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Zhao Y, D'Souza R, Gao Y, Hao Q, Kallas-Silva L, Steen JP, Guyatt G. Progestogens in women with threatened miscarriage or recurrent miscarriage: A meta-analysis. Acta Obstet Gynecol Scand 2024; 103:1689-1701. [PMID: 38481031 PMCID: PMC11324929 DOI: 10.1111/aogs.14829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 08/16/2024]
Abstract
INTRODUCTION Clinical practice guidelines provide inconsistent recommendations regarding progestogen supplementation for threatened and recurrent miscarriage. We conducted a systematic review and meta-analysis to assess the effectiveness and safety of progestogens for these patients. MATERIAL AND METHODS We searched Medline, Embase, and Cochrane Central Registry of Controlled Trials up to October 6, 2023 for randomized control trials (RCTs) comparing progestogen supplementation to placebo or no treatment for pregnant women with threatened or recurrent miscarriage. We assessed the risk of bias using a modified version of the Cochrane risk-of-bias tool and the certainty of evidence using the GRADE approach. RESULTS Of 15 RCTs (6616 pregnancies) reporting on threatened or recurrent miscarriage, 12 (5610 pregnancies) reported on threatened miscarriage with or without a prior history of miscarriage. Results indicated that progesterone probably increases live births (relative risk (RR) 1.04, 95% confidence interval (CI) 0.99-1.10, absolute increase 3.1%, moderate certainty). Of these RCTs, three (1973 pregnancies) reporting on threatened miscarriage with a prior history of miscarriage indicated that progesterone possibly increases live births (RR 1.06, 95% CI: 0.97-1.16, absolute increase 4.4%; low certainty), while four (2540 pregnancies) reporting on threatened miscarriage and no prior miscarriage left the effect very uncertain (RR 1.02, 95% CI: 0.96-1.10, absolute increase 1.7%; very low certainty). Three trials reporting on 1006 patients with a history of two or more prior miscarriages indicated progesterone probably increases live births (RR 1.08, 95% CI: 0.98-1.19, absolute increase 5.7%, moderate certainty). Six RCTs that reported on 2979 patients with at least one prior miscarriage indicated that progesterone probably increases live births (RR 1.07, 95% CI: 1.01-1.13, absolute increase 5.0%; moderate certainty). Progesterone probably has little or no effect on congenital anomalies (RR 1.06, 95% CI: 0.76-1.48, absolute increase 0.1%; moderate certainty), and other serious adverse pregnancy events (RR 1.07, 95% CI: 0.83-1.40, absolute increase 0.2%, moderate certainty). CONCLUSIONS In women at increased risk of pregnancy loss, progestogens probably increase live births without increasing adverse maternal and neonatal events. It remains possible that the benefit is restricted to those with prior miscarriages.
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Affiliation(s)
- Yunli Zhao
- Department of Geriatric Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Municipality Clinical Research Center for Geriatrics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- The Center of Gerontology and Geriatrics (National Clinical Research Center for Geriatrics), West China Hospital, Sichuan University, Chengdu, China
| | - Rohan D'Souza
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Ya Gao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Qiukui Hao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Lucas Kallas-Silva
- Faculdade Israelita de Ciȇncias da Saúde Albert Einstein, São Paulo, Brazil
| | - Jeremy P Steen
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Zhao Y, Gao Y, Guyatt G, Uyeki TM, Liu P, Liu M, Shen Y, Chen X, Luo S, Li X, Huang R, Hao Q. Antivirals for post-exposure prophylaxis of influenza: a systematic review and network meta-analysis. Lancet 2024; 404:764-772. [PMID: 39181596 PMCID: PMC11369964 DOI: 10.1016/s0140-6736(24)01357-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 06/23/2024] [Accepted: 06/26/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Antiviral post-exposure prophylaxis with neuraminidase inhibitors can reduce the incidence of influenza and the risk of symptomatic influenza, but the efficacy of the other classes of antiviral remains unclear. To support an update of WHO influenza guidelines, this systematic review and network meta-analysis evaluated antiviral drugs for post-exposure prophylaxis of influenza. METHODS We systematically searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Global Health, Epistemonikos, and ClinicalTrials.gov for randomised controlled trials published up to Sept 20, 2023 that evaluated the efficacy and safety of antivirals compared with another antiviral or placebo or standard care for prevention of influenza. Pairs of reviewers independently screened studies, extracted data, and assessed the risk of bias. We performed network meta-analyses with frequentist random effects model and assessed the certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. The outcomes of interest were symptomatic or asymptomatic infection, admission to hospital, all-cause mortality, adverse events related to antivirals, and serious adverse events. This study is registered with PROSPERO, CRD42023466450. FINDINGS Of 11 845 records identified by our search, 33 trials of six antivirals (zanamivir, oseltamivir, laninamivir, baloxavir, amantadine, and rimantadine) that enrolled 19 096 individuals (mean age 6·75-81·15 years) were included in this systematic review and network meta-analysis. Most of the studies were rated as having a low risk of bias. Zanamivir, oseltamivir, laninamivir, and baloxavir probably achieve important reductions in symptomatic influenza in individuals at high risk of severe disease (zanamivir: risk ratio 0·35, 95% CI 0·25-0·50; oseltamivir: 0·40, 0·26-0·62; laninamivir: 0·43, 0·30-0·63; baloxavir: 0·43, 0·23-0·79; moderate certainty) when given promptly (eg, within 48 h) after exposure to seasonal influenza. These antivirals probably do not achieve important reductions in symptomatic influenza in individuals at low risk of severe disease when given promptly after exposure to seasonal influenza (moderate certainty). Zanamivir, oseltamivir, laninamivir, and baloxavir might achieve important reductions in symptomatic zoonotic influenza in individuals exposed to novel influenza A viruses associated with severe disease in infected humans when given promptly after exposure (low certainty). Oseltamivir, laninamivir, baloxavir, and amantadine probably decrease the risk of all influenza (symptomatic and asymptomatic infection; moderate certainty). Zanamivir, oseltamivir, laninamivir, and baloxavir probably have little or no effect on prevention of asymptomatic influenza virus infection or all-cause mortality (high or moderate certainty). Oseltamivir probably has little or no effect on admission to hospital (moderate certainty). All six antivirals do not significantly increase the incidence of drug-related adverse events or serious adverse events, although the certainty of evidence varies. INTERPRETATION Post-exposure prophylaxis with zanamivir, oseltamivir, laninamivir, or baloxavir probably decreases the risk of symptomatic seasonal influenza in individuals at high risk for severe disease after exposure to seasonal influenza viruses. Post-exposure prophylaxis with zanamivir, oseltamivir, laninamivir, or baloxavir might reduce the risk of symptomatic zoonotic influenza after exposure to novel influenza A viruses associated with severe disease in infected humans. FUNDING World Health Organization.
