Time to intravenous antibiotic administration (TIbiA) in severe open tibial fractures: Impact of change to national guidance

Abstract

Introduction Severe open tibial fractures are limb-threatening injuries. Outcomes depend on a complex interplay of patient, injury and treatment factors. 2009 guidelines from the British Orthopaedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) recommend prophylactic intravenous antibiotic administration within three hours of injury. More recent National Institute for Health and Care Excellence (NICE) 2016 guidelines recommend pre-hospital antibiotic administration where possible. This study aimed to analyse the impact of time to antibiotics on development of deep infection. Methods Adult acute Gustilo-Anderson 3B open tibial fractures managed at a single UK Major Trauma Centre were reviewed retrospectively over a three-year period, including a period before and after the regional ambulance service introduced a policy of administering prehospital intravenous antibiotics to open fractures in 2016. Development of deep infection was recorded as the primary outcome measure. Complete case regression analysis was performed. Time was assessed as a continuous variable and as thresholds with antibiotics received within one or three hours of injury. Results 156 patients with 159 fractures were included. Following introduction of new guidance in 2016, median time to antibiotics decreased from 180 to 160 minutes and more patients received pre-hospital antibiotics (2% vs. 33%). Overall, 7.5% developed deep infection (n=12) within a median follow-up of 26 months. Logistic regression found no relationship between any independent variable, including time to antibiotic administration, and development of deep infection. Conclusions There are a variety of factors identified in the literature and in national policies and treatment guidelines as potentially modifiable to reduce the risk of deep infection following open fractures. In this study, time to antibiotic administration was not associated with the risk of developing deep infection. The results of this study demonstrate a low infection rate, which may be due to expedient expert care delivered by a dedicated orthoplastic service in line with national guidance where achievable.

Practical Guidelines for the Orthoplastic Approach: A Systematic Review of High-Quality Evidence for the Lower Extremity Trauma

“…Details about the selection process are outlined in the owchart [Figure 1]. Regarding the surgical treatment of lower extremity open fractures, 15 cohort studies [9,[11][12][13][14][15][16][17][18][19][20][21][22][23][24], ve clinical trials [25][26][27][28][29] and eight systematic reviews with meta-analysis [30][31][32][33][34][35][36][37][38] were included. About the role of the negative pressure wound therapy (NPWT), ve cohort studies [39][40][41][42][43], seven clinical trials [10,[44][45][46][47][48][49] and three systematic reviews with meta-analysis [50][51][52] were included.…”

Why Has the Outcome of Gustilo-Anderson Type III Fracture Not Improved over Two Decades?

“…The average prevalence of GAIIIB fractures was 28.4% in 2000-2009 and 25.1% in 2010-2022, with no significant differences between the periods 1,5,7,12,13,15,17,[19][20][21][22][23][24][25] .…”

“…However, the evidence reported by You et al in 2020 recommends that the first debridement be performed within 24 h of injury 33) . Hendrickson et al examined infection rates in 112 patients admitted to 4 major trauma centers, of whom 38% (n = 44) received primary debridement within 12 h and 90% within 24 h. The incidence of infectious complications with debridement before and after 12 hours was 4.5 vs. 5.6%, respectively, with no significant difference between the two groups 25) . Rymer et al reported that 84 patients with open leg fractures were referred to university hospitals, and 83 (98.8%) underwent initial debridement within 24 h. Of these, half underwent their first surgery outside normal working hours 34) .…”

Tibial bone and soft-tissue concentrations following combination therapy with vancomycin and meropenem – evaluated by microdialysis in a porcine model

“…Treatment of open tibial fractures includes appropriate and prompt antibiotic treatment (within three hours), 22 , 23 surgical debridement, irrigation, bone stabilization, and fast and sufficient soft-tissue coverage. 24 When considering the high infection rates, the diversity of the encountered bacteria and the devastating consequences, e.g.…”