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© Copyright 2000 Eastern Association For The Surgery Of Trauma www.east.org
EAST PRACTICE MANAGEMENT GUIDELINES WORK GROUP:
PRACTICE MANAGEMENT GUIDELINES FOR PROPHYLACTIC
ANTIBIOTIC USE IN OPEN FRACTURES
Fred A. Luchette, MD,1 Lawrence B. Bone, MD,2 Christopher T. Born, MD,3
William G. DeLong, Jr,3 MD, William S. Hoff, MD,3 Daniel Mullins, PhD,4
Francis Palumbo, PhD, JD,4 Michael D. Pasquale, MD5
1University of Cincinnati Medical Center, Cincinnati, OH
2State University of New York at Buffalo, Buffalo, NY
3University of Pennsylvania Health System, Philadelphia, PA
4University of Maryland School of Pharmacy, Baltimore, MD
5Lehigh Valley Hospital and Health Network, Allentown, PA
Address for Correspondence and Reprints:
Fred A. Luchette, MD
Department of Surgery ML-0558
231 Bethesda Avenue
Cincinnati, Ohio 45267-0558
Phone: (513)-558-5661
Fax: (513)-558-3136
E-mail:[email protected]
2
I. Statement of the Problem
Extremity fractures are caused by either low or high energy forces and may be isolated or
combined with other injuries. When the underlying fracture is associated with a cutaneous wound,
prevention of wound sepsis remains the primary objective in the management of the soft tissue.
There is universal agreement that these wounds require emergency treatment as soon as possible to
minimize infectious complications. To help standardize care and comparison of similar injuries in
studies, Gustilo et al.1 classified open fractures into three categories:
Grade (Type) I: Open fracture with a skin wound less than 1 cm long and clean.
Grade (Type) II: Open fracture with a laceration more than 1 cm long without extensive
soft tissue damage, flaps, or avulsions.
Grade (Type) III: Either an open segmental fracture, an open fracture with extensive soft
tissue damage, or a traumatic amputation.
In their review, the infection rate for type III open fractures was a major problem with an
incidence of 24%. Grade III fractures encompassed a wide range of soft tissue wounds and was felt
to be too imprecise for standardizing care and comparison. Thus, Gustilo further stratified these
wounds according to worsening prognosis with a wound sepsis rate as follows: IIIa - 4%; IIIb -
52%; IIIc - 42%.2
IIIa: Adequate soft tissue coverage of a fractured bone despite extensive soft tissue
laceration or flaps, or high energy trauma irrespective of the size of the wound.
IIIb: Extensive soft tissue injury loss with periosteal stripping and bone exposure, usually
associated with massive contamination.
IIIc: Open fractures associated with arterial injury requiring repair.
3
The importance of describing type III open fractures with this more accurate classification scheme
cannot be overstated. This A/B/C stratification also allows for subsequent upward revision for a
wound which evidences progressive soft tissue necrosis following initial evaluation. Although this
scoring system is the one most widely used for management decisions and comparison of results of
treatment among different series, a recent report has claimed that interobserver agreement is
moderate to poor and is case dependent.3
An appropriate management plan for open extremity fractures would include coverage with a
sterile dressing with gentle pressure applied as necessary to control bleeding. Splinting is carried out,
the patient is prophylaxed for tetanus and parenteral antibiotics are administered. Operative wound
care should be done under general or regional anesthesia as soon as the patient has been stabilized
and cleared for the operating room. Whenever possible, delays of more than six hours should be
avoided because of the increased risk of infection. Wound care should involve a thorough
debridement of devascularized muscle, fascia, subcutaneous tissue, skin, bone and all foreign
material. The importance of adequate surgical debridement can not be overemphasized in controlling
wound sepsis since antibiotics are only adjunctive therapy. Determination of the fracture grade
should be made at this time. The margins of the wound of compounding are extended as required for
debridement and appropriate stabilization of the fracture is effected. The wound is left open under a
sterile moisture retaining dressing. A “second-look” may be advisable at 24-48 hours with further
debridement if necessary. Ultimately, wound closure may be accomplished by delayed primary
closure, split thickness skin graft, local muscle flap rotation, or free tissue transfer with
microvascular anastomosis.
Various factors have been recognized as increasing the risk for infection: (1) failure to utilize
prophylactic antibiotics; (2) resistance of wound organisms to wound antibiotics; (3) increased time
4
from injury to initiation of antimicrobial agent and operative debridement; (4) extent of soft tissue
damage; (5) open tibial fractures; (6) positive post debridement-irrigation cultures; and (7) wound
closure in the presence of Clostridium perfringens. Other factors shown to have no effect include
the length of antibiotic treatment (3 versus 5 to 10 days) and type of wound closure. Stabilization is
now usually obtained by unreamed nailing or external fixation.4 Low infection rates have been
reported after severe open fractures treated by reamed intramedullary nailing.5 Dellinger et al.
performed a multivariate logistic regression analysis and identified local factors at the fracture site as
more significant risk factors for subsequent infection than Injury Severity Score (ISS), the
requirement for blood transfusion, the amount of blood transfused, or the presence of more than one
fracture.6
Norden found convincing evidence that antibiotics administered before incision reduced the
risk of infection after surgical stabilization of closed hip fractures or proximal femoral endoprosthetic
replacement.7 The group receiving antibiotics had a 78% lower rate of infection compared with
controls. This study was included in this review to demonstrate the role of prophylactic antibiotics
following orthopedic procedures for closed fractures. However, Norden did not address the role of
prophylactic antibiotics with regard to open fractures in which bacterial contamination is present
preoperatively in 48% to 60% of all wounds and 100% of severe wounds.
Dellinger provided an in depth report of prophylactic antibiotics in open fractures in 1991.8
He performed a detailed analysis of controlled trials in open fractures and the various studies
evaluating choices of antibiotics as well as duration of therapy for these extremity injuries.
Subsequent investigations have been carried out to analyze the impact of various antibiotic regimens
and the appropriate length of time for continuing therapy.15-17,22
II. Process
5
A. Identification of references
These recommended guidelines for prophylactic antibiotic usage for open fractures are
evidence-based. Articles were identified from the literature by independent searches performed by
two of the reviewers. One search was performed using OVID MEDLINE and covered the literature
from 1985 to 1997. Key words used in this search were “open fracture, antibiotics, prophylaxis, and
management”. References from 1975 to 1985 were identified through a MEDLINE search using the
following key words: “antibiotic prophylaxis; human; open fractures; bacterial infections - prevention
and control; fracture healing; fracture-complications; and surgical wound infections”. These
combined searches identified 313 articles. The bibliography of each article was reviewed for
additional references which were not identified in the two original searches. Letters to the editors,
case reports, and review articles were excluded from further evaluation. This identified 56 studies
for evidentiary review. The articles were reviewed by 3 orthopedic trauma surgeons, 2 general
surgeons, and two pharmaceutical outcome researchers with interest in pharmacokinetics and health
care economics. These individuals then collaborated to produce the guidelines.
1. Quality of the references
The references were classified in the methodology established by the Agency for
Health Care Policy and Research (AHCPR) of the U.S. Department of Health and Human
Services. Additional criteria and use for Class I articles were taken from a tool described by
Oxman et al.9 Thus, the classifications were:
Class I: Prospective, Randomized, Double-Blinded Study
Class II: Prospective, Randomized, Non-Blinded Trial
Class III: Retrospective Analysis of Patient Series
III. Recommendations
6
A. Level I
There are sufficient Class I and II data to recommend preoperative dosing with prophylactic
antibiotics (as soon as possible after injury) for coverage of gram positive organisms as optimum
care for trauma patients with open fractures. For Grade III fractures, additional coverage for gram
negative organisms should be given. High-dose penicillin should be added to the antibiotic regimen
when there is a concern for fecal/Clostridial contamination such as in farm related injuries.
B. Level II
There are sufficient Class I and Class II data to recommend antibiotics be discontinued 24
hours after wound closure for Grade I and II fractures. For Grade III wounds, the antibiotics should
be continued for only 72 hours after the time of injury or not more than 24 hours after soft tissue
coverage of the wound is achieved, whichever occurs first (See page 10, paragraph C for
discussion).
Definition of Level I recommendation: This recommendation is convincingly justifiable based
on the available scientific information alone. It is usually based on Class I data, however, strong
Class II evidence may form the basis for a level 1 recommendation, especially if the issue does not
lend itself to testing in a randomized format. Conversely, weak or contradictory Class I data may not
be able to support a level 1 recommendation.
Definition of Level II recommendation: This recommendation is reasonably justifiable by
available scientific evidence and strongly supported by expert critical care opinion. It is usually
supported by Class II data or a preponderance of Class III evidence.
IV. Scientific Foundation
A. Historical background
7
An open fracture was for many thousands of years a sentence of death. Amputation was
often considered as the only viable alternative to death. The mortality rate of all kinds of open
fractures in the Franco Prussian War was 41%; it was 50% for the lower leg, 66% for the thigh, and
77% for open fractures of the knee joint. Other reports claimed a mortality rate ranging from 54 to
99% for open femur fractures.10
In War World I, the mortality rate for an open fracture of the femur remained approximately
80%. The immediate use of the Thomas splint for femur fractures was introduced in 1916, and the
mortality rate for open fractures of the femur fell promptly to 16%. Karpmen later recognized that
restoration of the bone length reduced the volume of the fascial compartments and therefore the
magnitude of blood loss associated with the open fracture, which explained the reduction in mortality
observed with the Thomas splint. Also in World War I, Orr evolved a policy of wound excision and
debridement, reduction of the fracture, stabilization with plaster, and leaving the traumatic wound
open.11 During the Spanish Civil War, Truetta confirmed Orr’s experience with a reported 0.6%
septic mortality rate in 1069 open fractures.12 Thus, World War I was the first time that the role of
wound debridement was correlated with a reduction in septic mortality for open fractures. This
reduction occurred prior to antibiotics, blood transfusions, intravenous fluids, and modern
anesthesia.