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Affiliation(s)
- Yunli Zhao
- Department of Gerontology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Municipality Clinical Research Center for Geriatrics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; Precision Medicine Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ya Gao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Timothy M Uyeki
- Influenza Division, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ping Liu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ming Liu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Yanjiao Shen
- Innovation Institute for Integration of Medicine and Engineering, Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoyan Chen
- The Center of Gerontology and Geriatrics (National Clinical Research Center for Geriatrics), West China Hospital, Sichuan University, Chengdu, China
| | - Shuyue Luo
- The Center of Gerontology and Geriatrics (National Clinical Research Center for Geriatrics), West China Hospital, Sichuan University, Chengdu, China
| | - Xingsheng Li
- Department of Gerontology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Municipality Clinical Research Center for Geriatrics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rongzhong Huang
- Department of Gerontology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Municipality Clinical Research Center for Geriatrics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; Precision Medicine Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiukui Hao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada.
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Appelbaum RD, Farrell MS, Gelbard RB, Hoth JJ, Jawa RS, Kirsch JM, Mandell S, Nohra EA, Rinderknecht T, Rowell S, Cuschieri J, Stein DM. Antibiotic prophylaxis in injury: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document. Trauma Surg Acute Care Open 2024; 9:e001304. [PMID: 38835634 PMCID: PMC11149135 DOI: 10.1136/tsaco-2023-001304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/11/2024] [Indexed: 06/06/2024] Open
Affiliation(s)
- Rachel D Appelbaum
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael S Farrell
- Department of Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Rondi B Gelbard
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - J Jason Hoth
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Randeep S Jawa
- Department of Surgery, Stony Brook University, Stony Brook, New York, USA
| | - Jordan M Kirsch
- Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Samuel Mandell
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eden A Nohra
- Department of Surgery, University of Colorado, Denver, Colorado, USA
| | | | - Susan Rowell
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Joseph Cuschieri
- Department of Surgery at ZSFG, University of California San Francisco, San Francisco, California, USA
| | - Deborah M Stein
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
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Lauer H, Vasselli B, Bressler M, Illg C, Baumgartner H, Braun BJ, Heinzel J, Kolbenschlag J, Daigeler A, Thiel JT. Lower Extremity Open Fractures Fix and Flap: Does Initial Management in Non-specialized Hospitals Really Compromise its Outcome? Cureus 2024; 16:e60380. [PMID: 38883017 PMCID: PMC11178680 DOI: 10.7759/cureus.60380] [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] [Accepted: 05/15/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Managing open lower extremity fractures is challenging, with potential complications such as amputation and infection. The aim of the study was to determine whether the time delay and initial treatment of the patients treated in a non-specialized hospital before being transferred to a dedicated level I trauma center led to a worse outcome. Methods Retrospective data from 44 patients (37 males and seven females) undergoing free tissue transfer for lower extremity open fractures from January 2017 to December 2022 were analyzed. Group A received primary care externally and was later transferred for definitive treatment (n=17, 38.6%), while group B received initial care at a level I trauma center (n=27, 61.4%). Surgical outcomes, complications, the duration of the hospital stay, and assessment times were compared. Various demographic variables, co-morbidities, prior interventions, and flap types were analyzed. Results Average age (A: 55.1±16.7; B: 38.7±19.8 years; p=0.041), overall hospitalization (A: 55.7±22.8; B: 42.8±21.3 days; p=0.041), and time to soft tissue reconstruction differed significantly between groups (A: 30.7±12.2; B: 18.9±9.3 days; p=0.013). Overall, 31.8% had multiple injuries without statistical differences between groups A and B (29.4% vs. 33.3%; p>0.05). There were no statistical differences between the groups in terms of major and minor complications and bone healing characteristics. Limb salvage was successful overall in 93.2% (A: 94.1%; B: 92.6%; P>0.05). Major complications occurred in 9.1%; three patients underwent major amputation (A: n=2; B: n=1). Minor complications were observed in 43.2% of patients (partial flap necrosis, wound dehiscence and non-union; A: 41.2%; B: 44.4%; p>0.05). Overall, 65.9% of patients (A: 64.7%; B: 66.7%; p>0.05) experienced uneventful bone healing, while 18.2% of patients (A: 23.5%; B: 14.8%; p>0.05) experienced delayed healing. Flaps used were mostly musculocutaneous (71.7%). Various assessed demographic characteristics, including age and presence of polytrauma, showed no significant influence on complications (p>0.05). Conclusion Although there is a significant difference in the time course of externally treated patients with open fractures, prolonged treatment is not associated with a higher complication rate or compromised bone healing outcome. Despite the findings, it is important to avoid delays and strive for interdisciplinary collaboration.
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Affiliation(s)
- Henrik Lauer
- Department of Hand-Plastic, Reconstructive and Burn Surgery, Berufs-Genossenschaft Klinik Tuebingen, University of Tuebingen, Tuebingen, DEU
| | - Benedetta Vasselli
- Department of Hand-Plastic, Reconstructive and Burn Surgery, Berufs-Genossenschaft Klinik Tuebingen, University of Tuebingen, Tuebingen, DEU
| | - Michael Bressler
- Department of Hand-Plastic, Reconstructive and Burn Surgery, Berufs-Genossenschaft Klinik Tuebingen, University of Tuebingen, Tuebingen, DEU
| | - Claudius Illg
- Department of Hand-Plastic, Reconstructive and Burn Surgery, Berufs-Genossenschaft Klinik Tuebingen, University of Tuebingen, Tuebingen, DEU
| | - Heiko Baumgartner
- Department of Trauma and Reconstructive Surgery, Berufs-Genossenschaft Klinik Tuebingen, University of Tuebingen, Tuebingen, DEU
| | - Benedikt Johannes Braun
- Department of Trauma and Reconstructive Surgery, Berufs-Genossenschaft Klinik Tuebingen, University of Tuebingen, Tuebingen, DEU
| | - Johannes Heinzel
- Department of Hand-Plastic, Reconstructive and Burn Surgery, Berufs-Genossenschaft Klinik Tuebingen, University of Tuebingen, Tuebingen, DEU
| | - Jonas Kolbenschlag
- Department of Hand-Plastic, Reconstructive and Burn Surgery, Berufs-Genossenschaft Klinik Tuebingen, University of Tuebingen, Tuebingen, DEU
| | - Adrien Daigeler
- Department of Hand-Plastic, Reconstructive and Burn Surgery, Berufs-Genossenschaft Klinik Tuebingen, University of Tuebingen, Tuebingen, DEU
| | - Johannes Tobias Thiel
- Department of Hand-Plastic, Reconstructive and Burn Surgery, Berufs-Genossenschaft Klinik Tuebingen, University of Tuebingen, Tuebingen, DEU
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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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Shifko CR, Jenniches D, Holmberg K, Andreini D, Philp A, Altman DT, Bremmer D. Antibiotic Prophylaxis for Grade 3 Open Fractures: A Retrospective Comparison of Ceftriaxone Plus Vancomycin Versus Cefazolin Plus Gentamicin. Surg Infect (Larchmt) 2024; 25:39-45. [PMID: 38079252 DOI: 10.1089/sur.2023.137] [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: 01/31/2024] Open
Abstract
Background: Because of the established path of bacterial entry and contamination-associated mechanisms, grade 3 open orthopedic fractures represent a substantial infection risk. The Eastern Association for the Surgery of Trauma (EAST) guidelines recommended covering Staphylococcus aureus and adding aminoglycoside gram-negative coverage. Local institutional guidelines rely on ceftriaxone for gram negative coverage and add methicillin-resistant Staphylococcus aureus coverage with vancomycin. Patients and Methods: The electronic health records of adults admitted for a grade 3 open fracture between January 1, 2016, and October 31, 2021, were retrospectively reviewed. Patients who received cefazolin and gentamicin (CZ+GM) or ceftriaxone and vancomycin (CRO+VA) as prophylaxis were included. We recorded the rate of a composite treatment failure outcome of receipt of antibiotic agents, infection-related hospitalization, or subsequent debridement for injury-site skin and soft tissue infection or osteomyelitis. The presence of acute kidney injury (AKI) was also evaluated. Results: There were 65 patients included in the CZ+GM group and 53 patients in the CRO+VA group. Patients in the CZ+GM group were younger (mean 42.6 compared with 50.6 years; p = 0.02). Otherwise, there were no significant differences between groups' demographics, mechanism and site of injury, timeline of care, or surgical interventions. More patients in the CZ+GM arm met the composite treatment failure outcome, but it was not statistically significant (45% vs. 32%; p = 0.2). There were similar rates of treatment failure at 30 days (21% vs. 26%; p = 0.5) and for only osteomyelitis (8% vs. 9%; p = 1). Conclusions: The trend in numerically lower treatment failure rates in the CRO+VA group across outcomes provides sufficient evidence to continue the current local recommendations. Given our sample size, type 2 error may have occurred, and studies with greater power should analyze this question.
