Helbig Lars, Bechberger Maren, Aldeeri Riyadh, Ivanova Adriana, Haubruck Patrick, Miska Matthias, Schmidmaier Gerhard, Omlor Georg W
Department of Orthopaedics, Trauma Surgery and Paraplegiology.
Pharmacy Department, Heidelberg University Hospital, Heidelberg, Germany.
Ther Clin Risk Manag. 2018 Jan 4;14:59-67. doi: 10.2147/TCRM.S152008. eCollection 2018.
Infected nonunions of the long bones belong to the most feared complications in the field of orthopedic and trauma surgery. Optimal antibiotic therapy should start early with the first revision surgery. Therefore, the aim of this study was to evaluate our peri- and postoperative antibiotic regime in context with the microbial spectrum and antibiotic resistances of patients with infected nonunions and to assess the possible impact on healing rates.
We included all patients with first revision surgery during 2010-2015 due to nonunion of long bones with a clinical history of infection treated with radical debridement, local application of a gentamicin-impregnated bone cement, and systemic cefuroxime. Mean follow-up was 34.2 months. Data collection was performed retrospectively using a computerized databank with information about microbial species from intraoperatively acquired tissue samples and respective antibiograms. Bone fusion rates were evaluated based on findings of the latest X-rays and computed tomography scans.
Two hundred and twelve patients with nonunion and history of infection were selected; 171 patients had positive intraoperative microbial evidence of infection. Bacterial testing was mostly positive in fractures of the tibia (47.4%) and the femur (27.5%). Coagulase-negative spp. were the most frequently detected (44.4%) followed by mixed infections (18.7%) and (10.5%). Antibiograms revealed that 62.6% of our cases were cefuroxime sensitive; 87.7% were gentamicin sensitive. Only 10.5% showed resistance to both cefuroxime and gentamicin. There was no statistically significant difference of fusion rates between patients with different microbial species or different antibiograms.
Our data suggest that besides the high variety of different detected species, initial antibiotic treatment with a combination of systemic cefuroxime and local gentamicin-loaded bone cement is effective and in almost 90% the later determined microbial infection was sensitive to this treatment. Therefore, we recommend initial treatment according to this algorithm until specific antibiograms are available from intraoperatively acquired tissue samples.
长骨感染性骨不连是骨科和创伤外科领域最令人担忧的并发症之一。最佳抗生素治疗应在首次翻修手术时尽早开始。因此，本研究的目的是结合感染性骨不连患者的微生物谱和抗生素耐药性，评估我们的围手术期和术后抗生素方案，并评估其对愈合率的可能影响。
我们纳入了2010年至2015年期间因长骨骨不连且有感染临床病史而接受首次翻修手术的所有患者，这些患者接受了彻底清创、局部应用庆大霉素骨水泥和全身使用头孢呋辛治疗。平均随访时间为34.2个月。使用计算机数据库进行回顾性数据收集，该数据库包含术中获取的组织样本的微生物种类信息和相应的抗菌谱。根据最新的X线和计算机断层扫描结果评估骨融合率。
选择了212例有骨不连和感染病史的患者；171例患者术中微生物感染证据呈阳性。细菌检测在胫骨骨折（47.4%）和股骨骨折（27.5%）中大多呈阳性。凝固酶阴性菌是最常检测到的（44.4%），其次是混合感染（18.7%）和金黄色葡萄球菌（10.5%）。抗菌谱显示，我们的病例中有62.6%对头孢呋辛敏感；87.7%对庆大霉素敏感。只有10.5%对头孢呋辛和庆大霉素均耐药。不同微生物种类或不同抗菌谱的患者之间的融合率没有统计学显著差异。
我们的数据表明，除了检测到的不同种类繁多外，全身应用头孢呋辛和局部应用含庆大霉素的骨水泥联合进行初始抗生素治疗是有效的，并且在近90%的病例中，后来确定的微生物感染对这种治疗敏感。因此，我们建议根据该方案进行初始治疗，直到从术中获取的组织样本中获得特定的抗菌谱。
