SLR - February 2015 - Julie Rosner

Type III Open Tibia Fractures: Immediate Antibiotic Prophylaxis Minimizes Infection

Reference: Lack WD, Karunakar MA, Angerame MR, Seymour RB, Sims S, Kellam JF, Bosse MJ. TType III Open Tibia Fractures: Immediate Antibiotic Prophylaxis Minimizes Infection. J Orthop Trauma. 2015 Jan;29(1):1-6.

Scientific Literature Review

Reviewed By: Julie Rosner, DPM
Residency Program: Chino Valley Medical Center

Podiatric Relevance: Open tibial fractures are a common lower extremity injury with a high risk of infection. Grade III Gustilo-Anderson fractures have a higher risk of infection than grade I or II fractures. Administration of prophylactic antibiotics in open fractures has been shown to reduce infection rates. This article examines the incidence of deep tissue infection within 90 days of sustaining an open tibial fracture and the impact of early administration of prophylactic antibiotics in reducing infection rates. The authors hypothesized that a delay in administering antibiotic therapy would be associated with greater incidence of infection for type III open tibia fractures independent of other variables.

Methods: The authors performed a retrospective observational study of 137 patients who sustained a Gustilo-Anderson type III open tibia fractures between December 1, 2013 and January 31, 2013. Patients were excluded from the study for missing data, nonreconstructible limbs, and lack of 90-day outcome data. All fractures were treated surgically with appropriate fixation. Antibiotics were administered for 24 hours after surgery. Wound closure was performed when possible. Intermediate coverage of wounds with negative pressure wound therapy was implemented if wounds were unable to be closed. Electronic medical records were reviewed for age, smoking status, presence of diabetes mellitus, Gustilo-Anderson classification, and chronological data. Patients with 90 days of follow-up were used in this study.

Results: Administration of prophylactic antibiotics was administered within 3 hours to 94.9 percent of patients. Cefazolin was the sole prophylactic antibiotic agent in 93.4 percent of patients. Surgical debridement occurred within 24 hours for 94.7 percent of patients. Deep infection occurred in 17.5 percent of patients. There were no correlations to deep infection with smoking, diabetes, time to surgery and type of Gustilo-Anderson wound. Antibiotic delay most predictive of infection was 66 minutes (AUC= 0.63, P=0.03) and wound coverage delay of 5 days (AUC-0.73, P<0.001) was most predictive of infection.

Conclusions: This study illustrates the importance of early prophylactic antibiotic administration in Gustilo-Anderson Type III injuries. This study demonstrated the importance of early prophylactic antibiotic administration, ideally within 66 minutes of sustaining this type of injury. These findings are consistent with previous animal models. Greater than 5 days to definitive wound coverage was also independently associated with deep infection. The results of this study were similar to other studies in that the timing of surgical debridement did not affect infection rate. The study provides evidence that early administration of prophylactic antibiotics in lower extremity fractures and early wound coverage are independently associated with a decreased rate of deep infection. 

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