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Affiliation(s)
| | | | - Kyle Holmberg
- Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Derek Andreini
- Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Allan Philp
- Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | | | - Derek Bremmer
- Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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7
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Huang N, Miles DT, Read CR, White CC, Murray RD, Wilson AW, Doty JF. Postoperative Infection and Revision Surgery Rates in Foot and Ankle Surgery Without Routine Prescription of Prophylactic Antibiotics. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202303000-00005. [PMID: 36888925 PMCID: PMC9997784 DOI: 10.5435/jaaosglobal-d-23-00015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/22/2023] [Indexed: 03/10/2023]
Abstract
INTRODUCTION Surgical site infections (SSIs) are associated with patient morbidity and increased healthcare costs. Limited literature in foot and ankle surgery provides guidance about routine administration of postoperative antibiotic prophylaxis. The purpose of this study was to examine the incidence and revision surgery rates of SSI in outpatient foot and ankle surgeries in patients not receiving oral postoperative antibiotic prophylaxis. METHODS A retrospective review of all outpatient surgeries (n = 1517) conducted by a single surgeon in a tertiary referral academic center was conducted through electronic medical records. Incidence of SSI, revision surgery rate, and associated risk factors were determined. The median follow-up was 6 months. RESULTS Postoperative infection occurred in 2.9% (n = 44) of the surgeries conducted, with 0.9% of patients (n = 14) requiring return to the operating room. Thirty patients (2.0%) were diagnosed with simple superficial infections, which resolved with local wound care and oral antibiotics. Diabetes (adjusted odds ratio, 2.09; 95% confidence interval, 1.00 to 4.38; P = 0.049) and increasing age (adjusted odds ratio, 1.02; 95% confidence interval, 1.00 to 1.04; P = 0.016) were significantly associated with postoperative infection. DISCUSSION This study demonstrated low postoperative infection and revision surgery rates without the routine prescription of prophylactic postoperative antibiotics. Increasing age and diabetes are signficant risk factors for developing a postoperative infection.
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8
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Padgett AM, Torrez TW, Kothari EA, Conklin MJ, Williams KA, Gilbert SR, Ashley P. Comparison of nonoperative versus operative management in pediatric gustilo-anderson type I open tibia fractures. Injury 2023; 54:552-556. [PMID: 36522213 DOI: 10.1016/j.injury.2022.12.005] [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: 11/04/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recent studies suggest pediatric Gustilo-Anderson type I fractures, especially of the upper extremity, may be adequately treated without formal operative debridement, though few tibial fractures have been included in these studies. The purpose of this study is to provide initial data suggesting whether Gustilo-Anderson type I tibia fractures may be safely treated nonoperatively. METHODS Institutional retrospective review was performed for children with type I tibial fractures managed with and without operative debridement from 1999 through 2020. Incomplete follow-up, polytrauma, and delayed diagnosis of greater than 12 h since the time of injury were criteria for exclusion. Data including age, sex, mechanism of injury, management, time-to-antibiotic administration, and complications were recorded. RESULTS Thirty-three patients met inclusion criteria and were followed to union. Average age was 9.9 ± 3.7 years. All patients were evaluated in the emergency department and received intravenous antibiotics within 8 h of presentation. Median time-to-antibiotics was 2 h. All patients received cefazolin except one who received clindamycin at an outside hospital and subsequent cephalexin. Three patients (8.8%) received augmentation with gentamicin. Twenty-one patients (63.6%) underwent operative irrigation and debridement (I&D), and of those, sixteen underwent surgical fixation of their fracture. Twelve (36.4%) patients had bedside I&D with saline under conscious sedation, with one requiring subsequent operative I&D and intramedullary nailing. Three infections (14.3%) occurred in the operative group and none in the nonoperative group. Complications among the nonoperative patients include delayed union (8.3%), angulation (8.3%), and refracture (8.3%). Complications among the operative patients include delayed union (9.5%), angulation (14.3%), and one patient experienced both (4.8%). Other operative group complications include leg-length discrepancy (4.8%), heterotopic ossification (4.8%), and symptomatic hardware (4.8%). CONCLUSION No infections were observed in a small group of children with type I tibia fractures treated with bedside debridement and antibiotics, and similar non-infectious complication rates were observed relative to operative debridement. This study provides initial data that suggests nonoperative management of type I tibial fractures may be safe and supports the development of larger studies.
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Affiliation(s)
- Anthony M Padgett
- University of Alabama at Birmingham, Department of Orthopaedic Surgery, Birmingham, AL, United States.
| | - Timothy W Torrez
- University of Utah, Department of Orthopaedics, Salt Lake City, UT
| | - Ezan A Kothari
- University of Alabama at Birmingham, Department of Orthopaedic Surgery, Birmingham, AL, United States
| | - Michael J Conklin
- University of Alabama at Birmingham, Department of Orthopaedic Surgery, Birmingham, AL, United States; Children's of Alabama, Division of Orthopedic Surgery, Birmingham, AL, United States
| | - Kevin A Williams
- University of Alabama at Birmingham, Department of Orthopaedic Surgery, Birmingham, AL, United States; Children's of Alabama, Division of Orthopedic Surgery, Birmingham, AL, United States
| | - Shawn R Gilbert
- University of Alabama at Birmingham, Department of Orthopaedic Surgery, Birmingham, AL, United States; Children's of Alabama, Division of Orthopedic Surgery, Birmingham, AL, United States
| | - Philip Ashley
- University of Alabama at Birmingham, Department of Orthopaedic Surgery, Birmingham, AL, United States; Children's of Alabama, Division of Orthopedic Surgery, Birmingham, AL, United States
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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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Coombs J, Billow D, Cereijo C, Patterson B, Pinney S. Current Concept Review: Risk Factors for Infection Following Open Fractures. Orthop Res Rev 2022; 14:383-391. [PMID: 36385752 PMCID: PMC9651069 DOI: 10.2147/orr.s384845] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/01/2022] [Indexed: 12/14/2023] Open
Abstract
Infection following open fracture is a significant source of morbidity and mortality. Therefore, a central tenet of treatment is to minimize the risk of infection. The initial risk of infection is determined by wound characteristics, such as size, soft tissue coverage, vascular injury, and contamination. While no consensus exists on optimal antibiotic regimen, early administration of prophylactic antibiotics, within an hour of injury, when possible, has been shown definitively to decrease the risk of infection. Infection risk is further reduced by early irrigation with normal saline and aggressive debridement of devitalized tissue. Patient factors that increase risk of infection following open fracture include diabetes mellitus, smoking, male gender, and lower extremity fracture.
