革兰氏阴性骨折相关感染的危险因素及感染表现

Risk Factors and Infection Presentation of Gram-Negative Fracture Related Infections.

作者信息

Benson Elizabeth M, Rutz Robert W, Atkins Austin C, Carter Karen J, Gross Evan G, Yeager Matthew, Johnson Joseph P, Spitler Clay A

机构信息

University of Alabama Department of Orthopaedic Surgery Birmingham, AL.

出版信息

J Orthop Trauma. 2025 Apr 7. doi: 10.1097/BOT.0000000000002981.

OBJECTIVE

To assess factors associated with gram-negative (GN) fracture related infections (FRIs) and the impact of GN infections in treatment and outcomes in FRIs.

METHODS

Design: Retrospective cohort.

SETTING

Single Level I Trauma Center.

PATIENT SELECTION CRITERIA

All patients with extremity FRIs between 2013-2020.

OUTCOME MEASURES AND COMPARISONS

A univariate analysis of FRI bacteriology was conducted in two manners. Two group analysis compared Any GN (AGN) to Gram-positive (GP) only (GPO) FRIs . Three group analysis compared Gram-negative only (GNO) vs. GPO vs. Polymicrobial GN including GP (PGN) FRIs.

RESULTS

299 patients met inclusion criteria. The mean age was 45.59 (18-92), and 187 (62.5%) were male. 76 (25%) patients had a GN microbe on intraoperative culture. In the AGN vs. GPO comparison, there were more male GN FRI patients (AGN=74% vs. GPO=59%, p=0.02). Cardiovascular disease was less common in AGN FRI patients (AGN=17% vs. GPO=30%, p=0.028). Multisystem trauma (AGN=67% vs. GPO=50%, p=0.014), external fixation (AGN=50%, vs. GPO=33%, p=0.014), skin grafting (AGN=27% vs. GPO=15%, p=0.045) and flap coverage (AGN=32% vs. GPO=16%, p=0.011) were more common in the AGN FRI. AGN FRI patients had more sinus tracts on presentation (AGN=42% vs. GPO=27%, p=0.013) and higher rates of amputation (AGN=15% vs. GPO=6%, p=0.021. Nonunion rates did not differ between the groups (AGN=20% vs. GPO=22%, p=0.731). Total number of reoperations needed for infection clearance was similar between AGN (3.5 +/-2.7) and GPO (2.9 +/-2.5) FRIs (p=0.068). The 3-group comparison was performed between the following groups (GNO, GPO, PGN). Post-hoc analysis of the 3-group analysis demonstrated PGN infections had no significant differences from GNO FRI in regard to injury characteristics (lower extremity, polytrauma), surgical characteristics (external fixation, flap coverage) and sinus tract formation.

CONCLUSION

Male sex, multi-system trauma, external fixation, and need for flap coverage or skin graft were associated with gram negative FRIs. Nonunion rates were similar between Gram-negative vs. Gram-positive only or Gram-negative vs. polymicrobial including Gram-negative FRIs. In comparison to patients with Gram-positive only FRI, any Gram-negative FRI led to a higher rate of amputation.

LEVEL OF EVIDENCE

III.

目的

评估与革兰氏阴性（GN）骨折相关感染（FRI）相关的因素，以及GN感染对FRI治疗和预后的影响。

方法

设计：回顾性队列研究。

地点

单一的一级创伤中心。

患者选择标准

2013年至2020年间所有患有四肢FRI的患者。

结果测量与比较

对FRI细菌学进行单因素分析，采用两种方式。两组分析将任何革兰氏阴性（AGN）与仅革兰氏阳性（GP）（GPO）FRI进行比较。三组分析将仅革兰氏阴性（GNO）与GPO以及包括GP的混合性革兰氏阴性（PGN）FRI进行比较。

结果

299例患者符合纳入标准。平均年龄为45.59岁（18 - 92岁），男性187例（62.5%）。76例（25%）患者术中培养出GN微生物。在AGN与GPO的比较中，男性GN FRI患者更多（AGN = 74% vs. GPO = 59%，p = 0.02）。心血管疾病在AGN FRI患者中较少见（AGN = 17% vs. GPO = 30%，p = 0.028）。多系统创伤（AGN = 67% vs. GPO = 50%，p = 0.014）、外固定（AGN = 50%，vs. GPO = 33%，p = 0.014）、植皮（AGN = 27% vs. GPO = 15%，p = 0.045）和皮瓣覆盖（AGN = 32% vs. GPO = 16%，p = 0.011）在AGN FRI中更常见。AGN FRI患者就诊时窦道更多（AGN = 42% vs. GPO = 27%，p = 0.013），截肢率更高（AGN = 15% vs. GPO = 6%，p = 0.021）。两组间骨不连发生率无差异（AGN = 20% vs. GPO = 22%，p = 0.731）。AGN（3.5 ± 2.7）和GPO（2.9 ± 2.5）FRI清除感染所需再次手术的总数相似（p = 0.068）。在以下组（GNO、GPO、PGN）之间进行三组比较。三组分析的事后分析表明，PGN感染在损伤特征（下肢、多发伤）、手术特征（外固定、皮瓣覆盖）和窦道形成方面与GNO FRI无显著差异。

结论

男性、多系统创伤、外固定以及需要皮瓣覆盖或植皮与革兰氏阴性FRI相关。革兰氏阴性与仅革兰氏阳性或革兰氏阴性与包括革兰氏阴性的混合性FRI之间骨不连发生率相似。与仅革兰氏阳性FRI患者相比，任何革兰氏阴性FRI导致更高的截肢率。

证据级别

III级。