During World War II, there was initial enthusiasm for the use of chemotherapeutic agents
primarily in the form of sulfonamides in the immediate care of open fractures. The importance of
wound excision with debridement and healing by secondary intention was once again appreciated
when antibiotics failed to reduce infectious complications when wounds were primarily closed. The
role of delayed primary wound closure was evaluated in 25,000 wounds without antibiotic coverage.
8
There was a 95% success rate in wounds left open for 4 to 10 days despite positive bacterial
cultures from the wound.13
Patzakis et al. were the first to perform a prospective, randomized study comparing the
infectious rates for penicillin with streptomycin, cephalothin, and placebo.14 The rates were 13.9%
for controls, 9.7% for penicillin, and 2.3% for cephalothin. Unfortunately, the study was not double-
blinded and did not grade for severity of open fractures. Nonetheless, it was the first report showing
a benefit of prophylactic antibiotics in these severe extremity injuries. Since the Patzakis study, there
have been multiple reports14,15,20,26,27,32,35,37,44,61,63 comparing various antibiotic regimens for efficacy
in reducing infections and durations of therapy. These articles did stratify for grade of open fracture
and form the basis for this evidence-based outcome review.
B. Choice of antibiotic
The majority of studies contain populations of patients with various mechanisms of injury.
Hansraj et al.15 performed a non-blinded comparison of ceftriaxone to cefazolin in extra-articular
bony injuries due to gunshot wounds. The mean time between injury and the initial antibiotic dose
was 4 hours. All admission cultures were negative, and none of the patients subsequently developed
clinical signs of infection. They concluded that the cost of therapy was significantly less with
ceftriaxone and resulted in a 1-day reduction in length of stay.15 This study questions whether low
velocity missile injury to extra-articular cortical bone requires any antibiotic prophylaxis. 15 If one
feels compelled to use a prophylactic antibiotic in this low-risk group, the authors suggest a single-
dose, long-acting antimicrobial is cost effective in this patient population compared with a shorter-
acting, first generation cephalosporin which requires multiple dosing.
The benefit of antibiotic coverage in gunshot wounds producing skeletal fractures has also
been evaluated in children.16 Most of these wounds were caused by low velocity missiles. Forty-five
9
patients (59%) received a first generation cephalosporin for 48 hours. None of these patients
developed an infectious complication. The authors concluded that children with Grade I and II open
fractures produced by low velocity missiles require antibiotics for only 48 hours.
Hope and Cole evaluated the role of antibiotics in children with open tibial fractures.17
Despite broad-spectrum antibiotics for at least 48 hours, the wound infection rate was 11%.
However, the most important variable in these infections was felt to be the severity of the soft tissue
injury rather than the antibiotic coverage.17 In a similar review of open tibial fractures in children,
Buckley et al. reported a wound infection rate of 7.3%, osteomyelitis was 4.9%, and pin track
infection was 20%.18 Antibiotics were administered for 48-hour intervals and were repeated with
subsequent wound debridement. They concluded the most important variable in reducing wound
infection was utilizing delayed wound closure rather than primary closure.18 Patzakis and Wilkins
retrospectively reviewed their experience with various antibiotic regimens including penicillin,
cephalothin, and cefamandole as well as a control arm with no antibiotics.19 They also looked at the
infection rate for adults (7.2%) and pediatric patients (1.8%). The various infectious complication
rates were 13.9% for placebo, 10% for penicillin plus streptomycin, 5.6% for cephalothin, and 4.5%
for cefamandole plus tobramycin. The duration of antibiotic therapy was not correlated with the
reduction in infection rate. Thus, they concluded that, for severely contaminated wounds, broad-
spectrum antibiotics should be administered as soon as possible after injury and be continued for no
more than 72 hours.19
Other investigators have relied on wound cultures to direct antibiotic therapy. In a
prospective study of open fractures, Robinson et al. reported 83% of the initial cultures as being
positive.20 More importantly, over 90% of the organisms identified in these cultures were sensitive
to routine antibiotics (1st generation cephalosporins). Four patients had persistent positive cultures at
10
the time of a second debridement 24 hours after admission, and all developed a deep wound
infection. They concluded that sequential wound cultures facilitated antibiotic therapy in the
management of open extremity fractures. More recent investigations have shown no correlation of
wound cultures at the time of presentation or obtained during the initial debridement and subsequent
infection.21,22,61
The importance of prophylactic antibiotics for open fractures of the knee, ankle, hand, digits,
and skull has also been evaluated and found to be beneficial.23-33 Benson et al. compared clindamycin
against cefazolin and saw no difference in the infection rates.34 This study suggested that any
antimicrobial agent with Staphylococcus aureus coverage is adequate effective prophylaxis for open
fractures. Thus, there is adequate Class I and II data to document the benefit of prophylactic
antibiotics in open extremity fractures. Agents effective against Staphylococcus aureus would
appear to be adequate for Grade I and II fractures.1,14,34-38 Since various gram negative organisms
are cultured from Grade III wounds after the initial debridement, broader gram negative coverage
through the addition of an aminoglycoside is beneficial.17-20,26,39-53
C. Duration of therapy
Multiple studies have demonstrated the interaction between antibiotic therapy and wound
management.1,17-20,39,42,44,45,53-62 When Grade I or II wounds are closed primarily, an additional 24
hours of antibiotic coverage is adequate independent of time of initiation after injury.19,37,39,42,44,45,63
Dellinger et al. observed no relationship between the duration of antibiotic administration (1 day
versus 5 days) and the risk of infection, independent of the grade of the fracture.8,63 Other reports
have identified tibial fracture as being the most significant predictor of subsequent infection.2,6,19,63
D. Route of antibiotic delivery
11
Most studies report discussed above use intravenous antibiotics for prophylaxis. An
alternative technique, the antibiotic bead pouch, was developed in the late 1980’s . Several
investigators have utilized aminoglycoside-polymethyl methacrylate (PMMA) beads alone or in
addition to parenteral antimicrobials. It has been reported in several series as being useful in the
management of traumatic open wounds associated with fracture,57,68 particularly in cases of Gustilo
types IIIB and IIIC injuries with acute infection and types II and IIIB with chronic osteomyelitis
(3.7% versus 12%).56,69 This technique promotes high local tissue levels of antibiotic concentration
in the target area with a significantly decreased risk of potentially toxic systemic effects as seen with
high dose parenteral delivery. In the acute setting, PMMA beads, which have been impregnated with
an aminoglycoside antibiotic, are used in conjunction with 5 days of tradition systemic tobramycin,
cefazolin and penicillin prophylaxis.67 This is combined with a regimen of thorough, serial wound
debridements every 48 to 72 hours and bead exchanges with sterile self-adherent porous
polyethylene drapes used to seal the wound. Systemic aminoglycoside levels are monitored with
“peak” and “trough” levels with the doses being adjusted to maintain a therapeutic range. Soft tissue
coverage techniques are carried out based on the immediate needs of the injury, and can include
delayed primary closure, split-thickness skin grafting, local flaps or free-tissue transfers, as
warranted. Skeletal stabilization is generally managed with intramedullary nailing or external
fixation, the latter sometimes being converted to an intramedullary nail after soft tissue coverage has
been achieved.64 The determinants of wound closure/soft tissue coverage include the viability of the
local soft tissue envelope after adequate time for demarcation has been allowed, but generally should
be done in under 10 days.66 It is not clear whether local therapy provides adequate tissue levels of
antibiotic without systemic administration.
E. Evidentiary table
12
The evidentiary table contains 54 articles that were utilized to formulate these guidelines.
The data are listed alphabetically by Class and include 10 Class I articles, 8 Class II, and 36 Class III
references. The following data were retrieved and recorded from each article and are listed under the
conclusion sections: (1) protocol design; (2) antibiotics utilized; (3) infectious complications; and (4)
conclusions.
V. Summary
Multiple studies have documented the reduction in wound infections with the use of
prophylactic antibiotics in the care of patients with open fractures. Although studies with various
therapeutic agents have suggested an improved outcome with prolonged (> 24 hours) therapy, none
have been done with appropriate controls. The most difficult open fracture wound to care for is the
Grade IIIb tibial fracture. Although some authors advocate application of antibiotic impregnated
beads for local control of infection in addition to parenteral administration, supportive Class I and II
data are not available. These wounds (type III) should receive coverage for gram negative
organisms in addition to gram positive coverage.
VI. Future Investigation
There is a need to re-evaluate the current infection rate for long bone open fractures. Studies
should specifically focus on high-risk injuries, ie. the Grade IIIb tibial injury. The study design
should evaluate the effect of wound debridement, systemic and local antibiotics, duration, and
specific agents as well as cost analysis. Because of the relatively low rate of infection, a multi-
institutional effort would allow a meaningful study to be completed in a short time period.
