D. A. Zuelzer, G. S. Hautala, R. R. Mayer, C. A. Jacobs, R. D. Wright, E. S. Moghadamian, P. E. Matuszewski, Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA.
C. B. Hayes, Department of Orthopaedic Surgery, University of California-Davis, CA, USA.
Clin Orthop Relat Res. 2021 Mar 1;479(3):613-619. doi: 10.1097/CORR.0000000000001507.
Early administration of antibiotics and wound coverage have been shown to decrease the deep infection risk in all patients with Type 3 open tibia fractures. However, it is unknown whether early antibiotic administration decreases infection risk in patients with Types 1, 2, and 3A open tibia fractures treated with primary wound closure.
QUESTIONS/PURPOSES: (1) Does decreased time to administration of the first dose of antibiotics decrease the deep infection risk in all open tibia fractures with primary wound closure? (2) What patient demographic factors are associated with an increased deep infection risk in Types 1, 2, and 3A open tibia fractures with primary wound closure?
We identified 361 open tibia fractures over a 5-year period at a Level I regional trauma center that receives direct admissions and transfers from other hospitals which produces large variation in the timing of antibiotic administration. Patients were excluded if they were younger than 18 years, had associated plafond or plateau fractures, associated with compartment syndrome, had a delay of more than 24 hours from injury to the operating room, underwent repeat débridement procedures, had incomplete data, and were treated with negative-pressure dressings or other adjunct wound management strategies that would preclude primary closure. Primary closure was at the descretion of the treating surgeon. We included patients with a minimum follow-up of 6 weeks with assessment at 6 months and 12 months. One hundred forty-three patients with were included in the analysis. Our primary endpoint was deep infection as defined by the CDC criteria. We obtained chronological data, including the time to the first dose of antibiotics and time to surgical débridement from ambulance run sheets, transferring hospital records, and the electronic medical record to answer our first question. We considered demographics, American Society of Anesthesiologists classification, mechanism of injury, smoking status, presence of diabetes, and Injury Severity Score in our analysis of other factors. These were compared using one-way ANOVA, chi-square, or Fisher's exact tests. Binary regression was used to to ascertain whether any factors were associated with postoperative infection. Receiver operator characteristic curves were used to identify threshold values.
Increased time to first administration of antibiotics was associated with an increased infection risk in patients who were treated with primary wound closure; the greatest inflection point on that analysis occurred at 150 minutes, when the increased infection risk was greatest (20% [8 of 41] versus 4% [3 of 86]; odds ratio 5.6 [95% CI 1.4 to 22.2]; p = 0.01). After controlling for potential confounding variables like age, diabetes and smoking status, none of the variables we evaluated were associated with an increased risk of deep infection in Type 1, 2, and 3A open tibia fractures in patients treated with primary wound closure.
Our findings suggest that in open tibia fractures, which receive timely antibiotic administration, primary wound closure is associated with a decreased infection risk. We recognize that more definitive studies need to be performed to confirm these findings and confirm feasibility of early antibiotic administration, especially in the pre-hospital context.
Level III, therapeutic study.
在所有 3 型开放性胫骨骨折患者中，早期应用抗生素和伤口覆盖已被证明可降低深部感染风险。然而，目前尚不清楚在接受一期伤口闭合治疗的 1 型、2 型和 3A 型开放性胫骨骨折患者中，早期应用抗生素是否会降低感染风险。
问题/目的：(1) 第一剂抗生素的给药时间缩短是否会降低所有一期伤口闭合的开放性胫骨骨折的深部感染风险？(2) 在接受一期伤口闭合治疗的 1 型、2 型和 3A 型开放性胫骨骨折患者中，哪些患者的人口统计学因素与深部感染风险增加有关？
我们在一家一级区域创伤中心确定了 361 例开放性胫骨骨折，该中心直接接收来自其他医院的转诊患者，这导致抗生素给药时间存在很大差异。如果患者年龄小于 18 岁、合并颅底或平台骨折、合并筋膜间室综合征、受伤后到手术室的时间超过 24 小时、接受重复清创术、数据不完整、接受负压敷料或其他辅助伤口管理策略治疗（这会排除一期闭合），则将其排除在外。一期闭合由治疗医生决定。我们纳入了至少随访 6 周的患者，在 6 个月和 12 个月进行评估。分析中纳入了 143 例患者。我们的主要终点是根据 CDC 标准定义的深部感染。我们从救护车运行表、转院记录和电子病历中获取时间数据，包括第一剂抗生素的时间和手术清创的时间，以回答我们的第一个问题。我们在分析其他因素时考虑了人口统计学、美国麻醉师协会分类、损伤机制、吸烟状况、糖尿病存在情况和损伤严重程度评分。使用单因素方差分析、卡方检验或 Fisher 确切检验进行比较。二元回归用于确定是否有任何因素与术后感染有关。接收者操作特征曲线用于确定阈值值。
在接受一期伤口闭合治疗的患者中，抗生素首次给药时间的延长与感染风险的增加有关；在该分析中，最大的拐点发生在 150 分钟时，此时感染风险最大（20%[41 例中的 8 例] vs. 4%[86 例中的 3 例]；比值比 5.6[95%CI 1.4 至 22.2]；p=0.01）。在控制年龄、糖尿病和吸烟状况等潜在混杂变量后，我们评估的变量中没有一个与接受一期伤口闭合治疗的 1 型、2 型和 3A 型开放性胫骨骨折患者的深部感染风险增加有关。
我们的研究结果表明，在及时给予抗生素的开放性胫骨骨折中，一期伤口闭合与降低感染风险有关。我们认识到，需要进行更具确定性的研究来证实这些发现，并证实早期应用抗生素的可行性，尤其是在院前环境中。
III 级，治疗性研究。
