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EAST PRACTICE MANAGEMENT GUIDELINES WORK G

PRACTICE MANAGEMENT GUIDELINES FOR PROPHYL

ANTIBIOTIC USE IN OPEN FRACTURES

Fred A. Luchette, MD,1

Lawrence B. Bone, MD,2

Christopher T. Born, M

William G. DeLong, Jr,3

MD, William S. Hoff, MD,3

Daniel Mullins, PhD

Francis Palumbo, PhD, JD,4

Michael D. Pasquale, MD5

1University of Cincinnati Medical Center, Cincinnati, OH

2State University of New York at Buffalo, Buffalo, NY

3University of Pennsylvania Health System, Philadelphia, PA

4

University of Maryland School of Pharmacy, Baltimore, MD

5Lehigh Valley Hospital and Health Network, Allentown, PA

Address for Correspondence and Reprints:

Fred A. Luchette, MD

Department of Surgery ML-0558

231 Bethesda Avenue

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The importance of describing type III open fractures with this more accurate classifica

cannot be overstated. This A/B/C stratification also allows for subsequent upward rev

wound which evidences progressive soft tissue necrosis following initial evaluation. A

scoring system is the one most widely used for management decisions and comparison

treatment among different series, a recent report has claimed that interobserver agreem

moderate to poor and is case dependent.3

An appropriate management plan for open extremity fractures would include c

sterile dressing with gentle pressure applied as necessary to control bleeding. Splintin

the patient is prophylaxed for tetanus and parenteral antibiotics are administered. Ope

care should be done under general or regional anesthesia as soon as the patient has bee

and cleared for the operating room. Whenever possible, delays of more than six hours

avoided because of the increased risk of infection. Wound care should involve a thoro

debridement of devascularized muscle, fascia, subcutaneous tissue, skin, bone and all f

material. The importance of adequate surgical debridement can not be overemphasize

wound sepsis since antibiotics are only adjunctive therapy. Determination of the fractu

should be made at this time. The margins of the wound of compounding are extended

debridement and appropriate stabilization of the fracture is effected. The wound is lef

sterile moisture retaining dressing. A second-look may be advisable at 24-48 hours

debridement if necessary. Ultimately, wound closure may be accomplished by delayed

closure split thickness skin graft local muscle flap rotation or free tissue transfer with

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from injury to initiation of antimicrobial agent and operative debridement; (4) extent o

damage; (5) open tibial fractures; (6) positive post debridement-irrigation cultures; and

closure in the presence ofClostridium perfringens. Other factors shown to have no ef

the length of antibiotic treatment (3 versus 5 to 10 days)and type of wound closure. S

now usually obtained by unreamed nailing or external fixation.4

Low infection rates h

reported after severe open fractures treated by reamed intramedullary nailing.5

Delling

performed a multivariate logistic regression analysis and identified local factors at the

more significant risk factors for subsequent infection than Injury Severity Score (ISS),

requirement for blood transfusion, the amount of blood transfused, or the presence of

fracture.6

Norden found convincing evidence that antibiotics administered before incision

risk of infection after surgical stabilization of closed hip fractures or proximal femoral

replacement.7

The group receiving antibiotics had a 78% lower rate of infection comp

controls. This study was included in this review to demonstrate the role of prophylac

following orthopedic procedures for closed fractures. However, Norden did not addr

prophylactic antibiotics with regard to open fractures in which bacterial contamination

preoperatively in 48% to 60% of all wounds and 100% of severe wounds.

Dellinger provided an in depth report of prophylactic antibiotics in open fractu

He performed a detailed analysis of controlled trials in open fractures and the various s

evaluating choices of antibiotics as well as duration of therapy for these extremity injur

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A. Identification of references

These recommended guidelines for prophylactic antibiotic usage for open fract

evidence-based. Articles were identified from the literature by independent searches p

two of the reviewers. One search was performed using OVID MEDLINE and covere

from 1985 to 1997. Key words used in this search were open fracture, antibiotics, pr

management. References from 1975 to 1985 were identified through a MEDLINE se

following key words: antibiotic prophylaxis; human; open fractures; bacterial infectio

and control; fracture healing; fracture-complications; and surgical wound infections.

combined searches identified 313 articles. The bibliography of each article was review

additional references which were not identified in the two original searches. Letters to

case reports, and review articles were excluded from further evaluation. This identifie

for evidentiary review. The articles were reviewed by 3 orthopedic trauma surgeons,

surgeons, and two pharmaceutical outcome researchers with interest in pharmacokinet

care economics. These individuals then collaborated to produce the guidelines.

1. Quality of the references

The references were classified in the methodology established by the A

Health Care Policy and Research (AHCPR) of the U.S. Department of Health

Services. Additional criteria and use for Class I articles were taken from a too

Oxman et al.9

Thus, the classifications were:

Class I: Prospective Randomized Double-Blinded Study

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A. Level I

There are sufficient Class I and II data to recommend preoperative dosing with

antibiotics (as soon as possible after injury) for coverage of gram positive organisms a

care for trauma patients with open fractures. For Grade III fractures, additional cover

negative organisms should be given. High-dose penicillin should be added to the antib

when there is a concern for fecal/Clostridial contamination such as in farm related inju

B. Level II

There are sufficient Class I and Class II data to recommend antibiotics be disco

hours after wound closure for Grade I and II fractures. For Grade III wounds, the ant

be continued for only 72 hours after the time of injury or not more than 24 hours after

coverage of the wound is achieved, whichever occurs first (See page 10, paragraph C

discussion).

Definition of Level I recommendation: This recommendation is convincingly ju

on the available scientific information alone. It is usually based on Class I data, howev

Class II evidence may form the basis for a level 1 recommendation, especially if the is

lend itself to testing in a randomized format. Conversely, weak or contradictory Class

be able to support a level 1 recommendation.