VII. References
13
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twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone
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2. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe)
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6. Dellinger EP, Miller SD, Wertz MJ, Grypma M, Droppert B, Anderson PA. Risk of infection
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8. Dellinger EP. Antibiotic prophylaxis in trauma: penetrating abdominal injuries and open
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14
11. Orr H. The treatment of infected wounds without sutures, drainage tubes or antiseptic
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15. Hansraj KK, Weaver LD, Todd AO, et al. Efficacy of ceftriaxone versus cefazolin in the
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16. Victoroff BN, Robertson WW Jr, Eichelberger MR, Wright C. Extremity gunshot injuries
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18. Buckley SL, Smith GR, Sponseller PD, Thompson JD, Robertson WW Jr, Griffin PP. Severe
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20. Robinson D, On E, Hadas N, Halperin N, Hofman S, Boldur I. Microbiologic flora
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15
21. Chapman MW. Open Fractures. In: Chapman MW, (ed.). Operative Orthopaedics. 2nd
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24. Acello AN, Wallace GF, Pachuda NM. Treatment of open fractures of the foot and ankle: A
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25. Marsh JL, Saltzman CL, Iverson M, Shapiro DS. Major open injuries of the talus. J Orthop
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26. Sanders R, Pappas J, Mast J, Helfet D. The salvage of open grade IIIb ankle and talus
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27. Suprock MD, Hood JM, Lubahn JD. Role of antibiotics in open fractures of the finger. J
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28. Peacock KC, Hanna DP, Kirkpatrick K, Breidenbach WC, Lister GD, Firrell J. Efficacy of
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29. Sloan JP, Dove AF, Maheson M, Cope AN, Welsh KR. Antibiotics in open fractures of the
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31. Rosenwasser RH, Delgado TE, Buchheit WA. Compound frontobasal skull fractures:
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32. Mendelow AD, Campbell D, Tsementzis SA, et al. Prophylactic antimicrobial management of
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33. Pinckney LE, Currarino G, Kennedy LA. The stubbed great toe: A cause of occult compound
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34. Benson DR, Riggins RS, Lawrence RM, Hoeprich PD, Huston AC, Harrison JA. Treatment
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35. Wisniewski TF, Radziejowski MJ. Gunshot fractures of the humeral shaft treated with
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36. Johnson KD, Johnston DW. Orthopedic experience with methicillin-resistant Staphylococcus
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37. Bergman BR. Antibiotic prophylaxis in open and closed fractures: A controlled trial. Acta
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38. Kennedy T, Premer RF, Lagaard S, Gustilo RB. Management of tibial fractures. Minn Med
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17
43. Kreder HJ, Armstrong P. A review of open tibia fractures in children. J Pediatr Orthop
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45. Buckley SL, Smith G, Sponseller PD, Thompson JD, Griffin PP. Open fractures of the tibia
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47. Burgess AR, Poka A, Brumback RJ, Flagle CL, Loeb PE, Ebraheim NA. Pedestrian tibial
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48. Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative
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51. Christensen J, Greiff J, Rosendahl S. Fractures of the shaft of the tibia treated with AO-
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A review of 1085 consecutive cases. J Bone Joint Surg 1995;77B:93-97.
57. Ostermann PAW, Henry SL, Seligson D. The role of local antibiotic therapy in the
management of compound fractures. Clin Orthop 1993;295:102-111.
58. Hoffer MM, Johnson B. Shrapnel wounds in children. J Bone Joint Surg 1992;74A:766-769.
59. Kaltenecker G, Wruhs O, Quaicoe S. Lower infection rate after interlocking nailing in open
fractures of femur and tibia. J Trauma 1990;30:474-479.
60. Russell GG, Henderson R, Arnett G. Primary or delayed closure for open tibial fractures. J
Bone Joint Surg 1990;72B:125-128.
61. Merritt K. Factors increasing the risk of infection in patients with open fractures. J Trauma
1988;28:823-827.
62. Wilson NI. A survey, in Scotland, of measures to prevent infection following orthopaedic
surgery. J Hosp Infect 1987;9:235-242.
63. Dellinger EP, Caplan ES, Weaver LD, et al. Duration of preventive antibiotic administration
for open extremity fractures. Arch Surg 1988;123:333-339.
64. Keating JF, Blachut PA, O’Brien PJ, Meek RN, Broekhuyse HM. Reamed nailing of open
tibial fractures: Does the antibiotic bead pouch reduce the deep infection rate? J Orthop
Trauma 1996;10:298-303.
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65. Sangha KS, Miyagawa CI, Healy DP, Bjornson HS. Pharmacokinetics of once-daily dosing
of gentamicin in surgical intensive care unit patients with open fractures. Ann Pharmacother
1995;29:117-119.
66. Ostermann PA, Henry SL, Seligson D. Timing of wound closure in severe compound
fractures. Orthopedics 1994;17:397-399.
67. Seligson D, Ostermann PA, Henry SL, Wolley T. The management of open fractures
associated with arterial injury requiring vascular repair. J Trauma 1994;37:938-940.
68. Henry SL, Ostermann PA, Seligson D. The antibiotic bead pouch technique. The
management of severe compound fractures. Clin Orthop 1993;295:54-62.
69. Henry SL, Ostermann PA, Seligson D. The prophylactic use of antibiotic impregnated beads
in open fractures. J Trauma 1990;30:1231-1238.
20
PR
OPH
YL
AC
TIC
AN
TIB
IOT
IC U
SE I
N O
PEN
FR
AC
TU
RE
S: E
VID
EN
TIA
RY
TA
BL
E
Firs
t Aut
hor
Yea
r R
efer
ence
C
lass
Con
clus
ions
P
atza
kis
MJ
1974
Th
e ro
le o
f ant
ibio
tics
in th
e m
anag
emen
t of o
pen
fract
ures
. J
Bon
e Jo
int S
urg
56A
:532
-541
I
· 310
pts
. R
ando
miz
ed A
bx re
gim
ens
(10-
day
cour
se):
1) G
p 1
+ pl
aceb
o; 2
) Gp
II +
peni
cilli
n +
stre
ptom
ycin
; 3) G
p III
+ c
epha
loth
in.
· Inf
ectio
n ra
tes:
Gp
I (13
.95)
; Gp
II (9
.7%
); G
p III
(2.3
%)
· Rec
omm
end:
1) A
bx e
ffect
ive
for g
ram
pos
., gr
am n
eg.,
stap
h; 2
) wou
nd C
&S
bef
ore
debr
idem
ent m
ost l
ikel
y to
isol
ate
pote
ntia
lly in
fect
ious
org
anis
ms;
3) m
odify
Abx
bas
ed on
C
&S
resu
lts.
Ber
gman
BR
19
82
Ant
ibio
tic p
roph
ylax
is in
ope
n an
d cl
osed
frac
ture
s: A
con
trolle
d tri
al.
Act
a O
rthop
Sca
nd 5
3:57
-62
I
· Ope
n fra
ctur
es(n
=90)
: Gra
de I,
N=
55; G
rade
II &
III,
N=3
5. · A
bx in
clud
ed: 1
) dic
loxa
cilli
n; 2
) ben
zyl p
enic
illin;
3) p
lace
bo.
All
Abx
dis
cont
inue
d af
ter 4
8 hr
s. · N
o st
atis
tical
diff
eren
ce in
sup
erfic
ial i
nfec
tions
for e
ither
Abx
or b
y su
bset
ana
lysi
s fo
r sta
b w
ound
or l
acer
atio
ns, o
r Gra
de I,
II, o
r III
fract
ures
. · G
p 3
deve
lope
d si
gnifi
cant
ly m
ore
deep
infe
ction
s.
· No
diffe
renc
e be
twee
n di
clox
acill
in a
nd b
enzy
l pen
icill
in.
· Con
firm
s sh
ort d
urat
ion
prop
hyla
ctic
Abx
redu
ce d
eep
infe
ctio
ns fo
r ope
n fra
ctur
es.
Ben
son
DR
19
83
Trea
tmen
t of o
pen
fract
ures
: A
pros
pect
ive
stud
y.
J Tr
aum
a 23
:25-
30
I
· Com
pare
d th
e ef
fect
of c
linda
myc
in v
s ce
fazo
lin.
· Qua
ntita
tive
cultu
res
wer
e ob
tain
ed o
n ad
mis
sion
. · R
esul
ts: 4
6% o
f wou
nds
wer
e co
ntam
inat
ed a
t tim
e of
deb
ridem
ent.
Infe
ctio
n ra
te=6
.5%
· G
ram
neg
. org
. res
ista
nt to
pro
phyl
actic
age
nts
reco
vere
d on
ly 8
tim
es: 4
(50%
) bec
ame
infe
cted
. · N
o di
ffere
nce
in in
fect
ion
rate
with
eith
er a
gent
. S
loan
JP
19
87
Ant
ibio
tics
in o
pen
fract
ures
of t
he
dist
al p
hala
nx.
J H
and
Sur
g 12
B:1
23-1
24
I
· 85
open
dis
tal p
hala
nx fr
actu
res.
· Ran
dom
ized
gro
ups:
1) N
o A
bx; 2
) cep
hrad
ine
500
mg
po Q
ID x
5 d
ays;
3) c
ephr
adin
e 1
gm
IV p
re-o
p, th
en 5
00 m
g po
QID
x 5
day
s; 4
) cep
hrad
ine
1 gm
IV p
re-o
p, th
en 1
gm
po
post
op.
· 4.7
% in
fect
ion
rate
(n=4
); 3
infe
ctio
ns o
ccur
red
in “N
o A
bx” g
roup
. · N
o si
gnifi
cant
diff
eren
ce b
etw
een
3 A
bx re
gim
ens.
· R
ecom
men
d:1)
Abx
pro
phyl
axis
nec
. for
ope
n fra
ctur
es o
f dis
tal p
hala
nx; 2
) Adm
inis
tratio
n m
ode
does
not
influ
ence
infe
ctio
n ra
te; 3
) Reg
imen
#4
mos
t cos
t-effe
ctiv
e/ef
ficac
ious
. D
ellin
ger E
P 19
88
Dur
atio
n of
pre
vent
ive
antib
iotic
ad
min
istra
tion
for o
pen
extre
mity
fra
ctur
es.
