Episode 41: Scratch the Gent! Antibiotics for Open Fractures with Rob O’Connell

• Why this topic important?
  • Accidental injury is the most common cause of death in the United States in individuals between the ages of 1 and 45
  • Falls are the most common reasons for hospital admissions in this older age group and account for 87% of fractures.
  • Open fractures are high-energy injuries with an increased risk of infection due to potential exposure of bone and deep tissue to a variety of environmental debris.

• What is the Gustilo and Anderson classification of open fractures?
  • Definition: a grading system that offered prognostic information about the outcome of infected fractures created by Gustilo and Anderson in 1976 described their treatment of 1025 open fractures.  
  • Grade I: Wound less than 1 cm long, punctured from below.
  • Grade II: Laceration 5 cm long; no contamination or crush; no excessive soft tissue loss, flaps, or avulsion
  • Grade III: Large laceration, associated contamination or crush; frequently includes a segmental fracture.
    • IIIA: Involves extensive soft tissue stripping of bone
    • IIIB: Periosteal stripping has occurred
    • IIIC: Major vascular injury present

• Infection rates for open fractures
  • Type 1
    •  0-2% risk of developing an infection
  • Type II
    •  2-12% risk of developing an infection
  • Type III
    • 10-50%   risk of developing an infection                 

• What does the Eastern Association for the Surgery of Trauma (EAST) guidelines recommend for grade 1, 2, and 3 open fractures?
  • Systemic antibiotic coverage directed at gram-positive organisms should be initiated as soon as possible after injury.
  • Additional gram-negative coverage should be added for type III fractures.
  • High-dose penicillin should be added in the presence of fecal or potential clostridial contamination (e.g., farm-related injuries).
  • In type III fractures, antibiotics should be continued for 72 hours after injury or not 24 hours after soft tissue coverage has been achieved.
  • Once-daily aminoglycoside dosing is safe and effective for types II and III fractures.

• What pharmacologic agents can we use for Grade 1+2 open fractures
  • Preferred: Cefazolin 2 g (3 g if > 120 kg) IV q8h
  • Clindamycin 900 mg IV q8h
  • Known MRSA colonization: Add vancomycin 15 mg/kg IV q12h
  • Duration of prophylaxis: 24 hours

• What pharmacologic agents can we use for Grade 3 open fractures
  • Preferred: Ceftriaxone 2g q24 x 2 days
    • Based on a study by Rodrigeuz et al in 2014 that reported significantly decreased use of aminoglycoside and glycopeptide antibiotics with no increase in skin and soft tissue infection rates.
  • Severe beta-lactam allergy: Clindamycin 900 mg IV q8h + levofloxacin 500 mg IV q24h

• Is there additional coverage for contamination with soil or fecal material?
  • Ceftriaxone 2 g IV q24h + metronidazole 500 mg IV q8h
  • Severe Beta-lactam allergy: Levofloxacin 500 mg IV q24h + metronidazole 500 mg IV q8h

• Is there additional coverage for contamination with standing water:
  • Preferred: Zosyn 4.5 g q8
  •  Severe beta-lactam allergy: Levofloxacin + Flagyl
  • When should we give Td/Tdap for open fractures?
    • >10 years clean wound
    • >5  years dirty wound

• Do studies show that having EM PharmDs involved helped with the antibiotic selection
  • Harvey et al. Impact of an emergency medicine pharmacist on initial antibiotic prophylaxis for open fractures in trauma patients. Am J Emerg Med. 2018 Feb;36(2):290-293.
    • P: 146 Trauma patients with open fractures at Level 2 trauma center in Lakeland FL
    • I: Pharmacist participating during trauma resuscitation
    • C: Prior time without pharmacists’ involvement in trauma resuscitation
    • O: More patient’s initial antibiotic prophylaxis was in accordance with the EAST guideline recommendations with a PharmD compared to none.
      • 81% versus 47%  Pharm vs no-pharmacist present (p < 0.01)
    • Median door-to antibiotic time was 14 mins

References via QxMD Read

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