AAST 2013: Practice Guideline For Open Fractures

Evidence based guidelines continue to be part of the practice of medicine. They seek to standardize what we trauma professionals do to manage common clinical problems. A new orthopedic guideline was evaluated at the University of Michigan and the results are being reported at the upcoming AAST meeting in San Francisco.

There is considerable variation in the management of open fractures, ranging from timing of washout/repair, grading, and antibiotic management. The U of M group standardized the way they administered antibiotics in these patients. They implemented a protocol as follows:

  • Gustilo Grade I or II – cefazolin for 48 hours (clindamycin if allergic)
  • Gustilo Grade III – ceftriaxone for 48 hours (clinda or aztreonam if allergic)
  • No aminogyclosides, penicillin or vancomycin

They studied their results in 174 patients with open femur or tib/fib fractures (101 pre-protocol and 73 post; one apparently had both areas fractured). Risk adjusted surgical infection rates were calculated using the National Health Safety Index risk index, which is calculated using the ASA score, the wound classification, and the duration of the operative procedure. 

Here are the factoids:

  • The use of aminoglycosides and vancomycin decreased from 54% to 16%
  • Skin and soft tissue infection rates were not different (21% pre and 25% post)
  • People did not change their fracture grading to “game” the system
  • Infections with antibiotic resistant organisms or MRSA were similar in the two groups
  • The authors did not report time to operation in these open fractures

Bottom line: This is a good first shot at standardizing antibiotic use in patients with open fractures. The numbers are very small, and time to OR was not taken into account. Whereas the 8 hour rule for open fractures was dogma and has pretty much been discounted, antibiotic use is a case of “every man for himself.” It is important to continue this work, because I’m sure there will be cost and education benefits from following a protocol like this. More numbers need to be generated, and anyone who adopts this protocol now needs to closely watch their soft tissue and bone infection results in their PI process.

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Reference: Evidence-based protocol for prophylactic antibiotics in open fractures: improved antibiotic stewardship with no increase in infection rates. AAST 2013 Paper 62.

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