Arc
h S
urg
123:
1320
-132
7
I
· 248
ope
n fra
ctur
es-r
ando
miz
ed: 1
) cef
onic
id 2
gm
s x
1 da
y; 2
) cef
onic
id 2
gm
s x
1 da
y, th
en
1 gm
q 2
4 hr
s x
5 da
ys; 3
) cef
aman
dole
2 g
ms,
then
1 g
m q
6 h
rs x
5 d
ays.
· 1
3% in
fect
ion
rate
-no
sign
ifican
t diff
eren
ce a
mon
g 3
Abx
gro
ups.
· E
quiv
alen
t effi
cacy
for 1
-day
Abx
adm
inis
tratio
n co
mpa
red
to 5
day
s. · R
ecom
men
d br
ief A
bx c
ours
e fo
llow
ed b
y cl
ose
obse
rvat
ion
for p
osto
p in
fect
ion.
21
Firs
t Aut
hor
Yea
r R
efer
ence
C
lass
C
oncl
usio
ns
Pea
cock
KC
19
88
Effi
cacy
of p
erio
pera
tive
cefa
man
dole
w
ith p
osto
pera
tive
ceph
alex
in in
the
prim
ary
outp
atie
nt tr
eatm
ent o
f ope
n w
ound
s of
the
hand
. J
Han
d S
urg
13A
:960
-964
I
· 87
pts:
1) S
tudy
gro
up: c
efam
ando
le 1
gm
IV q
4 h
rs, t
hen
ceph
alex
in 5
00 m
g Q
ID x
3 d
ays
@ d
isch
arge
; 2) c
ontro
l: pl
aceb
o IV
, the
n pl
aceb
o po
@ d
isch
arge
. · I
nfec
tion
rate
= 0%
stu
dy g
roup
vs
2.1%
con
trol (
NS
). · A
bx n
ot ro
utin
ely
indi
cate
d; u
se A
bx fo
r ser
ious
inju
ries/
spec
ifica
lly id
entif
ied
infe
ctio
ns.
Sw
iont
kow
ski
MF
1989
C
riter
ia fo
r bon
e de
brid
emen
t in
mas
sive
low
er li
mb
traum
a.
Clin
Orth
op 2
43:4
1-47
I
· 60
pts
with
ope
n ex
trem
ity fr
actu
res.
· Abx
regi
men
: cep
halo
spor
ins
+ am
inog
lyco
side
s (ty
pe II
). · 9
.2%
dee
p in
fect
ion.
R
obin
son
D
1989
M
icro
biol
ogic
flor
a co
ntam
inat
ing
open
fra
ctur
es: I
ts s
igni
fican
ce in
the
choi
ce
of p
rimar
y an
tibio
tic a
gent
s an
d th
e lik
elih
ood
of d
eep
wou
nd in
fect
ion.
J
Orth
op T
raum
a 3:
283-
286
I
· 89
open
ext
rem
ity fr
actu
res.
· M
anag
emen
t pro
toco
l: 1)
wou
nd c
ultu
re o
n ad
mis
sion
; 2) r
epea
t cul
ture
@ d
ay 1
; 3)
cef
oxiti
n 1
gm T
ID x
24
hrs;
4) G
aram
ycin
80
mgs
TID
x 2
4 hr
s (G
rade
III).
· 83%
initi
al c
ultu
res
pos.
; >90
% o
rgan
ism
s is
olat
ed s
ensi
tive
to ro
utin
e A
bx.
· 1-d
ay p
os. c
ultu
re (n
=4) -
100
% d
evel
oped
dee
p w
ound
infe
ctio
n.
· Im
porta
nce
of w
ound
cle
ansi
ng a
nd a
ppro
pria
te A
bx.
· Seq
uent
ial w
ound
cul
ture
s pr
edic
t lik
elih
ood
of in
fect
ion.
Han
sraj
KK
19
95
Effi
cacy
of c
eftri
axon
e ve
rsus
cef
azol
in
in th
e pr
ophy
lact
ic m
anag
emen
t of
extra
-arti
cula
r cor
tical
vio
latio
n of
bon
e du
e to
low
-vel
ocity
gun
shot
wou
nds.
O
rthop
Clin
Nor
th A
m 2
6:9-
17
I
· No
infe
ctio
us c
ompl
icat
ions
in 1
00 p
ts ra
ndom
ized
to 1
of 2
Abx
pro
toco
ls (s
kin
wou
nd
<1cm
): 1)
cef
triax
one
1 gm
, the
n re
peat
1 g
m @
24
hrs;
2) c
efaz
olin
1 g
m, t
hen
1 gm
q 8
hrs
x
7 do
ses.
· C
eftri
axon
e/ce
fazo
lin b
oth
effe
ctiv
e pr
ophy
lact
ic a
gent
s. · C
eftri
axon
e re
gim
en d
ec. L
OS
by
1 da
y &
low
ers
cost
s ap
prox
. $23
00/p
atie
nt.
San
gha
KS
19
95
Pha
rmac
okin
etic
s of
onc
e-da
ily d
osin
g of
gen
tam
icin
in s
urgi
cal i
nten
sive
car
e un
it pa
tient
s w
ith o
pen
fract
ures
. A
nn P
harm
acot
her 2
9:11
7-11
9
I
· 11
pts.
with
type
II/II
I ope
n ex
trem
ity fr
actu
res:
1) g
enta
mic
in 6
mg/
kg q
24
hrs
x 48
hrs
(n=7
); 2)
gen
tam
icin
2 m
g/kg
q 8
hrs
x 4
8 hr
s (n
=4);
3) c
efaz
olin
1 g
m q
8 h
rs x
48
hrs
(n=1
1).
· Inc
reas
ed C
max
, Cpk
and
AU
C o
nce-
daily
regi
men
. · N
o re
latio
nshi
p to
clin
ical
out
com
e.
Gus
tilo
RB
1976
P
reve
ntio
n of
infe
ctio
n in
the
treat
men
t of
one
thou
sand
and
twen
ty-fi
ve o
pen
fract
ures
of l
ong
bone
s: R
etro
spec
tive
and
pros
pect
ive
anal
yses
. J
Bon
e Jo
int S
urg
58A
:453
-458
II
· 352
pts
. S
tand
ard
prot
ocol
: 1) d
ebrid
emen
t + c
opio
us ir
rigat
ion;
2) p
rimar
y cl
osur
e fo
r typ
e I/I
I fra
ctur
es; 3
) sec
onda
ry c
losu
re fo
r typ
e III
frac
ture
s; 4
) all
wou
nds
cultu
red
on a
dmis
sion
; 5)
oxac
illin
or a
mpi
cilli
n pr
e-op
, the
n x
72 h
rs.
· 158
pts
(70.
3%) h
ad w
ound
cul
ture
s w
ith in
fect
ion
rate
of 2
.5%
. Fro
m s
ensi
tivity
stu
dies
on
initi
al w
ound
cul
ture
s, c
epha
losp
orin
wou
ld b
e pr
ophy
lact
ic A
bx o
f cho
ice
for t
ype
III o
pen
fract
ures
. Inf
ectio
n ra
te w
as 9
% &
sig
nific
antly
low
er th
an re
trosp
ectiv
e co
ntro
l.
22
Firs
t Aut
hor
Yea
r R
efer
ence
C
lass
C
oncl
usio
ns
Pat
zaki
s M
J 19
83
Use
of a
ntib
iotic
s in
ope
n tib
ial
fract
ures
. C
lin O
rthop
178
:31-
35
II
· 363
con
secu
tive
open
tibi
al fr
actu
res.
· 4 tr
eatm
ent g
roup
s du
ring
10-y
ear p
erio
d: 1
) no
Abx
; 2) p
enic
illin
+stre
ptom
ycin
x 1
0 da
ys;
3) c
epha
loth
in-m
ost r
ecei
ved
5-da
y co
urse
of I
V th
erap
y fo
llow
ed b
y or
al c
epha
lexi
n x
5 da
ys;
4) c
efam
ando
le+t
obra
myc
in x
3 d
ays
if in
itial
cul
ture
s ne
g. a
nd 5
day
s if
cultu
res
pos.
· Inf
ectio
n ra
tes
high
est w
ith n
o A
bx (2
4%).
Low
est i
n Gp
4 (
4.5%
). · C
oncl
ude:
no
bene
fit to
con
tinui
ng A
bx b
eyon
d 3
days
. M
errit
t K
1988
Fa
ctor
s in
crea
sing
the
risk
of in
fect
ion
in p
atie
nts
with
ope
n fra
ctur
es.
J Tr
aum
a 28
:823
-827
II
· 70
pts-
tissu
e cu
lture
s @
deb
ridem
ent;
follo
w-up
re: d
evel
opm
ent o
f clin
ical
infe
ctio
n.
· All
rece
ived
com
bina
tion
ceph
alos
porin
/am
inog
lyco
side
. · I
nfec
tion
rate
= 1
9%.
· Inf
ectio
n ra
te lo
wer
in p
atie
nts
treat
ed 2
4-48
hrs
vs 3
-7 d
ays.
O
ster
man
n P
A
1993
Th
e ro
le o
f ant
ibio
tic th
erap
y in
the
man
agem
ent o
f com
poun
d fra
ctu
res.
C
lin O
rthop
295
:102
-111
II
· 704
con
secu
tive
open
frac
ture
s: 1
) Gp
A (n
=157
) - c
efaz
olin
/tobr
a/P
CN
; 2)
Gp
B (n
=547
) - c
efaz
olin
/tobr
a/P
CN
+ to
bra-
PM
MA
. · L
ower
inci
denc
e of
infe
ctio
n in
Gp
B v
s G
p A
(4%
vs
17%
). · A
dditi
on o
f tob
ra-P
MM
A to
par
ente
ral A
bx d
ec. i
nfec
tion
in h
ighl
y co
ntam
inat
ed w
ound
s an
d de
c. in
cide
nce
of p
olym
icro
bial
infe
ctio
n.
