Most surgeons believe that an open fracture of an extremity is an indication for antibiotic prophylaxis. However, few are familiar with the evidence to support this practice, and the optimum duration of treatment is unknown. In the June 2015 issue of JBJS Reviews, Chang et al. report the results of a systematic review of randomized controlled trials to help shed light on this question. The investigators performed a review of different antibiotic regimens, including antibiotic prophylaxis versus no prophylaxis, longer versus shorter durations of treatment, and the use of alternative drugs.
Using systematic review and meta-analysis methodology, the investigators identified 329 potentially eligible articles, of which seventeen were found to be eligible for inclusion in the analysis. Four randomized controlled trials that involved 472 patients demonstrated significantly lower rates of infection in patients who received antibiotic prophylaxis compared with those who did not receive antibiotic prophylaxis. Three studies involving 1104 patients demonstrated no difference in the infection rate when a longer duration of antibiotic prophylaxis was compared with a shorter duration (three to five days versus one day).
However, confidence in the estimates for both of these questions was low to moderate, and individual comparisons of alternate drugs yielded only low to very low confidence. The investigators concluded that the results of randomized controlled trials performed to date provide evidence that antibiotic prophylaxis reduces infection and that treatment for as short as one day is as effective as treatment for three to five days. Although the evidence warrants only low to moderate confidence, these findings provide support for the design and execution of a large, multicenter, randomized controlled trial to address the question of how antibiotics may be best used in the treatment of open extremity fractures.
Thomas A. Einhorn, MD
Editor, JBJS Reviews