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Affiliation(s)
- Jeffrey Coombs
- Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Damien Billow
- Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cesar Cereijo
- Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Brendan Patterson
- Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stephen Pinney
- Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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11
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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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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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13
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Ioannou P, Karakonstantis S, Schouten J, Kostyanev T, Charani E, Vlahovic-Palcevski V, Kofteridis DP. Indications for medical antibiotic prophylaxis and potential targets for antimicrobial stewardship intervention: a narrative review. Clin Microbiol Infect 2021; 28:362-370. [PMID: 34653572 DOI: 10.1016/j.cmi.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Most of the antimicrobial stewardship (AMS) literature has focused on antimicrobial consumption for the treatment of infections, for the prophylaxis of surgical site infection and for the prevention of endocarditis. The role of AMS for medical antibiotic prophylaxis (AP) has not been adequately addressed. AIMS To identify targets for AMS interventions for medical AP in adult patients. SOURCES Targeted searches were conducted in PubMed. CONTENT The various indications for medical AP and relevant evidence from practice guidelines are outlined. The following were identified as potential targets for AMS interventions: (a) addressing under-utilization of antibiotic-sparing strategies (e.g. for recurrent urinary tract infections, recurrent soft-tissue infections, recurrent exacerbations associated with bronchiectasis or chronic obstructive pulmonary disease), (b) reducing unnecessary AP beyond recommended indications (e.g. for acute pancreatitis, bite wounds, or urinary catheter manipulations), (c) reducing the use of AP with a broader spectrum than necessary, (d) reducing the use of AP for longer than the recommended duration (e.g. AP for prevention of osteomyelitis in open fractures or AP in high-risk neutropenia), (e) evaluating the role of antibiotic cycling to prevent the emergence of resistance during prolonged AP (e.g. in recurrent urinary tract infections or prophylaxis for spontaneous bacterial peritonitis), and (f) addressing research gaps regarding appropriate indications or antibiotic regimens for medical prophylaxis. IMPLICATIONS This review summarizes current trends in AP and proposes targets for AMS interventions.
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Affiliation(s)
- Petros Ioannou
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Stamatis Karakonstantis
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Jeroen Schouten
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Tomislav Kostyanev
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Esmita Charani
- Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
| | - Vera Vlahovic-Palcevski
- Department of Clinical Pharmacology, University Hospital Rijeka / Medical Faculty and Faculty of Health Studies, University of Rijeka, Rijeka, Croatia
| | - Diamantis P Kofteridis
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, Heraklion, Crete, Greece.
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Lefort H, Gil-Jardiné C, Chauvin A. Guidelines for the acute care of severe limb trauma patients. Eur J Emerg Med 2021; 28:339-340. [PMID: 34074981 DOI: 10.1097/mej.0000000000000835] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Hugues Lefort
- Structure des urgences, Hôpital d'Instruction des Armées Legouest, Metz
| | - Cédric Gil-Jardiné
- Pôle Urgences adultes SAMU-SMUR, CHU Bordeaux
- Bordeaux Population Health - INSERM U1219 - Université de Bordeaux, Equipe IETO, Bordeaux
| | - Anthony Chauvin
- Service d'Accueil des Urgences/SMUR, CHU Lariboisière, Université de Paris
- Inserm U942 MASCOT, Université de Paris, Paris, France
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15
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Nicolaides M, Pafitanis G, Vris A. Open tibial fractures: An overview. J Clin Orthop Trauma 2021; 20:101483. [PMID: 34262849 PMCID: PMC8254044 DOI: 10.1016/j.jcot.2021.101483] [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: 04/21/2021] [Revised: 06/06/2021] [Accepted: 06/19/2021] [Indexed: 12/31/2022] Open
Abstract
Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. The close proximity of the tibia to the skin makes it prone to extensive soft tissue damage and subsequent detrimental complications, such as infection and non-union. Thus, they were historically associated with high rates of amputation, sepsis, or even death. The advancement of surgical instruments and techniques, along the emergence of evidence-based guidance, have resulted in a significant reduction in complications. Peculiarly though, modern management strategies have a strong foundation in practices described in the ancient times. Nevertheless, post-operative complications are still a challenge in the management of open tibial fractures. Efforts are actively being made to refine the surgical approaches used, while noteworthy is the emergence of the Orthoplastic approach. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.
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Affiliation(s)
- Marios Nicolaides
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Group for Academic Plastic Surgery, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Georgios Pafitanis
- Group for Academic Plastic Surgery, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Plastic and Reconstructive Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexandros Vris
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Trauma and Orthopaedic Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
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16
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Pottecher J, Lefort H, Adam P, Barbier O, Bouzat P, Charbit J, Galinski M, Garrigue D, Gauss T, Georg Y, Hamada S, Harrois A, Kedzierewicz R, Pasquier P, Prunet B, Roger C, Tazarourte K, Travers S, Velly L, Gil-Jardiné C, Quintard H. Guidelines for the acute care of severe limb trauma patients. Anaesth Crit Care Pain Med 2021; 40:100862. [PMID: 34059492 DOI: 10.1016/j.accpm.2021.100862] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOAL To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre. DESIGN A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded. METHODS The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.
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Affiliation(s)
- Julien Pottecher
- Service d'Anesthésie-Réanimation & Médecine Péri-Opératoire, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098 Strasbourg Cedex, France; Université de Strasbourg, FMTS, France.