Definition of Level II recommendation: This recommendation is reasonably jus

available scientific evidence and strongly supported by expert critical care opinion. It is

supported by Class II data or a preponderance of Class III evidence

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An open fracture was for many thousands of years a sentence of death. Ampu

often considered as the only viable alternative to death. The mortality rate of all kinds

fractures in the Franco Prussian War was 41%; it was 50% for the lower leg, 66% for

77% for open fractures of the knee joint. Other reports claimed a mortality rate rangi

99% for open femur fractures.10

In War World I, the mortality rate for an open fracture of the femur remained a

80%. The immediate use of the Thomas splint for femur fractures was introduced in 1

mortality rate for open fractures of the femur fell promptly to 16%. Karpmen later re

restoration of the bone length reduced the volume of the fascial compartments and the

magnitude of blood loss associated with the open fracture, which explained the reducti

observed with the Thomas splint. Also in World War I, Orr evolved a policy of woun

debridement, reduction of the fracture, stabilization with plaster, and leaving the traum

open.11

During the Spanish Civil War, Truetta confirmed Orrs experience with a repo

septic mortality rate in 1069 open fractures.12

Thus, World War I was the first time th

wound debridement was correlated with a reduction in septic mortality for open fractu

reduction occurred prior to antibiotics, blood transfusions, intravenous fluids, and mo

anesthesia.

During World War II, there was initial enthusiasm for the use of chemotherape

primarily in the form of sulfonamides in the immediate care of open fractures. The im

wound excision with debridement and healing by secondary intention was once again a

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There was a 95% success rate in wounds left open for 4 to 10 days despite positive ba

cultures from the wound.13

Patzakis et al. were the first to perform a prospective, randomized study comp

infectious rates for penicillin with streptomycin, cephalothin, and placebo.14

The rates

for controls, 9.7% for penicillin, and 2.3% for cephalothin. Unfortunately, the study w

blinded and did not grade for severity of open fractures. Nonetheless, it was the first

a benefit of prophylactic antibiotics in these severe extremity injuries. Since the Patza

have been multiple reports14,15,20,26,27,32,35,37,44,61,63

comparing various antibiotic regimen

in reducing infections and durations of therapy. These articles did stratify for grade of

and form the basis for this evidence-based outcome review.

B. Choice of antibiotic

The majority of studies contain populations of patients with various mechanism

Hansraj et al.15

performed a non-blinded comparison of ceftriaxone to cefazolin in extr

bony injuries due to gunshot wounds. The mean time between injury and the initial an

was 4 hours. All admission cultures were negative, and none of the patients subsequen

clinical signs of infection. They concluded that the cost of therapy was significantly le

ceftriaxone and resulted in a 1-day reduction in length of stay.15

This study questions

velocity missile injury to extra-articular cortical bone requires any antibiotic prophylax

feels compelled to use a prophylactic antibiotic in this low-risk group, the authors sugg

dose long-acting antimicrobial is cost effective in this patient population compared wi

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the time of a second debridement 24 hours after admission, and all developed a deep w

infection. They concluded that sequential wound cultures facilitated antibiotic therapy

management of open extremity fractures. More recent investigations have shown no c

wound cultures at the time of presentation or obtained during the initial debridement a

infection.21,22,61

The importance of prophylactic antibiotics for open fractures of the knee, ankle

and skull has also been evaluated and found to be beneficial.23-33

Benson et al. compar

against cefazolin and saw no difference in the infection rates.34

This study suggested t

antimicrobial agent with Staphylococcus aureus coverage is adequate effective prophy

fractures. Thus, there is adequate Class I and II data to document the benefit of proph

antibiotics in open extremity fractures. Agents effective against Staphylococcus aureu

appear to be adequate for Grade I and II fractures.1,14,34-38

Since various gram negativ

are cultured from Grade III wounds after the initial debridement, broader gram negativ

through the addition of an aminoglycoside is beneficial.17-20,26,39-53

C. Duration of therapy

Multiple studies have demonstrated the interaction between antibiotic therapy

management.1,17-20,39,42,44,45,53-62

When Grade I or II wounds are closed primarily, an ad

hours of antibiotic coverage is adequate independent of time of initiation after injury.19

Dellinger et al. observed no relationship between the duration of antibiotic administrat

versus 5 days) and the risk of infection independent of the grade of the fracture8,63

O

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Most studies report discussed above use intravenous antibiotics for pro

alternative technique, the antibiotic bead pouch, was developed in the late 1980s . Se

investigators have utilized aminoglycoside-polymethyl methacrylate (PMMA) beads al

addition to parenteral antimicrobials. It has been reported in several series as being us

management of traumatic open wounds associated with fracture,57,68

particularly in cas

types IIIB and IIIC injuries with acute infection and types II and IIIB with chronic oste

(3.7% versus 12%).56,69

This technique promotes high local tissue levels of antibiotic

in the target area with a significantly decreased risk of potentially toxic systemic effect

high dose parenteral delivery. In the acute setting, PMMA beads, which have been im

an aminoglycoside antibiotic, are used in conjunction with 5 days of tradition systemic

cefazolin and penicillin prophylaxis.67

This is combined with a regimen of thorough, s

debridements every 48 to 72 hours and bead exchanges with sterile self-adherent porou

polyethylene drapes used to seal the wound. Systemic aminoglycoside levels are mon

peak and trough levels with the doses being adjusted to maintain a therapeutic ran

coverage techniques are carried out based on the immediate needs of the injury, and ca

delayed primary closure, split-thickness skin grafting, local flaps or free-tissue transfer

warranted. Skeletal stabilization is generally managed with intramedullary nailing or e

fixation, the latter sometimes being converted to an intramedullary nail after soft tissue

been achieved.64

The determinants of wound closure/soft tissue coverage include the v

local soft tissue envelope after adequate time for demarcation has been allowed but ge

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The evidentiary table contains 54 articles that were utilized to formulate these

The data are listed alphabetically by Class and include 10 Class I articles, 8 Class II, an

references. The following data were retrieved and recorded from each article and are

conclusion sections: (1) protocol design; (2) antibiotics utilized; (3) infectious complic

conclusions.