· Rou
tine
use
of p
roph
ylac
tic to
bra-
PM
MA
des
erve
s pr
ospe
ctiv
e m
ultic
ente
r tria
l. O
ster
man
n P
A
1994
Ti
min
g of
wou
nd c
losu
re in
sev
ere
com
poun
d fra
ctu
res.
O
rthop
edic
s 17
:397
-399
II
· 381
ope
n fra
ctur
es: 1
) IV
cef
azol
in/to
bra/
PC
N x
5 d
ays;
2) A
bx b
ead
pouc
h te
ch.
· Ove
rall
infe
ctio
n ra
te=G
rade
1(0
%);
Gra
de II
(2.6
%);
Gra
de II
I (8.
4%).
· No
defin
itive
con
clus
ions
due
to d
esig
n of
stu
dy (i
e. n
o ra
ndom
izatio
n, n
o co
ntro
l gro
up).
Ost
erm
ann
PA
1995
Lo
cal a
ntib
iotic
ther
apy
for s
ever
e op
en fr
actu
res.
A re
view
of 1
085
cons
ecut
ive
case
s.
J B
one
Join
t Sur
g 77
B:9
3-97
II
· 108
5 co
nsec
utiv
e op
en fr
actu
res.
Gp
1 (n
=845
): IV
cef
azol
in/to
bra/
PC
N+t
obra
-PM
MA
; G
p 2
(n=2
40):
IV c
efaz
olin
/tobr
a/P
CN
. · D
ec. o
vera
ll in
fect
ion
rate
Gp
1 (3
.7%
vs.
12%
); st
atis
tical
sig
nific
ance
onl
y in
type
III.
· Adj
uvan
t loc
al A
bx th
erap
y de
crea
ses
inci
denc
e of
late
infe
ctio
n. K
eatin
g JF
19
96
Rea
med
nai
ling
of o
pen
tibia
l fra
ctur
es: D
oes
the
antib
iotic
bea
d po
uch
redu
ce th
e de
ep in
fect
ion
rate
? J
Orth
op T
raum
a 10
:298
-303
II
· Par
ente
ral r
egim
en: C
efaz
olin
+ G
enta
mic
in x
72
hrs.
· Dec
reas
ed d
eep
infe
ctio
n ra
te in
type
II fr
actu
res
with
Abx
bea
d po
uch:
4%
vs
20%
(NS
). · D
ecre
ased
dee
p in
fect
ion
rate
in ty
pe II
I fra
ctur
es w
ith A
bx b
ead
pouc
h: 8
% v
s. 2
0% (N
S).
Wis
niew
ski T
F 19
96
Gun
shot
frac
ture
s of
the
hum
eral
sh
aft t
reat
ed w
ith e
xter
nal f
ixat
ion.
J O
rthop
Tra
uma
10:2
73-2
78
II
· Firs
t gen
erat
ion
ceph
alos
porin
x 7
2 hr
s. · I
ncid
ence
of i
nfec
tion
(21%
): de
ep w
ound
sep
sis
(2);
pin
track
infe
ctio
n (5
); o
steo
mye
litis
(1
). Fi
rst A
utho
r Y
ear
Ref
eren
ce
Cla
ss
Con
clus
ions
K
enne
dy T
19
75
Man
agem
ent o
f tib
ial f
ract
ures
. M
inn
Med
58:
525-
528
III
· 1
09 p
ts w
ith 1
18 o
pen
and
clos
ed ti
bial
frac
ture
s.
· Clo
sed
met
hods
+ e
arly
wei
ght-b
earin
g un
ion
in 9
8%.
· Pin
s an
d pl
aste
r 62.
5% d
elay
ed u
nion
rate
. · A
ll ty
pe I/
II cl
osed
prim
arily
. No
infe
ctio
n su
ppor
ting
use
of p
roph
ylac
tic A
bx.
23
· Inf
ectio
n ra
te 3
.8%
type
III w
ound
s. · T
ype
I/II w
ound
s ca
n be
clo
sed
prim
arily
pro
vide
d ad
equa
te d
ebrid
emen
t and
hig
h do
ses
or
pre
and
post
oper
ativ
e A
bx a
re u
sed.
· Wea
knes
ses:
no
men
tion
of A
bx o
r dur
atio
ns.
Cla
ncey
GJ
1978
O
pen
fract
ures
of t
he ti
bia:
A re
view
of
one
hund
red
and
two
case
s.
J B
one
Join
t Sur
g 60
B:1
18-1
22
III
· 1
02 o
pen
tibia
l fra
ctur
es.
· Pro
toco
l def
ined
by
grad
e of
sof
t tis
sue
inju
ry: I
, II,
or II
I. A
ll w
ound
s le
ft op
en re
gard
less
of t
ype
of fi
xatio
n em
ploy
ed.
· IV
met
hici
llin+
IM k
anam
ycin
x 7
2 hr
s. · S
uper
ficia
l & d
eep
infe
ctio
n ra
te s
imila
r (15
%) f
or c
astin
g &
inte
rnal
fixa
tion.
Gus
tilo
RB
1979
U
se o
f ant
imic
robi
als
in th
e m
anag
emen
t of o
pen
fract
ures
.
Arc
h S
urg
114:
805-
808
III
· 5
20 o
pen
fract
ures
; 50.
7% p
os. c
ultu
res
on a
dmis
sion
; var
ious
Abx
regi
men
s. · 2
.4%
infe
ctio
n ra
te w
ith c
epha
loth
in.
· Rec
omm
end:
1) A
bx e
ffect
ive
agai
nst S
taph
aur
eus-
infe
ctiv
e or
g. 6
-70%
; 2) c
epha
loth
in
effe
ctiv
e in
all
open
frac
ture
s; 3
) am
inog
lyco
side
s -ad
d fo
r sev
erel
y co
ntam
inat
ed w
ound
s;
4) A
bx d
urat
ion
≤ 3
days
. P
inck
ney
LE
1981
Th
e st
ubbe
d gr
eat t
oe: A
cau
se o
f oc
cult
com
poun
d fra
ctur
e an
d in
fect
ion.
R
adio
logy
138
:375
-377
III
· 6
chi
ldre
n w
ith o
pen
fract
ures
of d
ista
l pha
lanx
of g
reat
toe
caus
ed b
y st
ubbi
ng.
· Ana
tom
ic re
latio
nshi
p di
stal
pha
lanx
and
nai
l mak
e re
cogn
ition
of o
ccul
t com
poun
d fra
ctur
e di
fficu
lt by
phy
sica
l exa
m.
· His
tory
of s
mal
l am
ount
of b
leed
ing
from
the
nail
fold
or l
acer
atio
n pr
oxim
al to
nai
l fol
d si
gnifi
cant
for o
pen
phal
ange
al fr
actu
re.
· 1st
4 c
ases
wer
e de
laye
d pr
esen
tatio
n w
ith o
bvio
us in
fect
ion.
Last
2 c
ases
pre
sent
ed w
ithin
2
days
of i
njur
y. T
reat
ed w
ith 2
wks
of A
bx. N
one
dev.
infe
ctio
n. · C
oncl
ude:
stu
bbed
toes
in c
hild
ren
at g
reat
risk
of o
pen
com
poun
d fra
ctur
e an
d sh
ould
be
treat
ed p
rom
ptly
with
Abx
to a
void
dev
elop
men
t of o
steo
mye
litis
. C
hris
tens
en J
19
82
Frac
ture
s of
the
shaf
t of t
he ti
bia
treat
ed w
ith A
O-c
ompr
essi
on
oste
osyn
thes
is.
Inju
ry 1
3:30
7-31
4
III
· 4
0% o
f pts
had
ope
n fra
ctur
es. 9
3% re
ceiv
ed p
roph
ylac
tic A
bx o
n ad
mis
sion
. Non
e w
ith
open
frac
ture
s de
velo
ped
infe
ctio
ns.
· Abx
incl
uded
met
hici
llin+
gent
amic
in x
5 d
ays,
then
dic
loxa
cilli
n x
7 da
ys.
· Rig
id in
tern
al fi
xatio
n ad
voca
ted
for a
ll di
spla
ced
fract
ures
of t
ibia
l sha
ft, e
sp. o
pen
fract
ures
.
Firs
t Aut
hor
Yea
r R
efer
ence
C
lass
C
oncl
usio
ns
Men
delo
w A
D
1983
P
roph
ylac
tic a
ntim
icro
bial
m
anag
emen
t of c
ompo
und
depr
esse
d sk
ull f
ract
ure.
J
Roy
al C
oll S
urg
Edi
nb 2
8:80
-83
III
· 2
23 p
ts w
ith d
epre
ssed
sku
ll fra
ctur
es -
176
case
s w
ere
open
. · 1
07 p
ts tr
eate
d pr
ophy
lact
ical
ly w
ith a
mpi
cilli
n or
a s
ulfo
nam
ide.
· Inf
ectio
n ra
te o
f 1.9
% s
igni
fican
tly lo
wer
than
rate
of i
nfec
tion
in p
ts re
ceiv
ing
no A
bx o
r any
co
mbi
natio
n A
bx.
Fran
klin
JL
1984
Im
med
iate
inte
rnal
fixa
tion
of o
pen
ankl
e fra
ctur
es. R
epor
t of t
hirty
-eig
ht
case
s tre
ated
with
a s
tand
ard
prot
ocol
.