| | - Hugues Lefort
- Structure des urgences, Hôpital d'Instruction des Armées Legouest, BP 9000, 57077 Metz Cédex 03, France
| | - Philippe Adam
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 Avenue Molière, 67098 Strasbourg Cedex, France
| | - Olivier Barbier
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital d'Instruction des Armées Sainte Anne, 2 boulevard Sainte Anne, 83000 Toulon, France; Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France
| | - Pierre Bouzat
- Université Grenoble Alpes, Pôle Anesthésie-Réanimation, Centre Hospitalo-Universitaire Grenoble-Alpes, Grenoble, France
| | - Jonathan Charbit
- Soins critiques DAR Lapeyronie, CHU Montpellier, France; Réseau OcciTRAUMA, Réseau Régional Occitanie de prise en charge des traumatisés sévères, France
| | - Michel Galinski
- Pôle urgences adultes - SAMU 33, Hôpital Pellegrin, CHU de Bordeaux 3300 Bordeaux, France; INSERM U1219, ISPED, Bordeaux Population Health Research Center INSERM U1219-"Injury Epidemiology Transport Occupation" Team, F-33076 Bordeaux Cedex, France
| | - Delphine Garrigue
- Pôle d'Anesthésie Réanimation, Pôle de l'Urgence, CHU Lille, F-59000 Lille, France
| | - Tobias Gauss
- Service d'Anesthésie-Réanimation, Hôpital Beaujon, DMU PARABOL, AP-HP Nord, Clichy, France; Université de Paris, Paris, France
| | - Yannick Georg
- Service de Chirurgie Vasculaire et Transplantation Rénale, Hôpitaux Universitaire de Strasbourg, Strasbourg, France
| | - Sophie Hamada
- Département d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou, APHP, Université de Paris, Paris, France
| | - Anatole Harrois
- Département d'anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Saclay, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, France
| | - Romain Kedzierewicz
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Bureau de Médecine d'Urgence, Division Santé, Brigade de Sapeurs-Pompiers de Paris, 1 place Jules Renard, 75017 Paris, France
| | - Pierre Pasquier
- Département anesthésie-réanimation, Hôpital d'instruction des armées Percy, Clamart, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Bertrand Prunet
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Claire Roger
- Service de Réanimation Chirurgicale, Pôle Anesthésie Réanimation Douleur Urgence, CHU Carémeau, 30000 Nîmes, France
| | - Karim Tazarourte
- Service SAMU-Urgences, CHU Edouard Herriot, Hospices civils de Lyon, Lyon, France; Université Lyon 1 Hesper EA 7425, Lyon, France
| | - Stéphane Travers
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; 1ère Chefferie du Service de Santé, Villacoublay, France
| | - Lionel Velly
- Service d'Anesthésie Réanimation, CHU Timone Adultes, 264 rue St Pierre 13005 Marseille, France; MeCA, Institut de Neurosciences de la Timone - UMR 7289, Aix Marseille Université, Marseille, France
| | - Cédric Gil-Jardiné
- Pôle Urgences adultes SAMU-SMUR, CHU Bordeaux, Bordeaux Population Health - INSERM U1219 Université de Bordeaux, Equipe IETO, Bordeaux, France
| | - Hervé Quintard
- Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
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17
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The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2021; 11:diagnostics11061017. [PMID: 34199379 PMCID: PMC8228778 DOI: 10.3390/diagnostics11061017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 02/06/2023] Open
Abstract
Introduction: Open tibial fractures are complex injuries with variable outcomes that significantly impact patients’ lives. Surgical debridement is paramount in preventing detrimental complications such as infection and non-union; however, the exact timing of debridement remains a topic of great controversy. The aim of this study is to evaluate the association between timing of surgical debridement and outcomes such as infection and non-union in open tibial fractures. Materials and Methods: We performed a systematic review and meta-analysis of the literature to capture studies evaluating the association between timing of initial surgical debridement and infection or non-union, or other reported outcomes. We searched the MEDLINE, PubMed Central, EMBASE, SCOPUS, Cochrane Central and Web of Science electronic databases. Our methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane handbook for systematic reviews of interventions. Results: The systematic review included 20 studies with 10,032 open tibial fractures. The overall infection rate was 14.3% (314 out of 2193) and the overall non-union rate 14.2% (116 out of 817). We did not find any statistically significant association between delayed debridement and infection rate (OR = 0.87; 95% CI, 0.68 to 1.11; p = 0.23) or non-union rate (OR = 0.70; 95% CI, 0.42 to 1.15; p = 0.13). These findings did not change when we accounted for the effect of different time thresholds used for defining early and late debridement, nor with the Gustilo–Anderson classification or varying study characteristics. Conclusion: The findings of this meta-analysis support that delayed surgical debridement does not increase the infection or non-union rates in open tibial fracture injuries. Consequently, we propose that a reasonable delay in the initial debridement is acceptable to ensure that optimal management conditions are in place, such that the availability of surgical expertise, skilled staff and equipment are prioritised over getting to surgery rapidly. We recommend changing the standard guidance around timing for performing surgical debridement to ‘as soon as reasonably possible, once appropriate personnel and equipment are available; ideally within 24-h’.
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18
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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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19
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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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Abstract
PURPOSE Supracondylar humerus (SCH) fractures are the most common elbow fracture in children; however, they rarely occur as open injuries. Open fractures are associated with higher rates of infection, neurovascular injury, compartment syndrome, and nonunion. The purpose of this study was to evaluate the treatment and outcomes of open SCH fractures in children. METHODS Between 2008 and 2015, four children (1%) had open injuries among 420 treated for SCH fractures at a single center. The mean patient age was six years (range, four to eight years). Two patients had Gustilo-Anderson grade 1 open fractures and two had grade 2 fractures. Tetanus immunization was up-to-date in all. First dose of intravenous antibiotics was given on average 3hr 7min after onset of injury (range, 1hr 38min to 8hr 15min). Time from injury to irrigation and debridement (I&D) and closed reduction and percutaneous pinning (CRPP) was on average 8hr 16min (range, 4hr 19min to 13hr 15min). All patients received 24-hour intravenous antibiotics. Pins were removed at four weeks and bony union occurred by six weeks. RESULTS After an average follow-up period of 12 months (range, 6 to 22 months), there were no infections, neurovascular deficits, compartment syndromes, cubitus varus deformities, or range of motion losses. All outcomes were excellent according to the Flynn criteria. Due to the unstable nature of open SCH fractures, a medial pin was used in all four cases. No loss of reduction or ulnar nerve injury occurred. CONCLUSION Open injuries occur in approximately 1% of all SCH fractures in children. The authors recommend urgent intravenous antibiotics, I&D, and CRPP involving a medial pin to treat open SCH fractures. Excellent outcomes based on the Flynn criteria were obtained in four cases.
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Affiliation(s)
- Tommy Pan
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Hershey, USA
| | - Matthew R Widner
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Hershey, USA
| | - Michael M Chau
- Department of Orthopaedic Surgery, University of Minnesota Twin Cities, Minneapolis, USA
| | - William L Hennrikus
- Department of Orthopaedics and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Abstract
Open fractures of the lower limb remain a potentially devastating group of injuries that are challenging to manage. The primary aims of treatment are to optimise limb function and avoid serious complications such as infection and non-union, which are costly for both the patient and healthcare system. The management of these fractures has evolved significantly, and this is evident following the creation of national open fracture guidelines and a formal trauma system. These have served to standardise care for these injuries in the United Kingdom. The aim of this review is to update our colleagues on the current standard of lower limb open fracture care in the United Kingdom, and the impact this has had on patient outcomes.
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Affiliation(s)
- Khalid Al-Hourani
- Edinburgh Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Oliver Pearce
- Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom.
| | - Michael Kelly
- Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom
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22
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Gaudias J. Antibiotic prophylaxis in orthopedics-traumatology. Orthop Traumatol Surg Res 2021; 107:102751. [PMID: 33316449 DOI: 10.1016/j.otsr.2020.102751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 04/24/2020] [Indexed: 02/03/2023]
Abstract
When all rules of hygiene have been scrupulously applied, antibiotic prophylaxis (ABP) is the one remaining means of further reducing surgical site infection risk. Its efficacy in major orthopedic surgical procedures is proven. Guidelines for indications and ABP systemic administration have been long established and are able to address many questions. By extrapolation, the same protocols apply in closed fractures, whereas they are less certain in open fractures, where successive and still incomplete reassessments have been made. There are no specific ABP protocols in implant revision for mechanical or infectious causes or in high-grade open fractures, despite the high associated risk of surgical site infection. All means of prophylaxis need exploring in these contexts: various molecule combinations, and various local applications. Although ideas are by no means lacking, levels of evidence are low or undetermined. Awaiting more objective data, the focus has to be on the quality of implementation. It is easy enough to conceive of ABP in terms of the tissue pharmacokinetics of the antibiotic(s), but real-life implementation is a real organizational challenge. Optimizing practices in clearly defined indications is still the prime objective for surgical ABP.
