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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
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