III
· O
pen
ankl
e fra
ctur
es (n
=38)
. · S
tand
ard
prot
ocol
IV b
road
-spe
ctru
m c
epha
losp
orin
in E
D x
48
hrs.
· 1
dee
p in
fect
ion,
5 s
uper
ficia
l inf
ectio
ns.
24
J B
one
Join
t Sur
g 66
A:1
349-
1356
R
osen
was
ser
RH
1984
C
ompo
und
front
obas
al s
kull
fract
ures
: S
urgi
cal m
anag
emen
t of t
he a
cute
ph
ase.
S
outh
Med
J 7
7:34
7-35
0
III
· O
pen
skul
l fra
ctur
es (n
=5).
· Rec
omm
ende
d A
bx c
over
age:
naf
cilli
n 2
gms
IV q
6 h
rs, t
icar
cilli
n 2
gms
IV q
6 h
rs a
nd
tobr
amyc
in d
osed
acc
ordi
ng to
bod
y w
eigh
t. · 4
of 5
pts
had
no
infe
ctio
n.
John
son
KD
19
86
Orth
oped
ic e
xper
ienc
e w
ith m
ethi
cilli
n-re
sist
ant S
taph
yloc
occu
s au
reus
du
ring
a ho
spita
l epi
dem
ic.
Clin
Orth
op 2
12:2
81-2
88
III
· 2
3 pt
s w
ith o
pen
fract
ures
whi
ch c
ultu
red
for M
RS
A.
· 97%
rece
ived
1st
gen
. cep
halo
spor
in; 4
0% re
ceiv
ed to
bram
ycin
. · 2
2% re
quire
d am
puta
tion;
13%
hea
led
with
chr
onic
dra
inag
e. · M
RS
A in
fect
ions
rela
ted
to a
utho
r’s h
ospi
tal+
prio
r Abx
use
con
side
ratio
n fo
r all
Orth
o se
rvic
es in
larg
e ho
spita
ls.
· Pro
phyl
axis
invo
lves
pre
vent
ion
of c
ross-
infe
ctio
n, p
erso
nal h
ygie
ne, a
nd c
ontro
lled s
hort-
term
use
of b
road
-spe
ctru
m A
bx.
Bur
gess
AR
19
87
Ped
estri
an ti
bial
inju
ries.
J
Trau
ma
27:5
96-6
01
III
· 7
0 pt
s w
ith h
igh-
ener
gy (>
65%
Gra
de II
I) tib
ial f
ract
ures
. · R
ecei
ved
IV c
epha
losp
orin-
varia
ble
regi
men
s.
· Pro
phyl
actic
Abx
impo
rtant
fact
or in
redu
ctio
n of
mor
bidi
ty.
Gus
tilo
RB
1987
C
lass
ifica
tion
of ty
pe II
I (se
vere
) ope
n fra
ctur
es re
lativ
e to
trea
tmen
t and
re
sults
. O
rthop
edic
s 10
:178
1-17
88
III
· 3
03 o
pen
fract
ures
; est
ablis
hed
treat
men
t reg
imen
. · 4
.4%
wou
nd s
epsi
s: ty
pe I
(0%
); typ
e II
(2.5
%);
type
III (
13.7
%).
· Typ
e III
ope
n fra
ctur
es: c
epha
losp
orin
(29%
); ce
phal
ospo
rin+a
min
ogly
cosi
de (8
.8%
). · C
ontin
ue A
bx x
3 d
ays.
· Wou
nd c
ultu
res:
83%
pos
. ini
tially
; 30%
pos
. pos
t-deb
ridem
ent.
No
corr
elat
ion
betw
een
wou
nd c
ultu
re a
nd c
linic
al in
fect
ion.
· R
ecom
men
d: 1
) typ
e I/I
I: ce
fam
ando
le 2
gm
s @
adm
issi
on, 1
gm
q 8
hrs
x 3
day
s;
2) ty
pe II
I: ce
fam
ando
le (a
s ab
ove)
+ a
min
ogly
cosi
de 3-
5 m
g/kg
/24
hrs
x 3
days
; 3)
farm
inju
ries:
pen
icill
in 1
0-12
mill
ion
U; 4
) rep
eat A
bx: w
ound
clo
sure
, int
erna
l fix
atio
n,
bone
gra
fting
. Fi
rst A
utho
r Y
ear
Ref
eren
ce
Cla
ss
Con
clus
ions
W
ilson
NI
1987
A
sur
vey,
in S
cotla
nd, o
f mea
sure
s to
pr
even
t inf
ectio
n fo
llow
ing
orth
opae
dic
surg
ery.
J
Hos
p In
fect
9:2
35-2
42
III
· Q
uest
ionn
aire
stu
dy o
f orth
oped
ic s
urgeo
ns re
: det
ails
of A
bx p
roph
ylax
is.
· 75%
rout
inel
y us
e A
bx in
ope
n fra
ctur
es: p
enic
illin
ase-r
esis
tant
pen
icill
in (6
0%);
ceph
alos
porin
(36%
); ge
ntam
icin
(4%
). · D
urat
ion
of A
bx >
48
hrs
(79%
); 24
-48
hrs
(15%
); <
24 h
rs (6
%).
· Mos
t sel
ect a
ppro
pria
te A
bx.
· Reg
imen
s co
uld
be m
ore
cost
-effe
ctiv
e by
mor
e ac
cura
te ti
min
g &
dur
atio
n of
ther
apy.
Pat
zaki
s M
J 19
89
Fact
ors
influ
enci
ng in
fect
ion
rate
in
open
frac
ture
wou
nds.
C
lin O
rthop
243
:36-
40
III
· 7
7 in
fect
ions
in 1
104
open
frac
ture
s (7
%).
· Wou
nd c
ultu
red
@ a
dmis
sion
, @ d
ebrid
emen
t, an
d af
ter i
rrig
atio
n. · A
bx re
gim
ens:
1) n
o A
bx; 2
) pen
icill
in (I
V)+
stre
ptom
ycin
(IM
) x 1
0 da
ys; 3
) IV
cep
halo
thin
x
10 d
ays;
4) I
V c
epha
loth
in x
5 d
ays,
then
cep
hale
xin
(po)
x 5
day
s; 5
) IV
cef
aman
dole
+
tobr
amyc
in (I
M) x
3-5
day
s (b
ased
on
resu
lts o
f ini
tial w
ound
cul
t.).
· 7.2
% in
fect
ion
(adu
lts);
1.8%
infe
ctio
n (p
eds)
.
25
· Effe
ctiv
enes
s of
Abx
: no
Abx
-13.
9% in
fect
ion;
pen
icill
in/s
trept
omyc
in-10
%; c
epha
loth
in-
5.6%
; cef
aman
dole
/tobr
amyc
in-4
.5%
. · T
ime
to in
itiat
ion
of A
bx: <
3 h
rs-4
.7%
infe
ctio
n; >
3hr
s-7.
4% in
fect
ion.
· N
o co
rrel
atio
n w
ith d
urat
ion
of A
bx th
erap
y. · R
ecom
men
d: 1
) ear
ly s
urgi
cal d
ebrid
emen
t; 2)
bro
ad-s
pect
rum
Abx
AS
AP
afte
r inj
ury;
3)
con
tinue
Abx
for 3
day
s; 4
) typ
e I/I
I-par
tial w
ound
clo
sure
; 5) t
ype
III-de
laye
d w
ound
cl
osur
e, ti
ssue
tran
sfer
(7 d
ays)
. B
uckl
ey S
L 19
90
Ope
n fra
ctur
es o
f the
tibi
a in
chi
ldre
n.
J B
one
Join
t Sur
g 72
A:1
462-
1469
III
· W
ound
cul
ture
s in
ED
. · R
outin
e te
tanu
s pr
ophy
laxi
s. · P
roto
col:
1) m
in. 4
8 hr
s A
bx c
over
age;
2) 1
st g
en. c
epha
losp
orin
; 3) a
min
ogly
cosi
de (t
ype
III);
4) p
enic
illin
(far
m-re
late
d in
jury
); 5)
Abx
repe
ated
for s
ubse
quen
t pro
cedu
res
(48-
72 h
rs).
· Wou
nd in
fect
ion
rate
=7.3
%; o
steo
mye
litis
= 4
.9%
; pin-
track
infe
ctio
n =
20%
. · I
nfec
tion
rate
s lo
wer
in c
hild
ren
vs a
dults
; no
infe
ctio
n w
ith d
elay
ed w
ound
clo
sure
. H
enry
SL
1990
Th
e pr
ophy
lact
ic u
se o
f ant
ibio
tic
impr
egna
ted
bead
s in
ope
n fra
ctur
es.
J Tr
aum
a 30
:123
1-12
38
III
· 4
04 o
pen
fract
ures
/339
pts
.: G
rade
I (3
1.4%
); G
rade
II (3
8.9%
); G
rade
III (
30.7
%).
Gp A
(n
=70)
sys
tem
ic A
bx (c
efaz
olin
/tobr
a/P
CN
); G
p B
(n=3
34) s
yste
mic
Abx
+ to
bra
bead
s. · O
vera
ll in
fect
ion
rate
= 2
1.4%
Gp
A v
s 4.
2% G
p B
. · P
olym
icro
bial
infe
ctio
n=87
.5%
Gp
A v
s 55
.6%
Gp
B.
· Rec
omm
end
pros
pect
ive
mul
ticen
ter t
rial t
o es
tabl
ish
effic
acy o
f rou
tine
prop
hyla
ctic
use
. K
alte
neck
er G
19
90
Low
er in
fect
ion
rate
afte
r int
erlo
ckin
g na
iling
in o
pen
fract
ures
of f
emur
and
tib
ia.