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Affiliation(s)
- Jeannot Gaudias
- Pôle Locomax, hôpitaux universitaires de Strasbourg, avenue Molière, 67200 Strasbourg, France.
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Gupta R, Singhal A, Kapoor A, Dhillon M, Masih GD. Effect of COVID-19 on surgical management of open fractures and infection rates: A tertiary care experience in Indian set-up. J Clin Orthop Trauma 2021; 12:16-21. [PMID: 33132629 PMCID: PMC7587168 DOI: 10.1016/j.jcot.2020.10.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/19/2020] [Accepted: 10/23/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Open fractures form one of the most common musculoskeletal injuries and are often complicated by infection. In this unprecedented situation, the additional infection rates, further add to the burden of the already compromised healthcare setup. The present study is done to see the effect of COVID-19 on management of open fractures. METHODS A retrospective evaluation of patients with open fractures from March 25th, 2020 to July 21st, 2020 (group 1) and March 25th, 2019 to July 21st, 2019 (group 2) was performed. These patients were assessed for demographic details, diagnosis, type of surgery, delay from injury to admission, delay from admission to surgery, postoperative hospital stay, acute infection rates, readmission rates and associated injuries. RESULTS A total of 52 patients with 59 open fractures in 2020 and 89 patients with 101 open fractures in 2019 met the inclusion criteria. The mean age was 34.76 years and 32.74 years in 2020 and 2019 respectively. Road side accidents were predominant in both the groups, comprising of 38 (73.07%) and 67 (75.28%) respectively(n.s.); adult patients were 42 (80.76%) and 79 (88.76%) respectively(n.s.); paediatric patients were 10 (19.23%) and 10 (11.23%) respectively(n.s.); tibia was the most common bone involved, comprising of 14 (23.72%) and 27 (26.73%) open fractures respectively(n.s.); external fixator was the most commonly used implant during COVID-19 time with 42 (71.18%) and 51 (50.49%) respectively(p = 0.005); the infection rate was 25.42% and 20.79% respectively(n.s.); the time for administration of first intravenous antibiotic dose was on 6.75 h and 4.04 h respectively(p < 0.0001); average time between the admission and surgical debridement was 24.04 h and 19.32 h respectively(n.s.); referral cases were 33 (63.46%) and 44 (49.43%) respectively(n.s.); re-admission rates were 7/52 (13.46%) and 10/89(11.23%) respectively(n.s.). CONCLUSION Despite the decrease in total trauma cases, a delay in presentation to the emergency room/administration of first dose of antibiotic and increase in temporary fixation in form of external fixator was observed. Further, an increase in infection rates, referral cases and readmission rates were observed, though not statistically significant.
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Affiliation(s)
- Ravi Gupta
- Sports Injury Center, Government Medical College Hospital, Chandigarh, India
| | - Akash Singhal
- Government Medical College and Hospital, Chandigarh, India,Corresponding author.
| | - Anil Kapoor
- Department Of Orthopaedics, Government Medical College and Hospital, Chandigarh, India
| | - Mehar Dhillon
- Department Of Orthopaedics, Government Medical College and Hospital, Chandigarh, India
| | - Gladson David Masih
- Department Of Orthopaedics, Government Medical College and Hospital, Chandigarh, India
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Du X, Tian B. Application of external fixation combined with pedicled skin flap transposition in the treatment of open fracture of leg with soft tissue defect. Minerva Med 2020; 112:831-832. [PMID: 33242940 DOI: 10.23736/s0026-4806.20.07101-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Xingnan Du
- Department of Orthopedics, Affiliated Hospital of Jilin Medical University, Jilin, China -
| | - Baozhong Tian
- Department of Orthopedics, Affiliated Hospital of Jilin Medical University, Jilin, China
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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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26
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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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Stennett CA, O’Hara NN, Sprague S, Petrisor B, Jeray KJ, Leekha S, Yimgang DP, Joshi M, O’Toole RV, Bhandari M, P. Slobogean G. Effect of Extended Prophylactic Antibiotic Duration in the Treatment of Open Fracture Wounds Differs by Level of Contamination. J Orthop Trauma 2020; 34:113-120. [PMID: 32084088 PMCID: PMC8077225 DOI: 10.1097/bot.0000000000001715] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the association between prophylactic antibiotic duration after the definitive wound closure of an open fracture and deep surgical site infection (SSI). DESIGN Retrospective cohort study. SETTING 41 clinical sites in the United States, Canada, Australia, Norway, and India. PARTICIPANTS Patients (N = 2400) with open fractures of the extremities who participated in the Fluid Lavage of Open Wounds (FLOW) trial. INTERVENTION Extended antibiotic prophylaxis, defined as more than 72 hours of continuous antibiotic use after definitive wound closure. MAIN OUTCOME MEASUREMENT Deep SSI diagnosed within 1 year of enrollment. RESULTS Forty-two percent of participants received extended antibiotic prophylaxis. Deep SSI prevalence was 5%, 8%, and 23% for wounds with mild, moderate, and severe contamination, respectively. In open fractures with mild contamination, extended antibiotic use showed a trend toward increased odds [adjusted odds ratio (aOR) = 1.39; 95% confidence interval (CI), 0.92-2.11] of deep SSI compared with shorter use. No association was found among patients with moderate contamination (aOR = 1.09; 95% CI, 0.53-2.27). By contrast, extended antibiotic prophylaxis was strongly protective (aOR = 0.20; 95% CI, 0.07-0.60) against deep SSI in patients with severe contamination. Propensity score sensitivity analysis results were consistent with these findings. CONCLUSIONS The evidence suggests differential effects of extended postclosure antibiotic duration on SSI odds contingent on the degree of contamination in open fracture wounds. Although extended antibiotic duration resulted in lower odds of SSI among patients with severely contaminated wounds, we observed a trend toward higher odds of SSI in mildly contaminated wounds. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christina A. Stennett
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Nathan N. O’Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Sheila Sprague
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Brad Petrisor
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Kyle J. Jeray
- Department of Orthopaedic Surgery, Greenville Health System, Greenville, SC
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Doris P. Yimgang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Manjari Joshi
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Robert V. O’Toole
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Gerard P. Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
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Depypere M, Morgenstern M, Kuehl R, Senneville E, Moriarty TF, Obremskey WT, Zimmerli W, Trampuz A, Lagrou K, Metsemakers WJ. 'Pathogenesis and management of fracture-related infection' - Author's reply. Clin Microbiol Infect 2020; 26:652-653. [PMID: 32087322 DOI: 10.1016/j.cmi.2020.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/09/2020] [Indexed: 01/22/2023]
Affiliation(s)
- M Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Belgium
| | - M Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - R Kuehl
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland
| | - E Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, University of Lille, F-59000 Lille, France
| | | | - W T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - W Zimmerli
- Interdisciplinary Unit for Orthopaedic Infections, Kantonsspital Baselland, Rheinstrasse 26, 4410, Liestal, Switzerland
| | - A Trampuz
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - K Lagrou
- Department of Laboratory Medicine, University Hospitals Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - W-J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Belgium.
