SLR - June 2021 - Rebecca R. Calder

Low Adherence to Recommended Guidelines for Open Fracture Antibiotic Prophylaxis
Reference: Lin CA, O'Hara NN, Sprague S, O'Toole RV, Joshi M, Harris AD, Warner SJ, Johal H, Natoli RM, Hagen JE, Jeray KJ, Fowler JT, Phelps KD, Pilson HT, Gitajn IL, Bhandari M, Slobogean GP; PREP-IT Investigators. Low Adherence to Recommended Guidelines for Open Fracture Antibiotic Prophylaxis. J Bone Joint Surg Am. 2021 Apr 7;103(7):609-617
Level of Evidence: Level II

Scientific Literature Review
Reviewed By: Rebecca R. Calder, DPM
Residency Program: MetroWest Medical Center - Framingham, MA
Podiatric Relevance: Gustilo-Anderson classification is the most widely taught approach for prescribing antibiotics following open fractures despite originating from a 1976 study. A study by the Eastern Association for the Surgery of Trauma in 2011 generalized their recommendations to gram-positive versus gram-negative coverage for fracture types I and II rather than specific antibiotics, and recommended that antibiotics should be stopped within 72 hours from injury or 24 hours after soft-tissue coverage is achieved in Type-III fractures. This leaves a lot of ambiguity with antibiotic type and duration regimens. With outdated studies and recognition of side effects with the use of aminoglycosides as well as the increase of MRSA, there is question if the widely accepted Gustilo-Anderson guidelines are still being followed or is there a new common trend?
Methods: A total of 1,234 patient cases were evaluated as part of a sub study of two multicenter randomized controlled trials involving 24 medical centers in the US and Canada which looked at antiseptic skin solutions in orthopedic trauma. Inclusion criteria was 18 years of age and older who underwent ORIF of an open fracture.  Gustilo and OTA classifications were recorded, and data were collected prospectively including initial debridement, fracture fixation, type of wound closure and antibiotic use and duration. Prophylactic antibiotic use was defined as starting the same day as admission.
Results: All patients received antibiotics on the day of admission with the most common being cefazolin (92 percent), ceftriaxone (17.6 percent), and gentamicin (8.3 percent). The most common regimen was cefazolin monotherapy (53.6 percent). In all, fifty-four different combinations of prophylactic antibiotics were prescribed. In Type-I and Type-II Gustilo classification, cefazolin monotherapy was the most prescribed (61.1 percent). In Type-III Gustilo classification, cefazolin monotherapy was also the most prescribed (44.5 percent) with the traditional regimen being prescribed at 17.2 percent. With respect to antibiotic duration, the median was two days following wound closure regardless of Gustilo classification.  
Conclusions: Overall, there was moderate adherence to traditional guidelines for Gustilo I and II fractures and low adherence for Type-III fractures. It was found even with alternative antibiotics considered; almost half Type-III Gustilo classification fractures did not receive gram-negative coverage. The authors concluded this could be due to a focus now on treating MRSA infections with open fractures observed in the literature. They also concluded regions and seasons altering an antibiotic regimen and cases should possibly be customized when choosing antibiotics. Although most patients in the study received antibiotics for two days, 25 percent received antibiotics four to 15 days. Therefore, larger studies involving duration should be performed to help determine an algorithm for prescribing. This article leaves ambiguity with current regimens and it may be best to continue following the evidence found in popular historical studies until new studies are published.

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