McMurtrie Thompson, Prather John, Cone Ryan, Montgomery Tyler, Patel Chirag, McGwin Gerald, Spitler Clay
Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.
Surg Infect (Larchmt). 2021 Sep;22(7):662-667. doi: 10.1089/sur.2020.300. Epub 2020 Oct 16.
Responsible antibiotic stewardship requires surgeons treating open fractures to use the narrowest appropriate antibiotic coverage possible to prevent infection. Because inter-observer agreement about the application of the Gustilo-Anderson open fracture classification is moderate at best, antibiotic selection can be overly aggressive. The purpose of this study was to evaluate the outcomes of Type II open fractures treated with gram-positive coverage only (GP) versus broad-spectrum antibiotic coverage (BS) with piperacillin-tazobactam (PT). A retrospective review of all Type II open fractures was performed at a single Level one trauma center over a 5-year period (2013-2017). All patients received prophylactic antibiotics on arrival on the basis of the best judgment of classification by the house officer on call. The final Gustilo-Anderson open fracture classification was assigned intra-operatively by the operating surgeon. Two groups were created, a GP antibiotic group (cefazolin and/or clindamycin) and a BS group (PT). A minimum of 3-month follow-up was required for inclusion. Patient demographics, cost of treatment, fracture-related infection (FRI) rates, and infecting bacteria were assessed. The GP group contained 70 open fractures and the BS group contained 74 open fractures. Between the groups, there were no differences in age, sex, race, Body Mass Index, American Society of Anesthesiologists Class, or smoking status. There were no statistical differences in Injury Severity Score (ISS), fracture location, fixation method, or rates of staged management with external fixation. There was no difference in FRI rate between the GP and BS groups (8.6% versus 10.8%; p = 0.78). The bacteria responsible for FRI were similar in the GP and BS groups. The hospital charge for PT was 4.39 × the cost of cefazolin. The use of BS coverage in Type II open fractures does not result in a lower infection rate and adds significant cost to patient care. These data support the use of a GP-only antibiotic regimen for Type II open fractures.
负责任的抗生素管理要求治疗开放性骨折的外科医生尽可能使用最窄谱的合适抗生素覆盖范围来预防感染。由于观察者之间对 Gustilo-Anderson 开放性骨折分类应用的一致性充其量只是中等程度，抗生素选择可能会过于激进。本研究的目的是评估仅采用革兰氏阳性菌覆盖（GP）与使用哌拉西林-他唑巴坦（PT）进行广谱抗生素覆盖（BS）治疗Ⅱ型开放性骨折的结果。在一个一级创伤中心对 5 年期间（2013 - 2017 年）所有Ⅱ型开放性骨折进行了回顾性研究。所有患者在到达时根据值班住院医生对分类的最佳判断接受预防性抗生素治疗。最终的 Gustilo-Anderson 开放性骨折分类由主刀医生在术中确定。创建了两组，一组为 GP 抗生素组（头孢唑林和/或克林霉素），另一组为 BS 组（PT）。纳入研究要求至少随访 3 个月。评估了患者人口统计学特征、治疗费用、骨折相关感染（FRI）率和感染细菌。GP 组包含 70 例开放性骨折，BS 组包含 74 例开放性骨折。两组之间在年龄、性别、种族、体重指数、美国麻醉医师协会分级或吸烟状况方面没有差异。在损伤严重程度评分（ISS）、骨折部位、固定方法或外固定分期处理率方面没有统计学差异。GP 组和 BS 组的 FRI 率没有差异（8.6%对 10.8%；p = 0.78）。GP 组和 BS 组中导致 FRI 的细菌相似。PT 的住院费用是头孢唑林费用的 4.39 倍。对Ⅱ型开放性骨折使用 BS 覆盖范围并不会降低感染率，反而会给患者护理增加显著成本。这些数据支持对Ⅱ型开放性骨折仅使用 GP 抗生素方案。