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Sabapathy SR, Venkatramani H, Mohan M. Initial Assessment, Debridement, and Decision Making in the Salvage of Severely Injured Lower Extremity. Indian J Plast Surg 2019; 52:10-16. [PMID: 31456608 PMCID: PMC6664836 DOI: 10.1055/s-0039-1689741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
An open fracture with extensive skin and soft tissue loss is considered as a severely injured lower extremity. Advances in rapid transport, resuscitation, skeletal fixation, and microsurgical techniques to cover large soft tissue and bone defects have made possible the salvage of these severely injured limbs. Salvage exercise is skill and resource intensive and could take a long time frame. The goal of management is to obtain painless independent weight bearing walking in a time frame and cost that the patient can afford. Decisions taken and the quality of care provided on day 1 determine the ultimate success. Inappropriate decisions and treatment lead to increased morbidity and secondary amputation. Infection is the commonest complication. Limb salvage scores are helpful to predict salvage and guide the sequence of treatment. Once the decision is taken for salvage, debridement, early skeletal fixation, and soft tissue cover are the key to success.
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Affiliation(s)
- S Raja Sabapathy
- Department of Plastic Surgery, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Hari Venkatramani
- Department of Plastic Surgery, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Monusha Mohan
- Department of Plastic Surgery, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
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30
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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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31
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Retzky JS, Humbyrd CJ. Near-Complete Traumatic Amputation of the Forefoot After Motorboat Propeller Injury. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011418822278. [PMID: 35097315 PMCID: PMC8696818 DOI: 10.1177/2473011418822278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We report a case of a near-complete amputation of the forefoot of a 20-year-old man as a result of a motorboat propeller injury sustained in a saltwater river. He was treated with open reduction, percutaneous pinning, extensor tendon repair, and an extended course of antibiotic prophylaxis. We review the literature regarding motorboat propeller injuries to the foot and ankle.
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Affiliation(s)
- Julia S. Retzky
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Casey Jo Humbyrd
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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Hao Q, Tampi M, O'Donnell M, Foroutan F, Siemieniuk RA, Guyatt G. Clopidogrel plus aspirin versus aspirin alone for acute minor ischaemic stroke or high risk transient ischaemic attack: systematic review and meta-analysis. BMJ 2018; 363:k5108. [PMID: 30563866 PMCID: PMC6298178 DOI: 10.1136/bmj.k5108] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess the effectiveness and safety of dual agent antiplatelet therapy combining clopidogrel and aspirin to prevent recurrent thrombotic and bleeding events compared with aspirin alone in patients with acute minor ischaemic stroke or transient ischaemic attack (TIA). DESIGN Systematic review and meta-analysis of randomised, placebo controlled trials. DATA SOURCES Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Library, ClinicalTrials.gov, WHO website, PsycINFO, and grey literature up to 4 July 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS Two reviewers independently screened potentially eligible studies according to predefined selection criteria and assessed the risk of bias using a modified version of the Cochrane risk of bias tool. A third team member reviewed all final decisions, and the team resolved disagreements through discussion. When reports omitted data that were considered important, clarification and additional information was sought from the authors. The analysis was conducted in RevMan 5.3 and MAGICapp based on GRADE methodology. RESULTS Three eligible trials involving 10 447 participants were identified. Compared with aspirin alone, dual antiplatelet therapy with clopidogrel and aspirin that was started within 24 hours of symptom onset reduced the risk of non-fatal recurrent stroke (relative risk 0.70, 95% confidence interval 0.61 to 0.80, I2=0%, absolute risk reduction 1.9%, high quality evidence), without apparent impact on all cause mortality (1.27, 0.73 to 2.23, I2=0%, moderate quality evidence) but with a likely increase in moderate or severe extracranial bleeding (1.71, 0.92 to 3.20, I2=32%, absolute risk increase 0.2%, moderate quality evidence). Most stroke events, and the separation in incidence curves between dual and single therapy arms, occurred within 10 days of randomisation; any benefit after 21 days is extremely unlikely. CONCLUSIONS Dual antiplatelet therapy with clopidogrel and aspirin given within 24 hours after high risk TIA or minor ischaemic stroke reduces subsequent stroke by about 20 in 1000 population, with a possible increase in moderate to severe bleeding of 2 per 1000 population. Discontinuation of dual antiplatelet therapy within 21 days, and possibly as early as 10 days, of initiation is likely to maximise benefit and minimise harms.
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Affiliation(s)
- Qiukui Hao
- The Center of Gerontology and Geriatrics (National Clinical Research Center for Geriatrics), West China Hospital, Sichuan University, Chengdu, China
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Malavika Tampi
- American Dental Association, Center for Evidence-based Dentistry, Chicago, IL, USA
| | - Martin O'Donnell
- Health Research Board Clinical Research Facility, Department of Medicine, NUI Galway, Galway, Ireland
| | - Farid Foroutan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Reed Ac Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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33
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Morgenstern M, Vallejo A, McNally MA, Moriarty TF, Ferguson JY, Nijs S, Metsemakers WJ. The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis. Bone Joint Res 2018; 7:447-456. [PMID: 30123494 PMCID: PMC6076360 DOI: 10.1302/2046-3758.77.bjr-2018-0043.r1] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Objectives As well as debridement and irrigation, soft-tissue coverage, and osseous stabilization, systemic antibiotic prophylaxis is considered the benchmark in the management of open fractures and considerably reduces the risk of subsequent fracture-related infections (FRI). The direct application of antibiotics in the surgical field (local antibiotics) has been used for decades as additional prophylaxis in open fractures, although definitive evidence confirming a beneficial effect is scarce. The purpose of the present study was to review the clinical evidence regarding the effect of prophylactic application of local antibiotics in open limb fractures. Methods A comprehensive literature search was performed in PubMed, Web of Science, and Embase. Cohort studies investigating the effect of additional local antibiotic prophylaxis compared with systemic prophylaxis alone in the management of open fractures were included and the data were pooled in a meta-analysis. Results In total, eight studies which included 2738 patients were eligible for quantitative synthesis. The effect of antibiotic-loaded poly(methyl methacrylate) beads was investigated by six of these studies, and two studies evaluated the effect of local antibiotics applied without a carrier. Meta-analysis showed a significantly lower infection rate when local antibiotics were applied (4.6%; 91/1986) than in the control group receiving standard systemic prophylaxis alone (16.5%; 124/752) (p < 0.001) (odds ratio 0.30; 95% confidence interval 0.22 to 0.40). Conclusion This meta-analysis suggests a risk reduction in FRI of 11.9% if additional local antibiotics are given prophylactically for open limb fractures. However, due to limited quality, heterogeneity, and considerable risk of bias, the pooling of data from primary studies has to be interpreted with caution. Cite this article: M. Morgenstern, A. Vallejo, M. A. McNally, T. F. Moriarty, J. Y. Ferguson, S. Nijs, WJ. Metsemakers. Bone Joint Res 2018;7:447–456. The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis. DOI: 10.1302/2046-3758.77.BJR-2018-0043.R1
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Affiliation(s)