V. Summary

Multiple studies have documented the reduction in wound infections with the u

prophylactic antibiotics in the care of patients with open fractures. Although studies w

therapeutic agents have suggested an improved outcome with prolonged (> 24 hours)

have been done with appropriate controls. The most difficult open fracture wound to

Grade IIIb tibial fracture. Although some authors advocate application of antibiotic im

beads for local control of infection in addition to parenteral administration, supportive

data are not available. These wounds (type III) should receive coverage for gram neg

organisms in addition to gram positive coverage.

VI. Future Investigation

There is a need to re-evaluate the current infection rate for long bone open fra

should specifically focus on high-risk injuries, ie. the Grade IIIb tibial injury. The stud

should evaluate the effect of wound debridement, systemic and local antibiotics, durati

specific agents as well as cost analysis. Because of the relatively low rate of infection,

institutional effort would allow a meaningful study to be completed in a short time per

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1. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thou

twenty-five open fractures of long bones: retrospective and prospective analyse

Joint Surg1976;58A:453-458.

2. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type

open fractures: A new classification of type III open fractures.J Trauma 1984

3. Brumback RJ, Jones AL. Interobserver agreement in the classification of open

the tibia.J Bone Joint Surg1994;76-A:1162-1291.

4. Seligson D, Banis J, Metheny L. Tibia terrible. In: Coombs R, Green S, Sarmi

External Fixation and Functional Bracing. London: Orthotext, 1989:281-284

5. Court-Brown CM. Antibiotic prophylaxis in orthopaedic surgery. Scand J Infe

1990;70:74-79.

6. Dellinger EP, Miller SD, Wertz MJ, Grypma M, Droppert B, Anderson PA. R

after openfracture of the arm or leg.Arch Surg1988;123:1320-1327.

7. Norden CW. A critical review of antibiotic prophylaxis and orthopedic surgery

Dis 1983;5:928-932.

8. Dellinger EP. Antibiotic prophylaxis in trauma: penetrating abdominal injuries

fractures.Rev Infect Dis 1991;13:S847-857.

9. Oxman AD, Sackett DL, Guyatt GH. Users guide to the medical literature. I.

started. The Evidence-Based Medicine Working Group.JAMA 1993;270:2093

10 Cruse P Wound infections In Howard R Simmons R (Eds ) Epidemiology a

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11. Orr H. The treatment of infected wounds without sutures, drainage tubes or an

dressings.J Bone Joint Surg1928;10:605.

12. Truetta J. War surgeries of extremities: treatment of war wounds and fractures

1942;1:616.

13. Whelan T, Bucholz W, Gomez A. Management of war wounds. In Welch C (E

in Surgery. Chicago: Yearbook Medical Publishing, 1968:227-351.

14. Patzakis MJ, Harvey JP Jr, Ivler D. The role of antibiotics in the management

fractures. JBone Joint Surg1974;56A:532-541.

15. Hansraj KK, Weaver LD, Todd AO, et al. Efficacy of ceftriaxone versus cefaz

prophylactic management of extra-articular cortical violation of bone due to lo

gunshot wounds. Orthop Clin North Am 1995;26:9-17.

16. Victoroff BN, Robertson WW Jr, Eichelberger MR, Wright C. Extremity guns

treated in an urban childrens hospital.Pediatr Emerg Care 1994;10:1-5.

17. Hope PG, Cole WG. Open fractures of the tibia in children.J Bone Joint Surg

1992;74B:546-553.

18. Buckley SL, Smith GR, Sponseller PD, Thompson JD, Robertson WW Jr, Gri

(type III) open fractures of the tibia in children. J Pediatr Orthop 1996;16:627

19. Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wou

Orthop 1989;243:36-40.

20 Robinson D On E Hadas N Halperin N Hofman S Boldur I Microbiologic

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21. Chapman MW. Open Fractures. In: Chapman MW, (ed.). Operative Orthopae

Edition. Philadelphia: JB Lippincott Company 1993:365-372.

22. Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop1

23. Torchia ME, Lewallen DG. Open fractures of the patella.J Orthop Trauma 19

409.

24. Acello AN, Wallace GF, Pachuda NM. Treatment of open fractures of the foo

preliminary report.J Foot Ankle Surg1995;34:329-346.

25. Marsh JL, Saltzman CL, Iverson M, Shapiro DS. Major open injuries of the ta

Trauma 1995;9:371-376.

26. Sanders R, Pappas J, Mast J, Helfet D. The salvage of open grade IIIb ankle an

fractures.J Orthop Trauma 1992;6:201-208.

27. Suprock MD, Hood JM, Lubahn JD. Role of antibiotics in open fractures of th

Hand Surg1990;15A:761-764.

28. Peacock KC, Hanna DP, Kirkpatrick K, Breidenbach WC, Lister GD, Firrell J

perioperative cefamandole with postoperative cephalexin in the primary outpa

of open wounds of the hand.J Hand Surg1988;13A:960-964.

29. Sloan JP, Dove AF, Maheson M, Cope AN, Welsh KR. Antibiotics in open fra

distal phalanx.J Hand Surg1987;12B:123-124.

