Schrank Gregory M, Jozefowski Nicolas, Zura Robert D, Jeray Kyle J, Gary Joshua L, Gaski Greg E, Shannon Steven F, Bzovsky Sofia, Sprague Sheila, Slobogean Gerard P, Levack Ashley E
Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland.
Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois.
J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):28-35. doi: 10.2106/JBJS.24.01178.
We evaluated antimicrobial resistance (AMR) patterns following local antibiotic use in a large cohort of patients with fractures from the PREP-IT (A Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma) study. We hypothesized that, among patients with extremity fractures who developed fracture-related infection (FRI), there would be no difference in AMR rates between those who had or had not received local antibiotic therapy with surgical fixation.
This was a secondary analysis of all patients in the PREP-IT trial who developed FRI. Patient demographics, injury and fracture characteristics, and the primary outcome of the presence of an antimicrobial-resistant FRI were evaluated on the basis of whether the patient had or had not received local antibiotics in the operating room prior to, or at, definitive fixation.
A total of 555 FRIs in 546 patients (mean age, 50 years; 39% female; and 82% White) were included. A total of 268 fractures (264 patients) received local antibiotics. The Injury Severity Score and the proportion of open fractures were higher among patients and fractures that received local antibiotics, respectively. There were more Gustilo-Anderson type-IIIB or IIIC fractures in the local antibiotic group, but the rate did not differ significantly from that in the group with no local antibiotics (20% versus 14%; p = 0.14). Other baseline and fracture characteristics were similar between the groups, with the exception of age (lower in the group with local antibiotics). When examining FRIs with gram-positive organisms, we found that 3 (1.7%) of the FRIs in fractures that had been treated with local vancomycin had organisms resistant to vancomycin compared with 2 (0.9%) of the FRIs in fractures for which local vancomycin had not been used (p = 0.67). When examining FRIs with gram-negative organisms, the number of FRIs with aminoglycoside-resistant organisms was 8 (11.6%) among fractures that received local aminoglycosides and 10 (6.2%) among fractures that did not receive local aminoglycosides (p = 0.26).
Among extremity fractures that developed FRI, we were unable to detect differences in the rates of AMR between fractures treated with or without local antibiotic prophylactic strategies in our analysis of a randomized trial of various skin preparation solutions for extremity trauma surgery. These findings provide cautious reassurance regarding the safety of local antibiotics but underscore the need for further prospective analysis.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
我们在PREP-IT（一项评估骨科创伤术前抗菌皮肤溶液的随机试验项目）研究中的一大群骨折患者中，评估了局部使用抗生素后的抗菌药物耐药性（AMR）模式。我们假设，在发生骨折相关感染（FRI）的四肢骨折患者中，接受或未接受手术固定时局部抗生素治疗的患者之间，AMR率没有差异。
这是对PREP-IT试验中所有发生FRI的患者进行的二次分析。根据患者在确定性固定之前或之时在手术室是否接受局部抗生素治疗，评估患者的人口统计学、损伤和骨折特征，以及抗菌药物耐药性FRI存在的主要结局。
共纳入546例患者的555例FRI（平均年龄50岁；39%为女性；82%为白人）。共有268处骨折（264例患者）接受了局部抗生素治疗。接受局部抗生素治疗的患者和骨折中，损伤严重程度评分和开放性骨折的比例分别更高。局部抗生素组中Gustilo-Anderson IIIB型或IIIC型骨折更多，但与未使用局部抗生素的组相比，该比例差异无统计学意义（20%对14%；p = 0.14）。除年龄外（局部抗生素组年龄较低），两组之间的其他基线和骨折特征相似。在检查革兰氏阳性菌引起的FRI时，我们发现接受局部万古霉素治疗的骨折中，有3例（1.7%）FRI的病原体对万古霉素耐药，而未使用局部万古霉素的骨折中，有2例（0.9%）FRI的病原体对万古霉素耐药（p = 0.67）。在检查革兰氏阴性菌引起的FRI时，接受局部氨基糖苷类药物治疗的骨折中，对氨基糖苷类药物耐药的FRI有8例（11.6%），未接受局部氨基糖苷类药物治疗的骨折中有10例（6.2%）（p = 0.26）。
在我们对一项针对四肢创伤手术的各种皮肤准备溶液的随机试验分析中，在发生FRI的四肢骨折中，我们未能检测到采用或未采用局部抗生素预防策略治疗的骨折之间AMR率的差异。这些发现为局部抗生素的安全性提供了谨慎的保证，但强调了进一步进行前瞻性分析的必要性。
治疗性III级。有关证据水平的完整描述，请参阅作者须知。
