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Antibiotics and open fractures of the lower extremity: less is more

  • Original Article
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European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Purpose

Infectious complications in open lower extremity fractures contribute to significant morbidity. Historically, orthopedic guidelines have recommended Grade III fractures receive a first generation cephalosporin and an aminoglycoside. Despite these guidelines, few studies have evaluated the utility of adding an aminoglycoside in this patient population. At our trauma center, we have a unique trauma service where half of our surgeons treat Grade III open fractures with a cephalosporin alone and half use a cephalosporin + aminoglycoside. We hypothesized that our outcomes were the same between the two groups.

Methods

We identified all Grade III fractures of the lower extremity admitted to our urban Level I Trauma Center over the 5-year study period. Charts were retrospectively reviewed to identify demographic information, injury severity score (ISS), fracture location, grade of fracture, type of antibiotic administered, incidence of acute kidney injury (AKI), surgical site infection (SSI), hardware removal, hospital length of stay (HLOS), and disposition. Patients were classified into two groups: those treated with a cephalosporin alone (CEPH) or cephalosporin + an aminoglycoside (CEPH + AG).

Results

A total of 126 grade III fractures of the lower extremity were admitted our Trauma Center during the 5-year study period. There were 65 (52%) patients in the CEPH group and 61 (48%) in the CEPH + AG group. Demographics, ISS, fracture location, grade of fracture, rate of SSI, need for hardware removal, and disposition were not different between the two groups. In contrast, patients in the CEPH group had a 4% incidence of AKI, while the incidence was 10% of patients in the CEPH + AG group (p < 0.05).

Conclusion

The addition of an AG to antibiotic prophylaxis in open lower extremity fractures was associated with a significant increase in AKI with no change in the incidence of wound infection or hardware removal. Cephalosporins alone may be sufficient for prophylaxis in Grade III open fractures of the lower extremity. A large-scale prospective randomized trial is needed to confirm these findings and inform clinical practice.

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Abbreviations

ISS:

Injury severity score

ICU:

Intensive care unit

LOS:

Length of stay

SSI:

Surgical site infection

DSI:

Deep space infection

OSI:

Organ space infection

AKI:

Acute kidney injury

IM nail:

Intramedullary nail

ORIF:

Open reduction internal fixation

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Author information

Authors and Affiliations

  1. Department of Surgery-Graduate Medical Education, Methodist Dallas Medical Center, 1411 N. Beckley Ave, Dallas, TX, 75205, USA

    B. Bankhead-Kendall, T. Gutierrez, J. Murry & M. S. Truitt

  2. Department of Orthopedic Surgery, Methodist Dallas Medical Center, Dallas, TX, USA

    D. Holland

  3. Clinical Research Institute, Methodist Dallas Medical Center, Dallas, TX, USA

    V. Agrawal, K. Almahmoud & C. Pearcy

Authors
  1. B. Bankhead-Kendall
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  2. T. Gutierrez
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  3. J. Murry
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  4. D. Holland
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  5. V. Agrawal
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  6. K. Almahmoud
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  7. C. Pearcy
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  8. M. S. Truitt
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Corresponding author

Correspondence to T. Gutierrez.

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Conflict of interest

Brittany Bankhead-Kendall, Tim Gutierrez, Jason Murry, Danny Holland, Vaidehi Agrawal, Khalid Almahmoud, Christopher Pearcy, and Michael S. Truitt declare that they have no conflict of interests.

Statement of human and animal rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Informed consent

After IRB review, this study was deemed exempt from informed consent.

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Bankhead-Kendall, B., Gutierrez, T., Murry, J. et al. Antibiotics and open fractures of the lower extremity: less is more. Eur J Trauma Emerg Surg 45, 125–129 (2019). https://doi.org/10.1007/s00068-017-0847-x

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  • DOI: https://doi.org/10.1007/s00068-017-0847-x

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