30. Franklin JL, Johnson KD, Hansen ST Jr. Immediate internal fixation of open an

Report of thirty-eight cases treated with a standard protocol J Bone Joint Sur

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32. Mendelow AD, Campbell D, Tsementzis SA, et al. Prophylactic antimicrobial

compound depressed skull fracture.J Royal Coll Surg Edinb 1983;28:80-83.

33. Pinckney LE, Currarino G, Kennedy LA. The stubbed great toe: A cause of oc

fracture and infection.Radiology 1981;138:375-377.

34. Benson DR, Riggins RS, Lawrence RM, Hoeprich PD, Huston AC, Harrison J

of open fractures: A prospective study.J Trauma 1983;23:25-30.

35. Wisniewski TF, Radziejowski MJ. Gunshot fractures of the humeral shaft treat

external fixation.J Orthop Trauma 1996;10:273-278.

36. Johnson KD, Johnston DW. Orthopedic experience with methicillin-resistant S

aureus during a hospital epidemic. Clin Orthop 1986;212:281-288.

37. Bergman BR. Antibiotic prophylaxis in open and closed fractures: A controlled

Orthop Scand1982;53:57-62.

38. Kennedy T, Premer RF, Lagaard S, Gustilo RB. Management of tibial fracture

1975;58:525-528.

39. Cullen MC, Roy DR, Crawford AH, Assenmacher J, Levy MS, Wen D. Open

tibia in children.J Bone Joint Surg1996;78A:1039-1047.

40. Grimard G, Naudie D, Laberge LC, Hamdy RC. Open fractures of the tibia in

Orthop 1996;332:62-70.

41. Song KM, Sangeorzan B, Benirschke S, Browne R. Open fractures of the tibia

Pediatr Orthop 1996;16:635-639

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43. Kreder HJ, Armstrong P. A review of open tibia fractures in children.J Pediat

1995;15:482-488.

44. Bednar DA, Parikh J. Effect of time delay from injury to primary management

incidence of deep infection after open fractures of the lower extremities caused

trauma in adults. J Orthop Trauma 1993;7:532-535.

45. Buckley SL, Smith G, Sponseller PD, Thompson JD, Griffin PP. Open fracture

in children.J Bone Joint Surg1990;72A:1462-1469.

46. Swiontkowski MF. Criteria for bone debridement in massive lower limb traum

1989;243:41-47.

47. Burgess AR, Poka A, Brumback RJ, Flagle CL, Loeb PE, Ebraheim NA. Pede

injuries.J Trauma 1987;27:596-601.

48. Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fra

to treatment and results. Orthopedics 1987;10:1781-1788.

49. Patzakis MJ, Wilkins J, Moore TM. Use of antibiotics in open tibial fractures.

1983;178:31-35.

50. Patzakis MJ, Wilkins J, Moore TM. Considerations in reducing the infection ra

tibial fractures. Clin Orthop 1983;178:36-41.

51. Christensen J, Greiff J, Rosendahl S. Fractures of the shaft of the tibia treated

compression osteosynthesis.Injury 1982;13:307-314.

52 Gustilo RB Use of antimicrobials in the management of open fractures Arch S

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54. Steiner AK, Kotisso B. Open fractures and internal fixation in a major African

Injury 1996;27:625-630.

55. Geissler WB, Powell TE, Blickenstaff KR, Savoie FH. Compression plating of

shaft fractures. Orthopedics 1995;18:655-660.

56. Ostermann PAW, Seligson D, Henry SL. Local antibiotic therapy for severe op

A review of 1085 consecutive cases.J Bone Joint Surg1995;77B:93-97.

57. Ostermann PAW, Henry SL, Seligson D. The role of local antibiotic therapy in

management of compound fractures. Clin Orthop 1993;295:102-111.

58. Hoffer MM, Johnson B. Shrapnel wounds in children.J Bone Joint Surg1992

59. Kaltenecker G, Wruhs O, Quaicoe S. Lower infection rate after interlocking na

fractures of femur and tibia. J Trauma 1990;30:474-479.

60. Russell GG, Henderson R, Arnett G. Primary or delayed closure for open tibia

Bone Joint Surg1990;72B:125-128.

61. Merritt K. Factors increasing the risk of infection in patients with open fractur

1988;28:823-827.

62. Wilson NI. A survey, in Scotland, of measures to prevent infection following o

surgery.J Hosp Infect1987;9:235-242.

63. Dellinger EP, Caplan ES, Weaver LD, et al. Duration of preventive antibiotic a

for open extremity fractures.Arch Surg1988;123:333-339.

64 Keating JF Blachut PA OBrien PJ Meek RN Broekhuyse HM Reamed nai

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65. Sangha KS, Miyagawa CI, Healy DP, Bjornson HS. Pharmacokinetics of once

of gentamicin in surgical intensive care unit patients with open fractures.Ann P

1995;29:117-119.

66. Ostermann PA, Henry SL, Seligson D. Timing of wound closure in severe com

fractures. Orthopedics 1994;17:397-399.

67. Seligson D, Ostermann PA, Henry SL, Wolley T. The management of open fra

associated with arterial injury requiring vascular repair.J Trauma 1994;37:938

68. Henry SL, Ostermann PA, Seligson D. The antibiotic bead pouch technique. T

management of severe compound fractures. Clin Orthop 1993;295:54-62.

69. Henry SL, Ostermann PA, Seligson D. The prophylactic use of antibiotic impr

in open fractures.J Trauma 1990;30:1231-1238.

lina

b gm p

.n e

n

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20

PROPHYLACTIC

ANTIBIOTIC

USEIN

OPEN

FRACTURES:EVIDENTIARY

TABL

E

FirstAuthor

Year

Reference

Class

Conclusions

PatzakisMJ

1974

Theroleofantibioticsinthe

managementofopenfractures.

