grows, understanding the different research findings in order to implement the evidence into practice is critical for all surgeons. In this article, we approach commonly encountered challenges in CTS management and take a methodological viewpoint to guide evidence-based practice.
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