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Published on: March 3, 2023
Outcomes Associated with Choice of Prophylactic Antibiotics in Open Fractures
Carol A Lin1, Tim Kobes2, Eric Kholodovsky3
1Cedars Sinai Medical Center, Los Angeles, California.
Insights
Cefazolin monotherapy is a standard for open fracture antibiotic prophylaxis. Ceftriaxone did not improve outcomes for Type I/II fractures, while cefazolin plus gentamicin showed a trend toward reducing infection in Type III fractures.
Area of Science:
- Orthopedic Surgery
- Infectious Disease
- Pharmacology
Background:
- The optimal antibiotic prophylaxis for open fractures remains undetermined.
- This study evaluates outcomes associated with various antibiotic prophylaxis regimens in open fracture patients.
Purpose of the Study:
- To compare the efficacy of different antibiotic prophylaxis regimens in preventing surgical site infections (SSIs) and reoperations in open fracture patients.
- To analyze outcomes based on antibiotic choice and fracture severity (Gustilo-Anderson classification).
Main Methods:
- Secondary analysis of data from the PREP-IT study.
- Antibiotic prophylaxis defined as intravenous antibiotics on admission day.
- Outcomes assessed: SSI within 90 days, reoperation within 1 year.
- Statistical analysis included logistic regression and instrumental variable analysis to control for confounding factors.
- Subgroup analysis stratified by Gustilo-Anderson classification (Type I/II vs. Type III).
Main Results:
- 3,331 participants included; common regimens were cefazolin monotherapy (58%), ceftriaxone monotherapy (10%), and cefazolin plus gentamicin (6%).
- Instrumental variable analysis showed no significant difference in infection odds between ceftriaxone or cefazolin plus gentamicin versus cefazolin monotherapy overall.
- In Type I/II fractures, ceftriaxone showed a trend towards increased infection odds (OR 2.73, p=0.06) compared to cefazolin.
- In Type III fractures, cefazolin plus gentamicin showed a trend towards decreased infection odds (OR 0.25, p=0.19) compared to cefazolin monotherapy.
Conclusions:
- Ceftriaxone monotherapy offers no significant advantage over cefazolin monotherapy for preventing infection in Type I and II open fractures.
- Cefazolin plus gentamicin may potentially reduce infection risk in Type III open fractures, though this finding was not statistically significant.
- Current antibiotic prophylaxis strategies for open fractures require further investigation to establish optimal regimens based on fracture severity.
Background:
The ideal antibiotic prophylaxis for open fractures is unknown. We evaluated outcomes following different antibiotic prophylaxis regimens for open fractures.
Methods:
This is a secondary analysis of data from PREP-IT. Prophylactic antibiotics were defined as any intravenous antibiotic given on the day of admission. The outcomes were surgical site infection (SSI) within 90 days and reoperation within 1 year. Logistic regression and an instrumental variable analysis that leveraged site-level variation accounted for confounding. Subgroup variation was evaluated by stratifying by Gustilo-Anderson classification (Types I and II versus III).
Results:
Of the 3,331 included participants, the mean age was 45 ± 18 years, 63% were male, 73% were White, 21% were Black, 2% were Asian, and 10% were Hispanic. Cefazolin monotherapy (58% of patients), ceftriaxone monotherapy (10%), and cefazolin plus gentamicin (6%) were the most common regimens. In the instrumental variable analysis, the odds of infection did not significantly differ with ceftriaxone use (odds ratio [OR], 1.24; 95% confidence interval [CI], 0.70 to 2.20; p = 0.45) or cefazolin plus gentamicin use (OR, 0.25; 95% CI, 0.03 to 2.04; p = 0.20) compared with cefazolin monotherapy. There were no significant differences between the regimens with respect to infection when stratified by Gustilo-Anderson type. However, we did observe a nearly 3-fold increase in the odds of infection with ceftriaxone use compared with cefazolin monotherapy (OR, 2.73; 95% CI, 0.96 to 7.79; p = 0.06) in Type-I and II fractures, and a 75% decrease in the odds of infection with cefazolin plus gentamicin use (OR, 0.25; 95% CI, 0.03 to 2.02; p = 0.19) compared with cefazolin monotherapy in Type-III fractures.
Conclusions:
Among patients with open fractures, antibiotic prophylaxis with ceftriaxone monotherapy did not provide significant benefits compared with cefazolin monotherapy in preventing infection in Type-I and II fractures. The findings suggest that cefazolin plus gentamicin might reduce the odds of infection in Type-III fractures compared with cefazolin monotherapy, but this difference was not statistically significant.
Level Of Evidence:
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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