JBoneJointSurg56A:532-541

I

31

0pts.RandomizedAbxregime

ns(10-daycourse):1)Gp1+placebo;2)GpII+penicil

+streptomycin;3)GpIII+cephalothin.

Infectionrates:GpI(13.95);GpII

(9.7%);GpIII(2.3%)

Recommend:1)Abxeffectiveforgrampos.,gramneg.,staph;2)woundC&Sbefore

deb

ridementmostlikelytoisolatep

otentiallyinfectiousorganisms;

3)modifyAbxbasedon

C&Sresults.

BergmanBR

1982

Antibioticprophylaxisinopenand

closedfractures:Acon

trolledtrial.

ActaOrthopScand53:57-62

I

Openfractures(n=90):GradeI,N=55;GradeII&III,N=35.

Abxincluded:1)dicloxacillin;2)benzylpenicillin;3)placebo.

AllAbxdiscontinuedafter48hrs.

NostatisticaldifferenceinsuperficialinfectionsforeitherAbxorb

ysubsetanalysisforsta

woundorlacerations,orGradeI,II,orIIIfractures.

Gp3developedsignificantlymore

deepinfections.

Nodifferencebetweendicloxacillinandbenzylpenicillin.

Confirmsshortdurationprophylac

ticAbxreducedeepinfectionsforopenfractures.

BensonDR

1983

Treatmentofopenfractures:A

prospectivestudy.

JTrauma23:25-30

I

Comparedtheeffectofclindamycinvscefazolin.

Quantitativecultureswereobtaine

donadmission.

Results:46%ofwoundswerecon

taminatedattimeofdebridement.Infectionrate=6.5%

Gramneg.org.resistanttoprophylacticagentsrecoveredonly8times:4(50%)became

infe

cted.

Nodifferenceininfectionratewith

eitheragent.

SloanJP

1987

Antibioticsinopenfracturesofthe

distalphalanx.

JHandSurg12B:123-1

24

I

85

opendistalphalanxfractures.

Randomizedgroups:1)NoAbx;2

)cephradine500mgpoQIDx5

days;3)cephradine1g

IVpre-op,then500mgpoQIDx5days;4)cephradine1gmIVpre-op,then1gmpopostop

4.7%infectionrate(n=4);3infectionsoccurredinNoAbxgroup.

Nosignificantdifferencebetween

3Abxregimens.

Recommend:1)Abxprophylaxisnec.foropenfracturesofdistalphalanx;2)Administration

modedoesnotinfluenceinfectionr

ate;3)Regimen#4mostcost-effective/efficacious.

DellingerEP

1988

Durationofpreventiveantibiotic

administrationforopen

extremity

fractures.

ArchSurg123:1320-13

27

I

24

8openfractures-randomized:1

)cefonicid2gmsx1day;2)cefonicid2gmsx1day,the

1gmq24hrsx5days;3)cefaman

dole2gms,then1gmq6hrsx

5days.

13

%infectionrate-nosignificantdifferenceamong3Abxgroups.

Equivalentefficacyfor1-dayAbxadministrationcomparedto5days.

RecommendbriefAbxcoursefollowedbycloseobservationforpostopinfection.

ys rsx

=7);

pe n;5)

n

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21

FirstAuthor

Year

Reference

Class

Conclusions

PeacockKC

1988

Efficacyofperioperativ

ecefamandole

withpostoperativecephalexininthe

primaryoutpatienttreatmentofopen

woundsofthehand.

JHandSurg13A:960-9

64

I

87

pts:1)Studygroup:cefamandole1gmIVq4hrs,thencephalexin500mgQIDx3day

@discharge;2)control:placeboIV

,thenplacebopo@d

ischarge.

Infectionrate=0%studygroupvs

2.1%control(NS).

Abxnotroutinelyindicated;useAbxforseriousinjuries/specificallyidentifiedinfections.

Swiontkowski

MF

1989

Criteriaforbonedebrid

ementin

massivelowerlimbtrauma.

ClinOrthop243:41-47

I

60

ptswithopenextremityfractures.

Abxregimen:cephalosporins+am

inoglycosides(typeII).

9.2%deepinfection.

RobinsonD

1989

Microbiologicfloracontaminatingopen

fractures:Itssignificanceinthechoice

ofprimaryantibioticag

entsandthe

likelihoodofdeepwoundinfection.

JOrthopTrauma3:283

-286

I

89

openextremityfractures.

Managementprotocol:1)woundc

ultureonadmission;2)repeatc

ulture@day1;

3)cefoxitin1gmTIDx24hrs;4)G

aramycin80mgsTIDx24hrs(GradeIII).

83

%initialculturespos.;>90%organismsisolatedsensitivetoroutineAbx.

1-

daypos.culture(n=4)-100%developeddeepwoundinfection.

Im

portanceofwoundcleansingandappropriateAbx.

Sequentialwoundculturespredictlikelihoodofinfection.

HansrajKK

1995

Efficacyofceftriaxoneversuscefazolin

intheprophylacticman

agementof

extra-articularcorticalviolationofbone

duetolow-velocitygun

shotwounds.

OrthopClinNorthAm2

6:9-17

I

Noinfectiouscomplicationsin100

ptsrandomizedto1of2Abxp

rotocols(skinwound

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FirstAuthor

Year

Reference

Class

Conclusions

PatzakisMJ

1983

Useofantibioticsinopentibial

fractures.

ClinOrthop178:31-35

II

363consecutiveopentibialfractu

res.

4

treatmentgroupsduring10-yearperiod:1)noAbx;2)penicillin+

streptomycinx10days;

3)cephalothin-mostreceived5-day

courseofIVtherapyfollowedb

yoralcephalexinx5da

4)cefamandole+tobramycinx3daysifinitialculturesneg.and5daysifculturespos.

