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      Current Concepts of Prophylactic Antibiotics in Trauma: A Review

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          Abstract

          Traumatic injuries cause 5.8 million deaths per year globally. Before the advent of antibiotics, sepsis was considered almost inevitable after injury. Today infection continues to be a common complication after traumatic injury and is associated with increases in morbidity and mortality and longer hospital stays. Research into the prevention of post-traumatic infection has predominantly focused on thoracic and abdominal injuries. In addition, because research on sepsis following musculoskeletal injuries has predominantly been on open fractures. There is a paucity of research into the prevention of soft tissue infections following traumatic injuries. This review analyses the evidence for the role of prophylactic antibiotics in the management of soft tissue injuries. Emphasis is placed on assessing the strength of the presented evidence according to the Oxford Level of Evidence scale.

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          The effect of time to definitive treatment on the rate of nonunion and infection in open fractures.

          To determine the association between time to definitive surgical management and the rates of nonunion and infection in open fractures resulting from blunt trauma. To determine the association of other clinical determinants with these same adverse events. Retrospective review of a consecutive series of open long bone fractures. Referral trauma center with transport times often extending beyond eight hours from the time of injury. A total of 227 skeletally mature patients with 241 open long bone fractures were treated between January 1996 and December 1998; 215 fractures were available for review at a minimum of twelve months postinjury. Medical charts of all patients were reviewed using a standardized data collection form. All available records and radiograph reports were inspected. All cases were followed to clinical and radiographic union of the fracture or until a definitive procedure for nonunion or deep infection was carried out. Occurrence of deep infections or nonunions after fracture treatment. The mean time to definitive treatment was eight hours and twenty-five minutes (range 1 hour 35 minutes to 30 hours 40 minutes). Forty patients went on to nonunion, and twenty developed a deep infection. In the final multivariate regression model, time was not a significant factor in predicting either nonunion or infection (p > 0.05). The strongest determinants for nonunion were found to be presence of infection and grade of injury (p < 0.05). The strongest predictors for the development of a deep infection were fracture grade and a lower extremity fracture (p < 0.05). The risk of developing an adverse outcome was not increased by aggressive debridement/lavage and definitive fixation up to thirteen hours from the time of injury when early prophylactic antibiotic administration and open fracture first aid were instituted.
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            Surgical Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline.

            Prolonged courses of broad-spectrum antibiotics are often cited as the standard of care for prevention of infective complications of open fractures. The origins of these recommendations are obscure, however, and multi-drug-resistant systemic infections attributable to antibiotic overuse are common life-threatening problems in current intensive care unit practice. To review systematically the effects of prophylactic antibiotic administration on the incidence of infections complicating open fractures. Computerized bibliographic search of published research and citation review of relevant articles. All published clinical trials claiming to evaluate, or cited elsewhere as being authoritative regarding, the role of antibiotics in open fracture management were identified and then evaluated according to published guidelines for evidence-based medicine. Only small studies (<20 patients), practice surveys, pharmacokinetic studies, and reviews or duplicative publications presenting primary data already considered were excluded from analysis. Information on demographics, study dates, fracture grade, antibiotic type, duration and route of administration, surgical interventions, infection-related outcomes, and the methodologic quality of the studies was extracted by the authors. The primary results were submitted to the Therapeutic Agents Committee of the Surgical Infection Society for review prior to creation of the final consensus document. Current antibiotic management of open fractures is based on a small number of studies that generally are more than 30 years old and do not reflect current management priorities in trauma and critical care. With a few noteworthy exceptions, these primary studies suffer from a variety of methodologic problems, including co-mingling of prospective and retrospective data sets, absence of or inappropriate statistical analysis, lack of blinding, or failure of randomization. The data support the conclusion that a short course of first-generation cephalosporins, begun as soon as possible after injury, significantly lowers the risk of infection when used in combination with prompt, modern orthopedic fracture wound management. There is insufficient evidence to support other common management practices, such as prolonged courses or repeated short courses of antibiotics, the use of antibiotic coverage extending to gram-negative bacilli or clostridial species, or the use of local antibiotic therapies such as beads. Large, randomized, blinded trials are needed to prove or disprove the value of these traditional approaches. Such trials should be performed in patients with high-grade fractures who (1) are well-stratified according to the degree of local injury and (2) undergo standardized fracture and wound management. Trials also must be powered to study the effects of extended antibiotic coverage on nosocomial infections. Antibiotic regimens confirmed to improve local fracture outcomes in such studies could then be used rationally, balancing the risks of local fracture-related infections and of multi-drug-resistant systemic infections to achieve optimal global outcomes.
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              Osteomyelitis in grade II and III open tibia fractures with late debridement.

              The purpose of this study was to compare the incidence of infection in grade II and III open tibia fractures with respect to early and late debridement. All grade II and III tibia fractures treated between January 1988 and January 1992 were reviewed. Forty-seven fractures (25 grade II and 22 grade III) in 46 patients were eligible for entry into the study. In all grade II and III fractures, one of 15 fractures (7%) debrided in 5 h after injury became infected (p < 0.03). Overt manifestations of infection did not appear until an average of 4.8 months from the time of injury, and the infecting organisms correlated with the initial cultures in only 25% of the cases. Negative postdebridement cultures did not preclude subsequent infection. The Injury Severity Score did not appear to correlate with increased risk of subsequent osteomyelitis.
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                Author and article information

                Journal
                Open Orthop J
                Open Orthop J
                TOORTHJ
                The Open Orthopaedics Journal
                Bentham Open
                1874-3250
                30 November 2012
                2012
                : 6
                : 511-517
                Affiliations
                [1 ]Department of Plastic Surgery, Guy’s and St Thomas’s Hospital, Westminster Bridge Road, London SE1 7EH, UK
                [2 ]Brighton and Sussex Medical School, Brighton, BN25XL, UK
                [3 ]Department of Plastic Surgery, Whiston Hospital, Warrington Road, L355DR, UK
                [4 ]University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA74LP, UK
                Author notes
                [* ]Address correspondence to this author at the Department of Plastic Surgery, Whiston Hospital, Warrington Road, L355DR, UK; Tel: + 44(0)1244366265; Fax: +44(0)1244366265; E-mail: hindocha2001@ 123456yahoo.com
                [§]

                JCEL and NTM contributed equally.

                Article
                TOORTHJ-6-511
                10.2174/1874325001206010511
                3522105
                23248721
                013bebd5-5f75-4dc7-9c5b-d1255b1923ab
                © Lane et al.; Licensee Bentham Open.

                This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

                Categories
                Article
                Suppl 3

                Orthopedics

                antibiotic, infection, soft tissue, fracture, trauma., prophylaxis

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