- M Morgenstern
- Department of Orthopaedic Surgery and Traumatology, University Hospital Basel, Basel, Switzerland
| | - A Vallejo
- Orthopaedic and Traumatology Department, Clinica Leon Trece, Universidad Pontificia Bolivariana, Medellin, Columbia and AO Research Institute, Davos, Switzerland
| | - M A McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, UK
| | | | - J Y Ferguson
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, UK
| | - S Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium and Associate Professor, Faculty of Medicine, KU Leuven, University of Leuven, Leuven, Belgium
| | - W J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium and Associate Professor, Faculty of Medicine, KU Leuven, University of Leuven, Leuven, Belgium
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Crist BD, Oladeji LO, Della Rocca GJ, Volgas DA, Stannard JP, Greenberg DD. Evaluating the Duration of Prophylactic Post-Operative Antibiotic Agents after Open Reduction Internal Fixation for Closed Fractures. Surg Infect (Larchmt) 2018; 19:535-540. [DOI: 10.1089/sur.2018.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Brett D. Crist
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Lasun O. Oladeji
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Gregory J. Della Rocca
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - David A. Volgas
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - James P. Stannard
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - David D. Greenberg
- Department of Orthopaedic Surgery, St. Louis University Hospital, St. Louis, Missouri
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35
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Antibiotic Prophylaxis With Cefuroxime: Influence of Duration on Infection Rate With Staphylococcus aureus in a Contaminated Open Fracture Model. J Orthop Trauma 2018; 32:190-195. [PMID: 29558373 DOI: 10.1097/bot.0000000000001053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The optimal duration of perioperative antibiotic prophylaxis (PAP) for open fractures remains controversial because of heterogeneous or unclear guidelines and highly variable prophylactic regimens in clinical practice. We aimed at testing different PAP durations under controlled conditions in a contaminated rabbit fracture model. METHODS A complete humeral osteotomy in 18 rabbits was fixed with a 7-hole locking compression plate and inoculated with Staphylococcus aureus. Cefuroxime was administered in a weight-adjusted dosage equivalent to human medicine (18.75 mg/kg). PAP was administered as a single shot only; for 24 hours; or for 72 hours in separate groups of rabbits (n = 6 per group). Infection was assessed after 2 weeks by quantitative bacteriological evaluation of the tissues and hardware. RESULTS Postoperative duration of PAP had a significant impact on the success of antibiotic prophylaxis in this model. Whereas the single-shot regimen completely failed to prevent infection, the 24-hour regimen showed a reduced infection rate (1 of 6 rabbits infected), but only the 72-hour course was able to prevent fracture-related infection in all animals in our model. CONCLUSIONS When contamination with high bacterial loads is likely (eg, in an open fracture situation), a 72-hour course of intravenous cefuroxime seems to be superior in preventing fracture-related infection in our rabbit model compared with a single-shot or 24-hour antibiotic regimen.
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37
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Doshi P, Gopalan H, Sprague S, Pradhan C, Kulkarni S, Bhandari M. Incidence of infection following internal fixation of open and closed tibia fractures in India (INFINITI): a multi-centre observational cohort study. BMC Musculoskelet Disord 2017; 18:156. [PMID: 28410572 PMCID: PMC5391577 DOI: 10.1186/s12891-017-1506-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 03/29/2017] [Indexed: 12/31/2022] Open
Abstract
Background Trauma is a major public health problem, particularly in India due to the country’s rapid urbanization. Tibia fractures are a common and often complicated injury that is at risk of infection following surgical fixation. The primary objectives of this cohort study were to determine the incidence of infection within one year of surgery and to describe the distribution of infections by location and time of diagnosis for tibia fractures in India. Methods We conducted a multi-center, prospective cohort study. Patients who presented with an open or closed tibia fracture treated with internal fixation to one of the participating hospitals in India were invited to participate in the study. Participants attended follow-up visits at 3, 6, and 12 months post-surgery, where they were assessed for infections, fracture healing, and health-related quality of life as measured by the EurQol-5 Dimensions (EQ-5D). Results Seven hundred eighty-seven participants were included in the study and 768 participants completed the 12 month follow-up. The overall incidence of infection was 2.9% (23 infections). The incidence of infection was 1.6% (10 infections) in closed and 8.0% (13 infections) in open fractures. There were 7 deep and 16 superficial infections, with 5 being early, 7 being delayed, and 11 being late infections. Intra-operative antibiotics were given to 92.1% of participants and post-operative antibiotics were given to 96.8% of participants. Antibiotics were prescribed for an average of 8.3 days for closed fractures and 9.1 days for open fractures. Infected fractures took significantly longer to heal, and participants who had an infection had significantly lower EQ-5D scores. Conclusions The incidence of infection within this cohort is similar to those seen in developed countries. The duration of prophylactic antibiotic use was longer than standard practice in North America, raising concern for the potential development of antibiotic resistant microbes within Indian orthopaedic settings. Future research should aim to identify the best practice for antibiotic use in India to ensure that antibiotic usage patterns do not lead to unnecessary overuse, while maintaining a low incidence of infection. Trial registration NCT01691599, September 17, 2012.
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Affiliation(s)
- Prakash Doshi
- Division of Orthopaedic Surgery, McMaster University, Well-Health Building, 293 Wellington Street North, Suite 110, Hamilton, ON, L8L 8E7, Canada
| | - Hitesh Gopalan
- Division of Orthopaedic Surgery, McMaster University, Well-Health Building, 293 Wellington Street North, Suite 110, Hamilton, ON, L8L 8E7, Canada
| | - Sheila Sprague
- Division of Orthopaedic Surgery, McMaster University, Well-Health Building, 293 Wellington Street North, Suite 110, Hamilton, ON, L8L 8E7, Canada
| | - Chetan Pradhan
- Division of Orthopaedic Surgery, McMaster University, Well-Health Building, 293 Wellington Street North, Suite 110, Hamilton, ON, L8L 8E7, Canada
| | - Sunil Kulkarni
- Division of Orthopaedic Surgery, McMaster University, Well-Health Building, 293 Wellington Street North, Suite 110, Hamilton, ON, L8L 8E7, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, McMaster University, Well-Health Building, 293 Wellington Street North, Suite 110, Hamilton, ON, L8L 8E7, Canada.
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Type I Open Fractures Benefit From Immediate Antibiotic Administration But Not Necessarily Immediate Surgery. J Pediatr Orthop 2016; 36 Suppl 1:S6-S10. [PMID: 27100039 DOI: 10.1097/bpo.0000000000000766] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pediatric open fractures are rare, occurring in approximately 2% to 9% of all pediatric fractures. Type I open fractures represent the most common type of open fractures seen in pediatrics and are commonly caused by low-energy mechanisms. The management of these injuries has been primarily dictated by the adult literature. Immediate antibiotic administration, specifically a first generation cephalosporin, has been shown to reduce infection rates. The duration of antibiotic treatment is less clear, but longer courses of antibiotics have not been significantly better than a shorter course. Retrospective case series have shown no difference in infection rates with nonoperative management of type I open fractures. However, concern regarding serious and even life-threatening infection continues to limit the universal adoption of nonoperative treatment protocols. A prospective randomized control trial is underway and will hopefully elucidate which open fractures can be safely managed with prompt antibiotic administration and nonoperative care.
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