In

fectionrateshighestwithnoAbx(24%).LowestinGp4(4.5%).

Conclude:nobenefittocontinuingAbxbeyond3days.

MerrittK

1988

Factorsincreasingthe

riskofinfection

inpatientswithopenfractures.

JTrauma28:823-827

II

70pts-tissuecultures@debridem

ent;follow-upre:developmentofclinicalinfection.

Allreceivedcombinationcephalosporin/aminoglycoside.

In

fectionrate=19%.

In

fectionratelowerinpatientstreated24-48hrsvs3-7days.

Ostermann

PA

1993

Theroleofantibiotictherapyinthe

managementofcompoundfractures.

ClinOrthop295:102-1

11

II

704consecutiveopenfractures:1

)GpA(n=157)-cefazolin/tobra

/PCN;

2)GpB(n=547)-cefazolin/tobra/P

CN+tobra-PMMA.

LowerincidenceofinfectioninGp

BvsGpA(4%vs17%).

Additionoftobra-PMMAtoparenteralAbxdec.infectioninhighlycontaminatedwoundsa

dec.incidenceofpolymicrobialinfe

ction.

Routineuseofprophylactictobra-PMMAdeservesprospectivemu

lticentertrial.

Ostermann

PA

1994

Timingofwoundclosureinsevere

compoundfractures.

Orthopedics17:397-399

II

381openfractures:1)IVcefazolin/tobra/PCNx5days;2)Abxbe

adpouchtech.

Overallinfectionrate=Grade1(0%

);GradeII(2.6%);GradeIII(8.4%).

Nodefinitiveconclusionsduetod

esignofstudy(ie.norandomization,nocontrolgroup).

Ostermann

PA

1995

Localantibiotictherap

yforsevere

openfractures.Areviewof1085

consecutivecases.

JBoneJointSurg77B

:93-97

II

1085consecutiveopenfractures.

Gp1(n=845):IVcefazolin/tobra/PCN+tobra-PMMA;

Gp

2(n=240):IVcefazolin/tobra/PCN.

Dec.overallinfectionrateGp1(3

.7%vs.12%);statisticalsignific

anceonlyintypeIII.

AdjuvantlocalAbxtherapydecrea

sesincidenceoflateinfection.

KeatingJF

1996

Reamednailingofopentibial

fractures:Doesthean

tibioticbead

pouchreducethedee

pinfectionrate?

JOrthopTrauma10:2

98-303

II

Parenteralregimen:Cefazolin+G

entamicinx72hrs.

DecreaseddeepinfectionrateintypeIIfractureswithAbxbeadp

ouch:4%vs20%(NS).

DecreaseddeepinfectionrateintypeIIIfractureswithAbxbeadpouch:8%vs.20%(NS)

WisniewskiTF

1996

Gunshotfracturesofthehumeral

shafttreatedwithexte

rnalfixation.

JOrthopTrauma10:2

73-278

II

Firstgenerationcephalosporinx72hrs.

Incidenceofinfection(21%):deep

woundsepsis(2);pintrackinfection(5);osteomyelitis

(1).

FirstAuthor

Year

Reference

Class

Conclusions

KennedyT

1975

Managementoftibialfractures.

MinnMed58:525-528

III

109ptswith118openandclosed

tibialfractures.

Closedmethods+earlyweight-be

aringunionin98%.

Pinsandplaster62.5%delayedu

nionrate.

AlltypeI/IIclosedprimarily.Noinfectionsupportinguseofprophy

lacticAbx.

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pe

hrs).

e.

ys t

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25

EffectivenessofAbx:noAbx-13.9%infection;penicillin/streptomycin-10%;cephalothin-

5.6

%;cefamandole/tobramycin-4.5

%.

TimetoinitiationofAbx:3hrs-7.4%infection.

N

ocorrelationwithdurationofAb

xtherapy.

R

ecommend:1)earlysurgicaldebridement;2)broad-spectrumAbxASAPafterinjury;

3)continueAbxfor3days;4)type

I/II-partialwoundclosure;5)typeIII-delayedwound

clo

sure,tissuetransfer(7days).

BuckleySL

1990

Openfracturesofthe

tibiainchildren.

JBoneJointSurg72A

:1462-1469

III

W

oundculturesinED.

R

outinetetanusprophylaxis.

Protocol:1)min.48hrsAbxcoverage;2)1stgen.cephalosporin;

3)aminoglycoside(typ

III);4)penicillin(farm-relatedinjury

);5)Abxrepeatedforsubseque

ntprocedures(48-72h

W

oundinfectionrate=7.3%;osteomyelitis=4.9%;pin-trackinfection=20%.

In

fectionrateslowerinchildrenvsadults;noinfectionwithdelaye

dwoundclosure.

HenrySL

1990

Theprophylacticuse

ofantibiotic

impregnatedbeadsin

openfractures.

JTrauma30:1231-1238

III

404openfractures/339pts.:Grad

eI(31.4%);GradeII(38.9%);G

radeIII(30.7%).GpA

(n=

70)systemicAbx(cefazolin/tobra/PCN);GpB(n=334)systemicAbx+tobrabeads.

O

verallinfectionrate=21.4%Gp

Avs4.2%GpB.

Polymicrobialinfection=87.5%Gp

Avs55.6%GpB.

R

ecommendprospectivemulticen

tertrialtoestablishefficacyofroutineprophylacticuse

KalteneckerG

1990

Lowerinfectionratea

fterinterlocking

nailinginopenfracturesoffemurand

tibia.

JTrauma30:474-479

III

G

radeI/IIopenfractures:23femu

r/56tibia.

Protocol:1)woundcoveredinED

/nocultures;2)penicillin.

96.2%infection-freerate.

