The Role of Prophylactic Antibiotics in Open Fractures in an Era of Community acquired Methicillin-resistant Staphylococcus aureus

CARLA C. SAVELI, MD; ROBERT W. BELKNAP, MD; STEVEN J. MORGAN, MD; CONNIE S. PRICE, MD

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 with open fractures. Although widespread emergence of methicillinresistantStaphylococcus aureus (MRSA) has been described in both hospital and community settings

 Open

fractures are characterized by soft tissue disruption that results in communication of the fracture site with the outside environment.

DATA SOURCES
computerized

bibliographic search using the databases PubMed, Medline from 1950 to 2009 and Embase from 1980 to 2009 for English language studies. United States PreventiveServices Task Force to stratify the quality of evidence.

studies eligible as Level-I evidence were analyzed for antibiotic selection, timingand duration for prophylaxis in open fractures Thirteen articles were reviewed and referred to as evidence for the emergence of MRSA in orthopedic trauma patients.

DATA SUPPORTING CURRENT PROPHYLAXIS RECOMMENDATIONS

1974, Patzakis et al6 demonstrated a reduction of infections in patients with open fracture wounds Cephalothin,, was demonstrated to be superior to both no antibiotics and to a regimen of penicillin and streptomycin.
In

 Bergman,

in 1982, demonstrated a significant decrease in both superficial and deep wound infection in open fractures with severe soft tissue injury with the administration of perioperative dicloxacillin compared with placebo.

 The

current quality standard for the management of open fractures includes the administration of parenteral antibiotic prophylaxis with an effective regimen consisting of a first generation cephalosporin

 In

a 1999 double-blind controlled trial by Carsenti-Etesse et al, 616 patients with open tibial fracture requiring open reduction and internal fixation were randomized to receive pefloxacin versus cefazolin after their fracture and assessed for surgical site infection within 3 months

Summary of Trials Cited in This Review as Level I Evidence on Antibiotic Prophylaxis After Open Year 1974 1982 1987 1988 1999
Author

Fractures

Patzakis et al
RTC 310 Group I (79): no antibiotics. Group II (92): PCN streptomy cin for 10 d. Group III (84): cephalothi n for 10 d

Berman

Braun et al Dellinger et al
RTC-DB 87 Group I: Indistinguis hable placebo 44). Group II: Experimen tal (43) cloxacillin for 6 d RTC-DB 248 Group I (79): Cefonicid for 1 d. Group II (85): Cefonicid for 5 d. Group III (84): Cefaman dol

CarsentiEtesse et al
RTC-DB 616 Group I (316): Pefl oxacin single dose. Group II (300): Ceftazolin for 2 d followed by

Methods No. of patients Prophylact ic antibiotic regimen

RTC-DB 90 Group I: Placebo (30) saline. Group II: (60) PCN or dicloxaciln for 2 d

End point

Early clinical wound infection with either a positive gram stain or a positive culture

Early wound infection: Sub classified As superficial or deep

Early wound infection: wound inspection & swabs at weekly intervals during the postoperative course Not specifi ed Group II had significantly lower infection rate (4.6%) compared with Group I (27.2%)

Cellulitis, superficial or deep wound infections

Early wound infection

Length of follow-up Outcome

Not specifi ed Group III had significantly lower infections rate (2.3%) compared with Group I (13.9%). No significant difference between Group I & II Staphylococus aureus

Until wounds healed Group II had significantly lower infection rate compared with Group I

6 mo No significant difference between the 3 groups

3 mo No significant difference between the 2 groups (7% vs 8% P.51). No difference in the proportion of gram negative SSI Staphylococcu s aureus. Methicillin resistant Staphylococcu s

Leading cause of SSI

Staphylococcu s aureus

Staphylococcu s aureus

Staphylococcu s aureus

Timing and Duration of Prophylactic Antibiotics

Patzakis

and Wilkins demonstrated a clear benefit if antibiotics are given within 3 hours after the injury with a rate of infection of 4.7% compared with a rate of 7.4% if antibiotics were delayed for 3 hours.

 the

current guidelines recommend the administration of prophylactic antibiotics within 3 hours of the injury until 24 hours after the surgical intervention. Additional prophylaxis for 24 hours is recommended for subsequent interventions in the same surgical area.

EMERGENCE OF MRSA AS A CAUSE OF INFECTION AFTER OPEN FRACTURES

Shukla et al screened for MRSA colonization 2473 adult patients admitted to a trauma ward found that the rate of MRSA surgical site infection was significantly higher for MRSA carriers compared to those not colonized (8.8% vs 2.3%) concluded that MRSA carriers have a 2.5times higher risk of developing postoperative MRSA surgical site infection.

 Beginning

in 2003, major cities in the U.S have experienced increasing rates of MRSA colonization and infection originating in the community. Thiscommunity-acquired strain, frequent in patients without the classic risk factors, has similar virulence, resistance, and limited treatment options as those originating in the hospital

Johnsonet al characterized the infections seen in conjunction with combat-associated typeIII tibial fractures. In this case series, 35 patients wounded in Iraq or Afghanistan who received prophylactic cefazolin and surgical debridement for an open fracture 13 patients developed infection and delayed union. 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

The Society for Healthcare Epidemiology of America in collaboration with Infectious Diseases Society of America published their recommendations 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.

Johnson and Johnston reported a case series of 38 patients with MRSA infection The majority (84%) had surgical debridement and stabilization of a fracture with subsequent surgical site infection Found that orthopedic infections due to MRSA carry extreme morbidity as a result of prolonged hospitalization, increased number of surgical procedures per patient, higher amputation rates, loss of musculoskeletal function, and extreme cost for both medical care and time lost from productive employment

CONCLUSION
Antibiotic

selection for prophylaxis in open fractures should be influenced by organism most often implicated as a cause of infection. Selecting antibiotics active against MRSA for open fracture prophylaxis based on the local prevalence of MRSA carriage, surgical site infection rates and individualized risks factors