Low Adherence to Open-Fracture Antibiotic Guidelines

The prompt administration of prophylactic antibiotics is considered a critical component of open-fracture management. In 2011, the Eastern Association for the Surgery of Trauma (EAST) recommended updates to traditional antibiotic administration, including gram-positive coverage for Gustilo Type-I and Type-II fractures, the addition of gram-negative coverage for Type-III, and additional penicillin for the presence of fecal or clostridial contamination. Concerns regarding the side effects of antibiotics, along with changing patterns in bacteria resistance, have led many treating physicians to consider alternative antibiotic choices.

In a recent JBJS article, Lin et al. report on the level of adherence to open-fracture antibiotic guidelines (both traditional and EAST recommendations), analyzing data collected as part of 2 large, ongoing, multicenter trials. They also evaluated the association of Gustilo type, wound contamination, and multifracture injuries with antibiotic choice and duration.

Included were 1,234 patients from 24 medical centers in the US and Canada, all of whom received antibiotics on the day of admission. While cefazolin monotherapy was the most commonly prescribed regimen (53.6%), 54 different combinations of prophylactic antibiotics were prescribed. Lin et al. found moderate adherence to traditional antibiotic treatment guidelines for Gustilo Types-I and II fractures and low adherence for Type-III, and less-than-optimal compliance with the EAST recommendations: 31% of Gustilo Type-I and Type-II fractures received gram-negative coverage, and 54.9% of Type-III fractures did not.

The authors offer many plausible reasons for low compliance, including increased incidence of methicillin-resistant S. aureus infections, concerns regarding the nephrotoxicity of aminoglycosides, and the more frequent use of intraoperative topical antibiotics.

The median duration of antibiotic use following wound closure in this study was 2 days. The authors note that the most widely recommended duration in the literature is 3 days after wound closure, which they add, contradicts the <24 hours recommended by the EAST guidelines (for Type-III fractures, discontinuation within 72 hours post-injury or 24 hours after soft-tissue coverage).

The study provides helpful insight into the sometimes contradictory and confusing guidelines for open-fracture antibiotic prophylaxis and the variations that exist in current practice patterns. It also begs the question: is it time for a stringent new look at the guidelines and more high-quality research into which practices help ensure the best patient outcomes and the most sensible antibiotic stewardship?

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

 

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