Abxrequiredwheninterlockingnailsusedforstabilization.

FirstAuthor

Year

Reference

Class

Conclusions

RussellGG

1990

Primaryordelayedclosureforopen

tibialfractures.

JBoneJointSurg72B

:125-128

III

90consecutivepts.

C

omparedprimarywithdelayedc

losurefordeepinfection.

AllptsreceivedAbx(PCN,cloxac

illin,or1stgen.cephalosporin).

G

ustiloclassification:I(37);II(35

);IIIa(4);IIIb(1);IIIc(4).

Primaryclosure20%deepinfectionrate;3%delayedclosure.

C

onclude-avoidprimaryclosure.

SuprockMD

1990

Roleofantibioticsinopenfracturesof

thefinger.

JHandSurg15A:761-764

III

91fingerfractures:1)+Abx=po1stgen.cephalosporin/dicloxacillin/erythromycinx3day

(n=

45);2)-Abx=noAbx(n=45).

N

odifferenceinfectionratebetwe

engroups(8.7%vs8.9%).

R

outineAbxnotindicatedforope

nfingerfractures.

HofferMM

1992

Shrapnelwoundsinc

hildren.

JBoneJointSurg74A

:766-769

III

19childrenwithopenextremityfracture.

Allwoundsmanagedopen/closurebysecondaryintention.

Abxchoicebasedonavailability.

HopePG

1992

Openfracturesofthe

tibiainchildren.

III

95opentibiafractures:typeI(24%);typeII(55%);typeIII(21%)-

broad-spectrumAbxat

n,&

n+

; argeif

IIIc-

t . eads

n-

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26

JBoneJointSurg74B

:546-553

lea

st48hrs.

11%woundinfection-infectionra

tecorrelatedwithdegreeofsofttissueinjury.

M

osttypeI,sometypeIIwounds

suitableforprimaryclosureafte

rdebridement,irrigatio

useofsystemicAbxforatleast48

hrs:1)cephalosporinsq4hrsx

3days;2)gentamicin

penicillinduetogrosscontamination@t

imeofpresentation(3pts

).

2

documentedinfections(10%)/C

omplicationscorrelatedwithwo

undseverity.

SandersR

1992

ThesalvageofopengradeIIIbankle

andtalusfractures.

JOrthopTrauma6:20

1-208

III

11open,GradeIIIbanklefracture

s.

M

anagementprotocol:1)multiple

debridementsdevitalizedbone

&softtissue;

2)osseusdefectsfilledx/Abximp

regnatedbeads(tobra);3)temp

oraryexternalfixation

4)delayedclosure,bonegrafting,dynamiccompressionplating.

Antibioticprotocol:1)cephalothin

+tobramycin+penicillin;2)Abxd

iscontinued@d

ischa

serialboneculturesneg;3)specificAbxinitiatedforpos.boneculturesx6wks.

9.1%acuteinfection.

Protocolobtainswoundcoverage

,ankle/subtalarfusion,&eradic

atesosteomyelitis.

BednarDA

1993

Effectoftimedelayfrominjuryto

primarymanagement

onthe

incidenceofdeepinfectionafteropen

fracturesofthelower

extremities

causedbyblunttraum

ainadults.

JOrthopTrauma7:53

2-5

III

82openfracturesofthelowerextremity.

M

anagementprotocol:1)tetanus

prophylaxis;2)GradeI/II/IIIa-ce

fazolin;3)GradeIIIb/

cefazolin+gent/tobra;4)Abxcontinuedx48hrs,repeatwithanysubsequentsurg.

pro

cedure.

D

eepinfection=4.9%.

Shortdelaytodefinitiveprimarys

urgicalmanagementnotprogno

sticallyimportant.

FirstAuthor

Year

Reference

Class

Conclusions

HenrySL

1993

Theantibioticbeadpouchtechnique.

Themanagementofs

evere

compoundfractures.

ClinOrthop295:54-62

III

704consecutiveopenfractures.

227managedwithAbxbeadpouchtech.fortemp.coverageofwoundswithandwithou

softtissuedefects+cefazolin/tobra/PCNIV.

W

oundinfection=5.3%;osteomy

elitis=3.9%.

M

ostusefulforsevereGradeIIIw

ounds-beadpouchservesassu

bstituteforsofttissue.

R

ecommendprospectiverandomizedstudytodetermineifonlylo

calAbxdeliverybybe

issufficientandmayreplaceparen

teralAbx.

SeligsonD

1994

Themanagementofo

penfractures

associatedwitharterialinjuryrequiring

vascularrepair.

JTrauma37:938-940

III

M

ethods(n=72):1)cefazolin/tobra/PCNx5days(100%);2)Abxbeadpouch(43%)-non

ran

domized.

10woundinfections(14%);3osteomyelitis(4%).

R

ecommend:mandatoryparenteralbroad-spectrumAbxandadjuvantuseof

am

inoglycoside-PMMAbeads.

VictoroffBN

1994

Extremitygunshotinju

riestreatedin

anurbanchildrenshospital.

PediatrEmergCare1

0:1-5

III

76wounds:23fractures(30%)/53

softtissuewounds(70%);mos

tlow-velocity.

45ptsreceivedAbx:1stgen.cep

halosporin(45/45);cephalosporin=+aminoglycoside

(2/45).

19/24ptswithfractures(79%)rec

eivedAbxx48hrs.

N

oinfectionsin45ptsreceivingAbx.

R

ecommendGradeI/IIfractures-Abxfor48hrs.

- ted;

en h

ighly

ents

us m

in.

e;4)

njury.

d s. se

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27

AcelloAN

1995

Treatmentofopenfra

cturesofthe

footandankle:Apreliminaryreport.

JFootAnkleSurg34:329-346

III

In

itiationofappropriateAbxASAPisimportantvariableinreducingrateofinfection.