J Tr
aum
a 30
:474
-479
III
· G
rade
I/II
open
frac
ture
s: 2
3 fe
mur
/56
tibia
. · P
roto
col:
1) w
ound
cov
ered
in E
D/n
o cu
lture
s; 2
) pen
icill
in.
· 96.
2% in
fect
ion-
free
rate
. · A
bx re
quire
d w
hen
inte
rlock
ing
nails
use
d fo
r sta
biliz
atio
n. Fi
rst A
utho
r Y
ear
Ref
eren
ce
Cla
ss
Con
clus
ions
R
usse
ll G
G
1990
P
rimar
y or
del
ayed
clo
sure
for o
pen
tibia
l fra
ctur
es.
J B
one
Join
t Sur
g 72
B:1
25-1
28
III
· 9
0 co
nsec
utiv
e pt
s. · C
ompa
red
prim
ary
with
del
ayed
clo
sure
for d
eep
infe
ctio
n.
· All
pts
rece
ived
Abx
(PC
N, c
loxa
cilli
n, o
r 1st
gen
. cep
halo
spor
in).
· Gus
tilo
clas
sific
atio
n: I
(37)
; II (
35);
IIIa
(4);
IIIb
(1);
IIIc
(4).
· Prim
ary
clos
ure
20%
dee
p in
fect
ion
rate
; 3%
del
ayed
clo
sure
. · C
oncl
ude
- avo
id p
rimar
y cl
osur
e.
Sup
rock
MD
19
90
Rol
e of
ant
ibio
tics
in o
pen
fract
ures
of
the
finge
r. J
Han
d S
urg
15A
:761
-764
III
· 9
1 fin
ger f
ract
ures
: 1) +
Abx
=po
1st g
en. c
epha
losp
orin
/dicl
oxac
illin
/ery
thro
myc
in x
3 d
ays
(n=4
5); 2
) -A
bx=n
o A
bx (n
=45)
. · N
o di
ffere
nce
infe
ctio
n ra
te b
etw
een
grou
ps (8
.7%
vs
8.9%
). · R
outin
e A
bx n
ot in
dica
ted
for o
pen
finge
r fra
ctur
es.
Hof
fer M
M
1992
S
hrap
nel w
ound
s in
chi
ldre
n.
J B
one
Join
t Sur
g 74
A:7
66-7
69
III
· 1
9 ch
ildre
n w
ith o
pen
extre
mity
frac
ture
. · A
ll w
ound
s m
anag
ed o
pen/
clos
ure
by s
econ
dary
inte
ntio
n.
· Abx
cho
ice
base
d on
ava
ilabi
lity.
Hop
e P
G
1992
O
pen
fract
ures
of t
he ti
bia
in c
hild
ren.
J
Bon
e Jo
int S
urg
74B
:546
-553
III
· 9
5 op
en ti
bia
fract
ures
: typ
e I (
24%
); ty
pe II
(55%
); ty
pe II
I (21
%) - b
road
-spe
ctru
m A
bx a
t le
ast 4
8 hr
s.
26
J B
one
Join
t Sur
g 74
B:5
46-5
53
le
ast 4
8 hr
s.
· 11%
wou
nd in
fect
ion
- inf
ectio
n ra
te c
orre
late
d w
ith d
egre
e of
sof
t tis
sue
inju
ry.
· Mos
t typ
e I,
som
e ty
pe II
wou
nds
suita
ble
for p
rimar
y cl
osur
e af
ter d
ebrid
emen
t, irr
igat
ion,
&
use
of s
yste
mic
Abx
for a
t lea
st 4
8 hr
s: 1
) cep
halo
spor
ins
q 4
hrs
x 3
days
; 2) g
enta
mic
in +
pe
nici
llin
due
to g
ross
con
tam
inat
ion
@ ti
me
of p
rese
ntat
ion
(3 p
ts).
· 2 d
ocum
ente
d in
fect
ions
(10%
)/ C
ompl
icat
ions
cor
rela
ted
with
wou
nd s
ever
ity.
San
ders
R
1992
Th
e sa
lvag
e of
ope
n gr
ade
IIIb
ankl
e an
d ta
lus
fract
ures
. J
Orth
op T
raum
a 6:
201-
208
III
· 1
1 op
en, G
rade
IIIb
ank
le fr
actu
res.
· Man
agem
ent p
roto
col:
1) m
ultip
le d
ebrid
emen
ts d
evita
lized
bon
e &
sof
t tis
sue;
2
) oss
eus
defe
cts
fille
d x/
Abx
impr
egna
ted
bead
s (to
bra)
; 3) t
empo
rary
ext
erna
l fix
atio
n;
4) d
elay
ed c
losu
re, b
one
graf
ting,
dyn
amic
com
pres
sion
pla
ting.
· Ant
ibio
tic p
roto
col:
1) c
epha
loth
in+t
obra
myc
in+p
enic
illin
; 2) A
bx d
isco
ntin
ued
@ d
isch
arge
if
seria
l bon
e cu
lture
s ne
g; 3
) spe
cific
Abx
initi
ated
for p
os. b
one
cultu
res
x 6
wks
. · 9
.1%
acu
te in
fect
ion.
· P
roto
col o
btai
ns w
ound
cov
erag
e, a
nkle
/sub
tala
r fus
ion,
& e
radi
cate
s os
teom
yelit
is.
Bed
nar D
A
1993
E
ffect
of t
ime
dela
y fro
m in
jury
to
prim
ary
man
agem
ent o
n th
e in
cide
nce
of d
eep
infe
ctio
n af
ter o
pen
fract
ures
of t
he lo
wer
ext
rem
ities
ca
used
by
blun
t tra
uma
in a
dults
. J
Orth
op T
raum
a 7:
532-
5
III
· 8
2 op
en fr
actu
res
of th
e lo
wer
ext
rem
ity.
· Man
agem
ent p
roto
col:
1) te
tanu
s pr
ophy
laxi
s; 2
) Gra
de I/
II/III
a - c
efaz
olin
; 3) G
rade
IIIb
/IIIc
- ce
fazo
lin +
gen
t/tob
ra; 4
) Abx
con
tinue
d x
48 h
rs, r
epea
t with
any
sub
sequ
ent s
urg.
pr
oced
ure.
· D
eep
infe
ctio
n =
4.9%
. · S
hort
dela
y to
def
initi
ve p
rimar
y su
rgic
al m
anag
emen
t not
pro
gnos
tical
ly im
porta
nt.
Firs
t Aut
hor
Yea
r R
efer
ence
C
lass
C
oncl
usio
ns
Hen
ry S
L 19
93
The
antib
iotic
bea
d po
uch
tech
niqu
e.
The
man
agem
ent o
f sev
ere
com
poun
d fra
ctur
es.
Clin
Orth
op 2
95:5
4-62
III
· 7
04 c
onse
cutiv
e op
en fr
actu
res.
· 2
27 m
anag
ed w
ith A
bx b
ead
pouc
h te
ch. f
or te
mp.
cov
erag
e of
wou
nds
with
and
with
out
soft
tissu
e de
fect
s +
cefa
zolin
/tobr
a/P
CN
IV.
· Wou
nd in
fect
ion
= 5.
3%; o
steo
mye
litis
= 3
.9%
. · M
ost u
sefu
l for
sev
ere
Gra
de II
I wou
nds-b
ead
pouc
h se
rves
as
subs
titut
e fo
r sof
t tis
sue.
· Rec
omm
end
pros
pect
ive
rand
omiz
ed s
tudy
to d
eter
min
e if
only
loca
l Abx
del
iver
y by
bea
ds
is s
uffic
ient
and
may
repl
ace
pare
nter
al A
bx.
Sel
igso
n D
19
94
The
man
agem
ent o
f ope
n fra
ctur
es
asso
ciat
ed w
ith a
rteria
l inj
ury
requ
iring
va
scul
ar re
pair.
J
Trau
ma
37:9
38-9
40
III
· M
etho
ds (n
=72)
: 1) c
efaz
olin
/tobr
a/P
CN
x 5
day
s (1
00%
); 2)
Abx
bea
d po
uch
(43%
)-non
-ra
ndom
ized
. · 1
0 w
ound
infe
ctio
ns (1
4%);
3 os
teom
yelit
is (4
%).
· Rec
omm
end:
man
dato
ry p
aren
tera
l bro
ad-s
pect
rum
Abx
and
adj
uvan
t use
of
amin
ogly
cosi
de-P
MM
A b
eads
. V
icto
roff
BN
19
94
Ext
rem
ity g
unsh
ot in
jurie
s tre
ated
in
an u
rban
chi
ldre
n’s
hosp
ital.
Ped
iatr
Em
erg
Car
e 10
:1-5
III
· 7
6 w
ound
s: 2
3 fra
ctur
es (3
0%)/5
3 so
ft tis
sue
wou
nds
(70%
); m
ost l
ow-v
eloc
ity.
· 45
pts
rece
ived
Abx
: 1st
gen
. cep
halo
spor
in (4
5/45
); ce
phal
ospo
rin =
+ am
inog
lyco
side
(2/4
5).
· 19/
24 p
ts w
ith fr
actu
res
(79%
) rec
eive
d A
bx x
48
hrs.
· No
infe
ctio
ns in
45
pts
rece
ivin
g A
bx.
· Rec
omm
end
Gra
de I/
II fra
ctur
es -
Abx
for 4
8 hr
s.
27
Ace
llo A
N
1995
Tr
eatm
ent o
f ope
n fra
ctur
es o
f the
fo
ot a
nd a
nkle
: A p
relim
inar
y re
port.
