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Open Fractures: Are We Still Treating the Same Types of Infections?
Jack D Sudduth1, James A Moss2, Clay A Spitler1
1Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, Mississippi, USA.
Abstract:
To analyze the rate of methicillin-resistant Staphylococcus aureus (MRSA), gram-negative, and polymicrobial infections in open fractures, measure the efficacy of the current open fracture antibiotic regimen against these infections, identify the most effective agent(s) to cover these infections, and analyze risk factors for infection. We examined retrospectively 451 patients with open fractures from January 2008 to December 2012 who were treated at our facility. Positive cultures during surgical debridement after wound closure defined an infection. Infecting organisms and their antibiotic sensitivities were identified through microbiology culture reports. Rates of MRSA, gram-negative, and polymicrobial infections were determined. The efficacy of the current regimen (cefazolin and gentamicin) was calculated against gram-positive and gram-negative organisms. Efficacy profiles against infectious organisms were calculated for all commonly tested antibiotics. Patient factors, injury characteristics, and treatment options were analyzed to determine risk factors for infection. Ninety patients (20%) were identified as infected at surgical debridement. Of those 90, 21 (23.3%) were diagnosed with MRSA, 56 (62.2%) were found to have a gram-negative infection, and 46 (51.1%) had polymicrobial infections. Cephalosporins and β-lactam agents had a 59.2% efficacy rate against gram-positive bacteria and gentamicin showed a 94% sensitivity rate against gram-negative bacteria. Vancomycin (95.8% sensitivity) demonstrated the highest sensitivity for all gram-positive organisms. Amikacin (98.8% sensitivity), meropenem (96.3% sensitivity), and gentamicin (94.2% sensitivity) demonstrated excellent efficacy for all gram-negative organisms. Immuno-compromised status and Gustilo-Anderson type were the only independently predictive risk factors for infection in a multivariable model. Based on this analysis, the rate of MRSA, gram-negative, and polymicrobial infections in open fractures is high and increasing compared with historical cohorts. With the sensitivity of early generation cephalosporins being relatively poor against gram-positive organisms, the present antibiotic regimen for open, long-bone fractures may need to be reconsidered with these emerging trends.
Insights
Infections from methicillin-resistant Staphylococcus aureus (MRSA), gram-negative, and polymicrobial bacteria are increasing in open fractures. Current antibiotic regimens may require updates due to emerging resistance patterns.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Pharmacology
Background:
- Open fractures present a significant risk for bacterial infections, including methicillin-resistant Staphylococcus aureus (MRSA), gram-negative, and polymicrobial strains.
- Current antibiotic prophylaxis protocols for open fractures are based on historical susceptibility data and may not reflect current trends.
Purpose of the Study:
- To analyze the incidence of MRSA, gram-negative, and polymicrobial infections in open fractures.
- To evaluate the efficacy of the standard antibiotic regimen against these pathogens.
- To identify optimal antibiotic agents and risk factors for infection.
Main Methods:
- Retrospective analysis of 451 patients with open fractures treated between 2008 and 2012.
- Infections defined by positive cultures during surgical debridement.
- Microbiology reports used to identify organisms and antibiotic sensitivities.
- Multivariable analysis to determine risk factors for infection.
Main Results:
- A 20% infection rate was observed, with 23.3% MRSA, 62.2% gram-negative, and 51.1% polymicrobial infections.
- Standard cephalosporins showed limited efficacy (59.2%) against gram-positive bacteria; vancomycin demonstrated high sensitivity (95.8%).
- Amikacin, meropenem, and gentamicin showed high efficacy against gram-negative bacteria.
- Immunocompromised status and Gustilo-Anderson fracture type were significant risk factors.
Conclusions:
- The rates of MRSA, gram-negative, and polymicrobial infections in open fractures are high and increasing.
- The current antibiotic regimen's efficacy against gram-positive organisms is suboptimal.
- Reconsideration of the antibiotic prophylaxis strategy for open fractures is warranted based on current microbiological trends.
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