The effect of local antibiotic prophylaxis when treating open limb fractures

Abstract

ObjectivesAs well as debridement and irrigation, soft-tissue coverage, and osseous stabilization, systemic antibiotic prophylaxis is considered the benchmark in the management of open fractures and considerably reduces the risk of subsequent fracture-related infections (FRI). The direct application of antibiotics in the surgical field (local antibiotics) has been used for decades as additional prophylaxis in open fractures, although definitive evidence confirming a beneficial effect is scarce. The purpose of the present study was to review the clinical evidence regarding the effect of prophylactic application of local antibiotics in open limb fractures.MethodsA comprehensive literature search was performed in PubMed, Web of Science, and Embase. Cohort studies investigating the effect of additional local antibiotic prophylaxis compared with systemic prophylaxis alone in the management of open fractures were included and the data were pooled in a meta-analysis.ResultsIn total, eight studies which included 2738 patients were eligible for quantitative synthesis. The effect of antibiotic-loaded poly(methyl methacrylate) beads was investigated by six of these studies, and two studies evaluated the effect of local antibiotics applied without a carrier. Meta-analysis showed a significantly lower infection rate when local antibiotics were applied (4.6%; 91/1986) than in the control group receiving standard systemic prophylaxis alone (16.5%; 124/752) (p < 0.001) (odds ratio 0.30; 95% confidence interval 0.22 to 0.40).ConclusionThis meta-analysis suggests a risk reduction in FRI of 11.9% if additional local antibiotics are given prophylactically for open limb fractures. However, due to limited quality, heterogeneity, and considerable risk of bias, the pooling of data from primary studies has to be interpreted with caution.Cite this article: M. Morgenstern, A. Vallejo, M. A. McNally, T. F. Moriarty, J. Y. Ferguson, S. Nijs, WJ. Metsemakers. Bone Joint Res 2018;7:447–456. The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis. DOI: 10.1302/2046-3758.77.BJR-2018-0043.R1

General treatment principles for fracture-related infection: recommendations from an international expert group

“…Local antibiotics may be particularly effective in chronic/late onset infections, where the perfusion of systemic antibiotic is greatly reduced due to chronic tissue scarring. A recent systematic review [76] of contaminated open fracture wounds showed a considerable risk reduction if additional local antibiotics were applied. Although PMMA was the most studied material, the prophylactic effect of absorbable carriers for local antibiotic delivery showed also promising results [76].…”

Management of the High Energy Traumatism of the Limbs

“…The drug of choice for local treatment has been pearl gentamicin, tobramycin and vancomycin; currently on the market are present many formulations, some of them are combinations with osteoinduction molecules. It has been observed a reduction by 11.9% of the risk of infection when local therapy has been added to certain wounds [41].…”

„Plate-assisted segmental bone transport“ mit Verlängerungsnagel und Platte

“…Das beinhaltet u. a. konsequente und ggf. wiederholte chirurgische Débridements, die Applikation von lokalen und systemischen Antibiotika, temporären Wundverschluss und andere Maßnahmen [10,11,20].…”

“…Motorisierte intramedulläre Verlängerungsnägel in Kombinationen mit anderen Entwicklungen und Fortschritten der muskuloskeletalen und Weichteilchirurgie haben die Möglichkeiten der rekonstruktiven Chirurgie in zahlreichen Bereichen stark erweitert, die bislang der externen Fixation vorbehalten waren [9][10][11][12].…”