SLR - December 2018 - Jonathan Pajouh

Evidence-Based Protocol for Prophylactic Antibiotics in Open Fractures: Improved Antibiotic Stewardship with No Increase in Infection Rates

Reference: Rodriguez L, Jung HS, Goulet JA, Cicalo A, Machado-Aranda DA, Napolitano LM. Evidence-Based Protocol for Prophylactic Antibiotics in Open Fractures: Improved Antibiotic Stewardship with No Increase in Infection Rates, J Trauma Acute Care Surg. 2014;77(3):400–407.

Scientific Literature Review


Reviewed By: Jonathan Pajouh, DPM
Residency Program: Hunt Regional Medical Center, Greenville, TX

Podiatric Relevance: Correct antibiotic selection in the treatment of open ankle fractures plays an important role for optimal outcomes. Incorrect antibiotic selection in patients can lead to infection, toxicities and suboptimal results. The Gustilo and Anderson classification is still currently used as guidelines for antibiotic selection in open ankle fractures. This study reviewed a new protocol in which aminoglycosides, vancomycin and penicillin were removed from the treatment protocol. One hundred seventy-four patients with open femur and tibia/fibula fractures were evaluated. The purpose of the study was to determine if a decreased use of aminoglycosides and glycopeptide antibiotics resulted in an increase in skin and soft-tissue infections.

Methods: This was a level IV study. Based on the open fracture grade, certain antibiotics were given. For grade I and II open fractures, Cefazolin was prescribed (or Clindamycin if allergic). Patients with Grade III fractures were given Ceftriaxone (or Clindamycin and Aztreonam if allergic). This study analyzed 174 patients with open femur and tibia/fibula fractures with this new protocol, and the National Healthcare Safety Network risk was used to provide risk adjustment. Skin and soft-tissue infection rate per fracture event were evaluated. Patients who were moribund or managed at another facility for greater than 24 hours were excluded.

Results: The decreased use of aminoglycosides and glycopeptide antibiotics did not lead to an increase in skin and soft-tissue infection rates. The skin and soft-tissue infection rate pre protocol for fracture event was 20.8 percent versus 24.7 percent for post protocol. The use of aminoglycosides and glycopeptide antibiotics were significantly reduced by 53.4 percent versus 16.4 percent. The rate per fracture event for resistant gram positive and gram negative organisms (15.8 percent versus 17.8 percent) and methicillin-resistant S. aureus (2.8 percent versus 4.1 percent) was not significant.

Conclusions: This study demonstrated a decreased use of aminoglycosides and glycopeptide antibiotics with no significant increase in skin and soft-tissue infection and helps provide a basis for change from the routine antibiotic recommendations of Gustilo and Anderson. As time goes on, antibiotic recommendations will continue to change. Unfortunately, the increasing size of patient populations with diabetes and kidney disease will continue to make managing these types of injuries more difficult when compared to a patient without these comorbidities. Based on the results of this study, physicians who manage these complex injuries may consider limiting the use of aminoglycosides and glycopeptides (with their associated risks) and still achieve optimal outcomes. 

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