60-70%openfracturewoundscontaminated@t

imeofinitialinsp

ection(aerobic

GP

C/GPR).

In

creasingtrendtowardgramneg

.infectionshasreducedclinicalrelevanceof

pre

debridementwoundcultures.

N

ostudiesdocumentsuperiorityoflong-termvs.perioperativeAb

xcoverage.

R

ecommendedregimen(Gustilo):1)Type1:cefazolin;2)TypeII/III:cefazolin+amino-

gly

cosides;3)3-daycourse,additional3-daycoursewhenwoundinsurgicallymanipulat

4)1stgenerationcephalosporinad

equateafter3daysifwoundis

notclinicallyinfected.

R

etrospectivestudy:comparison

ofcefazolin/gent(n=19)vscefa

zolin/Cipro(n=6)inope

fracturesofthefootandankle.

C

/G=10.5%infection;C/C=0%

infectionrate.

FirstAuthor

Year

ReferenceTitle

Class

Conclusions

ColeJD

1995

Asequentialprotocol

formanagement

ofsevereopentibialfractures.

ClinOrthop315:84-103

III

P

rotocol:1)Cefazolininitiatedin

ED,continuedx36hrs;2)Amin

oglycosideaddedfor

contaminatedwoundsbyclinicalexamination.

In

fectionrate=2%,majorityofpu

blishedstudies.

Im

portanceofre-establishingphy

siologicwoundbarrier(i.e.early

woundclosure)preve

dessication/contaminationofwoun

ds.

IM

nailingsafeinopentibialfractures.

GeisslerWB

1995

Compressionplatingofacutefemoral

shaftfractures.

Orthopedics18:655-6

60

III

71femurfractures:58closed/13

open.

P

arenteralAbx.

In

fectionrate=0%.

C

ompressionplating(non-standard)requiresprophylacticAbx,bonegrafting,meticulou

tec

hnique.

KrederHJ

1995

Areviewofopentibia

fracturesin

children.

JPediatrOrthop15:482-488

III

P

rotocol:1)Tetanusprophy.whenappropriate;2)Woundcultures/AbxinED,continue

48

hrsoruntildefinitivewoundcov

erage;3)TypeI/II:broad-spectru

mgrampos.coverag

TypeIII:aminoglycoside;5)Anaerobiccoverage-contaminatedplayground/barnyard.

In

fectionrate=14%.

In

cidenceofinfectionfunctionoftimetoinjury(>6hrs)&presenceofneurovascularin

MarshJL

1995

Majoropeninjuriesofthetalus.

JOrthopTrauma9:37

1-376

III

17opentalarfractures-received

perioperativeAbx.

In

fectionrate=38%>otheropen

fractures.

R

ecommendedprimarytalarbodyexcisioninselectcases.

BuckleySL

1996

Severe(typeIII)open

fracturesofthe

tibiainchildren.

JPediatrOrthop16:627-634

III

P

rotocol:1)Cephalosporin+aminoglycosideinitiatedinED;2)P

enicillin-farm-related

injuries;3)MinimaldurationAbx=

48hrs;4)Abxrepeatedforsubsequentdebridements

O

steomyelitis(15%).

W

oundirrigation&debridement,

parenteralAbx,andearlysofttis

suecoveragedecreas

inc

idenceofosteomyelitis.

In

cidenceofcomplicationssimilarinpediatricandadulttypeIIfra

ctures;childrenmore

and

with

n;

,

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28

successfullytreatedforcomplications.

CullenMC

1996

Openfractureofthetibiainchildren.

JBoneJointSurg78A:1039-1047

III

2%superficialwoundinfection/0

%osteomyelitis.

P

revalenceofinfectionlowerinc

hildrenvs.adults.

P

reventiondependson1)thoroughdebridement,2)irrigation,3)

fracturestabilization,

4)

parentalAbx.

FirstAuthor

Year

ReferenceTitle

Class

Conclusions

GrimardG

1996

Openfracturesofthe

tibiain

children.

ClinOrthop332:62-70

III

B

road-spectrumAbx.

A

veragedurationAbx=5days.

7.1%infectionrate:GradeI(3);G

radeII(2);GradeIII(1).

N

ocorrelationbetweenrateofinfectionandgradeofinjury.

N

orelationshipbetweenrateofinfectionandtimetodebridement.

N

osignificanteffectoninfectionasafunctionoftypeofwoundclosure.

SteinerAK

1996

Openfracturesandin

ternalfixationin

amajorAfricanhospital.

Injury27:625-630

III

A

mpicillin=mostcommonlyused

Abx.

P

ostoperativeinfections(18.5%).

In

fectiouscomplicationsnotrelatedtoAbxuse.

SongKM

1996

Openfracturesofthe

tibiainchildren.

JPediatrOrthop16:6

35-639

III

P

rotocol:1)Tetanusprophylaxis

;2)1stgen.cephalosporinx24

hrs;3)RepeatAbxw

subsequentprocedures.

3

deepinfections(8%):Staphaureus;typeII(2)typeIII(1).

In

fectiouscomplicationsrelatedtochoiceoffixation(i.e.internalvs.external)andtime

externalfixatorleftinplace.

TorchiaME

1996

Openfracturesofthe

patella.

JOrthopTrauma10:4

03-409

III

10.7%deepwoundinfection-typ

eII(3)/typeIIIB(3).

In

fectionratecorrelateswithdegreeofsofttissuedamage.

C

ulturesatthetimeofinitialdebr

idementofnovalueinpredictingsubsequentinfectio

infectionfrequentlynosocomial:Pseudomonas(3),GroupDstrep.(2),Enterobacter(1)

En

teropeptococcus(1),Staphaureus(1).