The Role of Prophylactic Antibiotic in MRSA

8/2/2019 The Role of Prophylactic Antibiotic in MRSA

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The Role of ProphylacticAntibiotics in Open Fractures

in an Era of Community acquired

Methicillin-resistantStaphylococcus aureus

CARLA C. SAVELI, MD; ROBERT W. BELKNAP, MD;

STEVEN J. MORGAN, MD; CONNIE S. PRICE, MD


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ABSTRACT Infection is a feared complication and a

common cause of loss of function following

open fractures. Staphylococcus aureus, the most common

cause of surgical site infection in patients withopen fractures. Although widespreademergence of

methicillinresistantStaphylococcus aureus(MRSA) has been described in both hospitaland community settings


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Open fractures are characterized by softtissue disruption that results in

communication of the fracture site withthe outside environment.


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DATA SOURCES

computerized bibliographic search usingthe databases PubMed, Medline from

1950 to 2009 and Embase from 1980 to2009 for English language studies.

United States PreventiveServices TaskForce to stratify the quality of evidence.


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7 studies eligible as Level-I evidence were

analyzed for antibiotic selection, timingandduration for prophylaxis in open fractures

Thirteen articles were reviewed andreferred to as evidence for theemergence of MRSA

in orthopedic trauma patients.


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DATA SUPPORTING CURRENT

PROPHYLAXISRECOMMENDATIONS

In 1974, Patzakis et al6 demonstrated

a reduction of infections in patients withopen fracture wounds

Cephalothin,, was demonstrated to

be superior to both no antibiotics and to

a regimen of penicillin and streptomycin.


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Bergman, in 1982, demonstrated asignificant decrease in both superficial

and deep wound infection in openfractures with severe soft tissue injury withthe administration of perioperativedicloxacillin compared with placebo.


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The current quality standard for themanagement of open fractures includes

the administration of parenteral antibioticprophylaxis with an effective regimenconsisting of a first generationcephalosporin


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In a 1999 double-blind controlled trial byCarsenti-Etesse et al, 616 patients with

open tibial fracture requiring openreduction and internal fixation wererandomized to receive pefloxacin versuscefazolin after their fracture and assessed

for surgical site infection within3 months


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Summary of Trials Cited in This Review as Level I

Evidence on Antibiotic Prophylaxis After OpenFractures

Year 1974 1982 1987 1988 1999

Author Patzakis

et al

Berman Braun et al Dellinger

et al

Carsenti-

Etesse et

al

Methods RTC RTC-DB RTC-DB RTC-DB RTC-DB

No. ofpatients

310 90 87 248 616

Prophylact

ic

antibiotic

regimen

Group I

(79): no

antibiotics.

Group

II (92): PCNstreptomy

cin for 10

d. Group

III (84):

cephalothi

n for 10 d

Group I:

Placebo

(30) -

saline.

GroupII: (60) -

PCN or

dicloxaciln

for 2 d

Group I:

Indistinguis

hable

placebo

44). GroupII:

Experimen

tal

(43)

cloxacillin

for 6 d

Group I

(79):

Cefonicid

for 1 d.

GroupII (85):

Cefonicid

for 5 d.

Group III

(84):

Cefaman

dol

Group I

(316):

Pefl

oxacin

singledose.

Group II

(300):

Ceftazolin

for 2 d

followed

by


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End point Early clinicalwoundinfection witheithera positive gramstain or apositive

culture

Early woundinfection:Sub classifiedAs superficial ordeep

Early woundinfection:woundinspection &swabsat weeklyintervals

during thepostoperativecourse

Cellulitis,superficialor deepwoundinfections

Early woundinfection

Length offollow-up

Not specifi ed Until woundshealed

Not specifi ed 6 mo 3 mo

Outcome Group III hadsignificantlylower infectionsrate (2.3%)compared withGroup I(13.9%).No significantdifference

betweenGroup I & II

Group II hadsignificantlylower infectionrate comparedwith Group I

Group II hadsignificantlylower infectionrate (4.6%)compared withGroup I (27.2%)

No significantdifferencebetween the 3groups

No significantdifferencebetweenthe 2 groups(7%vs 8% P.51). Nodifference intheproportion of

gram negativeSSI

Leading causeof SSI

Staphylococus

aureusStaphylococcu

s

aureus

Staphylococcu

s

aureus

Staphylococcu

s

aureus

Staphylococcu

s

aureus.Methicillinresistant

Staphylococcus


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Timing and Duration of

ProphylacticAntibiotics

Patzakis and Wilkins demonstrated aclear benefit if antibiotics are given within

3 hours after the injury with a rate ofinfection of 4.7% compared with a rate of7.4% if antibiotics were delayed for 3hours.


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the current guidelines recommend theadministration of prophylactic antibiotics

within 3 hours of the injury until 24 hoursafter the surgical intervention. Additionalprophylaxis for 24 hours is recommendedfor subsequent interventions in the same

surgical area.

EMERGENCE OF MRSA AS A


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EMERGENCE OF MRSA AS ACAUSE OF

INFECTION AFTER OPENFRACTURES

Shukla et al screened for MRSA colonization2473 adult patients admitted to a trauma

ward found that the rate of MRSA surgical site

infection was significantly higher for MRSAcarriers compared to those not colonized(8.8% vs 2.3%)

concluded that MRSA carriers have a 2.5-times higher risk of developing postoperativeMRSA surgical site infection.


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Beginning in 2003, major cities in the U.Shave experienced increasing rates of

MRSA colonization and infectionoriginating in the community.

Thiscommunity-acquired strain, frequentin patients without the classic risk factors,

has similar virulence, resistance, andlimited treatment options as thoseoriginating in the hospital


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Johnsonet al characterized the infections seen inconjunction with combat-associated typeIII tibialfractures.

In this case series, 35 patients wounded in Iraq orAfghanistan who received prophylactic cefazolinand surgical debridement for an open fracture

13 patients developed infection and delayedunion. Cultures taken from the delayed union site

revealed S aureus in 69% of the cases(9 of 13 patients) with more than a third (4 of 13)

due to MRSA


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The Society for Healthcare Epidemiology of

America in collaboration with Infectious

Diseases Society of America published theirrecommendations to prevent surgical site

infection in acute care hospitals.

They highlighted the importance of prophylaxis

against MRSA and the need for prospective trials

looking at the addition of a glycopeptide to

standard antibiotic prophylaxis.


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Johnson and Johnston reported a case series of 38patients with MRSA infection

The majority (84%) had surgical debridement andstabilization of a fracture with subsequent surgicalsite infection

Found that orthopedic infections due to MRSAcarry extreme morbidity as a result of prolongedhospitalization, increased number of surgical

procedures per patient, higher amputation rates,loss of musculoskeletal function, and extreme costfor both medical care and time lost fromproductive employment


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CONCLUSION

Antibiotic selection for prophylaxis in openfractures should be influenced by

organism most often implicated as acause of infection.

Selecting antibiotics active against MRSAfor open fracture prophylaxis based on

the local prevalence of MRSA carriage,surgical site infection rates andindividualized risks factors

The Role of Prophylactic Antibiotic in MRSA

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