J
Foot
Ank
le S
urg
34:3
29-3
46
III
· I
nitia
tion
of a
ppro
pria
te A
bx A
SA
P is
impo
rtant
var
iabl
e in
redu
cing
rate
of i
nfec
tion.
· 60-
70%
ope
n fra
ctur
e w
ound
s co
ntam
inat
ed @
tim
e of
initi
al in
spec
tion
(aer
obic
G
PC
/GP
R).
· Inc
reas
ing
trend
tow
ard
gram
neg
. inf
ectio
ns h
as re
duce
d cl
inic
al re
leva
nce
of
pred
ebrid
emen
t wou
nd c
ultu
res.
· N
o st
udie
s do
cum
ent s
uper
iorit
y of
long
-term
vs.
per
iope
rativ
e A
bx c
over
age.
· Rec
omm
ende
d re
gim
en (G
ustil
o): 1
) Typ
e 1:
cef
azol
in; 2
) Typ
e II/
III: c
efaz
olin
+ a
min
o-gl
ycos
ides
; 3) 3
-day
cou
rse,
add
ition
al 3
-day
cou
rse
whe
n w
ound
in s
urgi
cally
man
ipul
ated
; 4)
1st
gen
erat
ion
ceph
alos
porin
ade
quat
e af
ter 3
day
s if
wou
nd is
not
clin
ical
ly in
fect
ed.
· Ret
rosp
ectiv
e st
udy:
com
paris
on o
f cef
azol
in/g
ent (
n=19
) vs
cefa
zolin
/Cip
ro (n
=6) in
ope
n fra
ctur
es o
f the
foot
and
ank
le.
· C/G
= 1
0.5%
infe
ctio
n; C
/C =
0%
infe
ctio
n ra
te.
Firs
t Aut
hor
Yea
r R
efer
ence
Titl
e C
lass
C
oncl
usio
ns
Col
e JD
19
95
A s
eque
ntia
l pro
toco
l for
man
agem
ent
of s
ever
e op
en ti
bial
frac
ture
s.
Clin
Orth
op 3
15:8
4-10
3
III
· P
roto
col:
1) C
efaz
olin
initi
ated
in E
D, c
ontin
ued
x 36
hrs
; 2) A
min
ogly
cosi
de a
dded
for h
ighl
y co
ntam
inat
ed w
ound
s by
clin
ical
exa
min
atio
n.
· Inf
ectio
n ra
te =
2%
, maj
ority
of p
ublis
hed
stud
ies.
· Im
porta
nce
of re
-est
ablis
hing
phy
siol
ogic
wou
nd ba
rrie
r (i.e
. ear
ly w
ound
clo
sure
) pre
vent
s de
ssic
atio
n/co
ntam
inat
ion
of w
ound
s. · I
M n
ailin
g sa
fe in
ope
n tib
ial f
ract
ures
. G
eiss
ler W
B 19
95
Com
pres
sion
pla
ting
of a
cute
fem
oral
sh
aft f
ract
ures
. O
rthop
edic
s 18
:655
-660
III
· 7
1 fe
mur
frac
ture
s: 5
8 cl
osed
/ 13
ope
n.
· Par
ente
ral A
bx.
· Inf
ectio
n ra
te =
0%
. · C
ompr
essi
on p
latin
g (n
on-s
tand
ard)
requ
ires
prop
hyla
ctic
Abx
, bon
e gr
aftin
g, m
etic
ulou
s te
chni
que.
K
rede
r HJ
1995
A
revi
ew o
f ope
n tib
ia fr
actu
res
in
child
ren.
J
Ped
iatr
Orth
op 1
5:48
2-48
8
III
· P
roto
col:
1)Te
tanu
s pr
ophy
. whe
n ap
prop
riate
; 2) W
ound
cul
ture
s/A
bx in
ED
, con
tinue
min
. 48
hrs
or u
ntil
defin
itive
wou
nd c
over
age;
3) T
ype
I/II:
broa
d-spe
ctru
m g
ram
pos
. cov
erag
e; 4
) Ty
pe II
I: am
inog
lyco
side
; 5) A
naer
obic
cov
erag
e-con
tam
inat
ed p
layg
roun
d/ba
rnya
rd.
· Inf
ectio
n ra
te =
14%
. · I
ncid
ence
of i
nfec
tion
func
tion
of ti
me
to in
jury
(> 6
hrs
) & p
rese
nce
of n
euro
vasc
ular
inju
ry.
Mar
sh J
L 19
95
Maj
or o
pen
inju
ries
of th
e ta
lus.
J
Orth
op T
raum
a 9:
371-
376
III
· 1
7 op
en ta
lar f
ract
ures
- re
ceiv
ed p
erio
pera
tive
Abx
. · I
nfec
tion
rate
= 3
8% >
oth
er o
pen
fract
ures
. · R
ecom
men
ded
prim
ary
tala
r bod
y ex
cisi
on in
sel
ect c
ases
. B
uckl
ey S
L 19
96
Sev
ere
(type
III)
open
frac
ture
s of
the
tibia
in c
hild
ren.
J
Ped
iatr
Orth
op 1
6:62
7-63
4
III
· P
roto
col:
1) C
epha
losp
orin
+ a
min
ogly
cosi
de in
itiat
ed in
ED
; 2) P
enic
illin
- far
m -
rela
ted
inju
ries;
3) M
inim
al d
urat
ion
Abx
= 4
8 hr
s; 4
) Abx
repe
ated
for s
ubse
quen
t deb
ridem
ents
. · O
steo
mye
litis
(15%
). · W
ound
irrig
atio
n &
deb
ridem
ent,
pare
nter
al A
bx, a
nd e
arly
soft
tissu
e co
vera
ge d
ecre
ase
inci
denc
e of
ost
eom
yelit
is.
· Inc
iden
ce o
f com
plic
atio
ns s
imila
r in
pedi
atric
and
adu
lt ty
pe II
frac
ture
s; c
hild
ren
mor
e
28
succ
essf
ully
trea
ted
for c
ompl
icat
ions
. C
ulle
n M
C
1996
O
pen
fract
ure
of th
e tib
ia in
chi
ldre
n. J
Bon
e Jo
int S
urg
78A
:103
9-10
47
III
· 2
% s
uper
ficia
l wou
nd in
fect
ion
/ 0%
ost
eom
yelit
is.
· Pre
vale
nce
of in
fect
ion
low
er in
chi
ldre
n vs
. adu
lts.
· Pre
vent
ion
depe
nds
on 1
) tho
roug
h de
brid
emen
t, 2)
irrig
atio
n, 3
) fra
ctur
e st
abili
zatio
n, a
nd
4) p
aren
tal A
bx.
Firs
t Aut
hor
Yea
r R
efer
ence
Titl
e C
lass
C
oncl
usio
ns
Grim
ard
G
1996
O
pen
fract
ures
of t
he ti
bia
in ch
ildre
n.
Clin
Orth
op 3
32:6
2-70
III
· B
road
-spe
ctru
m A
bx.
· Ave
rage
dur
atio
n A
bx =
5 d
ays.
· 7.1
% in
fect
ion
rate
: Gra
de I
(3);
Gra
de II
(2);
Gra
de II
I (1)
. · N
o co
rrel
atio
n be
twee
n ra
te o
f inf
ectio
n an
d gr
ade
of in
jury
. · N
o re
latio
nshi
p be
twee
n ra
te o
f inf
ectio
n an
d tim
e to
deb
ridem
ent.
· No
sign
ifica
nt e
ffect
on
infe
ctio
n as
a fu
nctio
n of
type
of w
ound
clo
sure
. S
tein
er A
K 19
96
Ope
n fra
ctur
es a
nd in
tern
al fi
xatio
n in
a
maj
or A
frica
n ho
spita
l. In
jury
27:
625-
630
III
· A
mpi
cilli
n =
mos
t com
mon
ly u
sed
Abx
. · P
osto
pera
tive
infe
ctio
ns (1
8.5%
). · I
nfec
tious
com
plic
atio
ns n
ot re
late
d to
Abx
use
. S
ong
KM
19
96
Ope
n fra
ctur
es o
f the
tibi
a in
chi
ldren
. J
Ped
iatr
Orth
op 1
6:63
5-63
9
III
· P
roto
col:
1) T
etan
us p
roph
ylax
is; 2
) 1st
gen
. cep
halo
spor
in x
24
hrs;
3) R
epea
t Abx
with
su
bseq
uent
pro
cedu
res.
· 3
dee
p in
fect
ions
(8%
): S
taph
aur
eus;
type
II (2
) typ
e III
(1).
· Inf
ectio
us c
ompl
icat
ions
rela
ted
to c
hoic
e of
fixa
tion
(i.e.
inte
rnal
vs.
ext
erna
l) an
d tim
e ex
tern
al fi
xato
r lef
t in
plac
e. To
rchi
a M
E 19
96
Ope
n fra
ctur
es o
f the
pat
ella
. J
Orth
op T
raum
a 10
:403
-409
III
· 1
0.7%
dee
p w
ound
infe
ctio
n - t
ype
II (3
) / ty
pe II
IB(3
). · I
nfec
tion
rate
cor
rela
tes
with
deg
ree
of s
oft t
issu
e da
mag
e.
· Cul
ture
s at
the
time
of in
itial
deb
ridem
ent o
f no
valu
e in
pre
dict
ing
subs
eque
nt in
fect
ion;
infe
ctio
n fre
quen
tly n
osoc
omia
l: P
seud
omon
as (3
), G
roup
D s
trep.
(2),
Ent
erob
acte
r (1)
,
Ent
erop
epto
cocc
us (1
), S
taph
aur
eus
(1).