Duration of preventive antibiotic administration for open extremity fractures. Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial Comparison of Antibiotic Beads and Intravenous Antibiotics in Open Fractures Prophylactic Antibiotics in Open Fractures: A Pilot Randomized Clinical Safety Study Antibiotic prophylaxis in the surgical treatment of peritrochanteric fractures: a comparative trial between two cephalosporins. Antibiotic prophylaxis in open and closed fractures: a controlled clinical trial. Antibiotic prophylaxis with two doses of cephalosporin in patients managed with internal fixation for a fracture of the hip. Role of prophylactic antibiotics in open and basilar fractures of the skull: a randomized study. Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. A double-blind clinical trial of prophylactic antibiotics in hip fractures. Treatment of open fractures: a prospective study. Novel concepts: emerging data and the role of extended prophylaxis following hip fracture surgery. The use of Prophylactic Flucloxacillin in Treatment of Open Fractures of the Distal Phalanx within an Accident and Emergency Department: A Double-Blind Randomized Placebo-Controlled Trial Severe Open Tibial Fractures: A Study Protocol Implementation of an evidence-based guideline to reduce duration of intravenous antibiotic therapy and length of stay for patients hospitalized with community-acquired pneumonia: a randomized controlled trial. Role of prophylactic intravitreal antibiotics in open globe injuries.
The necessary duration of antibiotic administration after open fracture has not been established . In a double-blind prospect i ve trial we r and omized 248 patients with open fractures to receive one or five days of cefonicid sodium therapy or five days of cefam and ole nafate therapy as part of the initial treatment . Rates of fracture-associated infections in the three groups were ten ( 13 % ) of 79 , ten ( 12 % ) of 85 , and 11 ( 13 % ) of 84 , respectively . The 95 % confidence limit for the difference in infection rates between the one-day group and the combined five-day groups was 0 % to 8.3 % . The actual difference was 0.2 % . A brief course of antibiotic administration is not inferior to a prolonged course of antibiotics for prevention of postoperative fracture-site infections BACKGROUND The efficacy of prophylactic antibiotics in fracture surgery remains controversial for lack of well-documented prospect i ve studies . We report here the findings of the Dutch Trauma Trial , a prospect i ve , r and omised , double-blind , placebo-controlled study of antibiotic prophylaxis in the primary operative treatment of limb fractures .  Ceftriaxone was chosen because of its pharmacokinetic profile , including high serum levels , high tissue penetration , and long elimination half-life , makes it suitable for single-dose prophylaxis . METHODS Patients aged 18 years or more , attending one of fourteen Dutch centres for acute treatment of closed fractures , were r and omly allocated to a single preoperative dose of ceftriaxone 2 g or placebo , and evaluated for development of wound infection and nosocomial infection at 10 days , 30 days , and 120 days . To assess the effects of drop-outs and withdrawals , best-case and worst-case analyses were performed . FINDINGS A total of 2195 patients were included . The incidence of superficial and deep wound infections after placebo was 8.3 % , compared with 3.6 % in the ceftriaxone group ( p < 0.001 , Pearson chi 2-test ) . The rate of nosocomial infection in the first month was 10.2 % with placebo and 2.3 % with ceftriaxone ( p < 0.001 , Pearson chi 2-test ) . Gram-positive bacteria were found in 74.5 % of wound infections and 13.4 % of nosocomial infections . INTERPRETATION Adequate single-dose prophylaxis with a long-acting broad-spectrum antibiotic substantially reduces the incidence of wound infection and early nosocomial infection after surgery for closed fractures This study compared the efficacy of antibiotic impregnated beads with conventional intravenous antibiotics in the treatment of open fractures . A r and omized prospect i ve study was design ed and conducted during a 29-month period . Sixty-seven patients with 75 open fractures were treated similarly , with the exception of the method of antibiotic administration , and were followed up for at least 1 year after injury . Infection occurred in two of 24 ( 8.3 % ) fractures treated with antibiotic beads alone and in two of 38 ( 5.3 % ) fractures treated with conventional intravenous antibiotics . In an unanticipated nonr and omized third cohort group , patients received antibiotic beads and intravenous antibiotics administered for nonorthopaedic reasons or limb threatening injury , or both . Two of 13 ( 15.4 % ) fractures in this high risk group became infected . Infection ultimately resolved in all fractures treated with antibiotic beads alone or antibiotic beads in conjunction with conventional intravenous antibiotics . This study was unable to achieve statistical significance ; however , the data suggest antibiotic beads may be useful in preventing infection in open fractures . Thus , a larger multicenter r and omized prospect i ve study of isolated open fractures , eliminating other variables , is justified Objective : To develop preliminary data on Staphylococcus aureus colonization and surgical site infections ( SSIs ) in patients with open fractures who received st and ard antibiotic prophylaxis  compared with a regimen including targeted methicillin-resistant Staphylococcus aureus ( MRSA ) coverage . Design : R and omized prospect i ve clinical trial . Patients : Adult patients who presented to the emergency department with an open fracture between April 2009 and July 2011 . Interventions : One hundred thirty patients were r and omized to receive prophylaxis with either cefazolin alone ( control arm ) or vancomycin and cefazolin ( experimental arm ) from presentation to the emergency department until 24 hours after the surgical intervention . Screening for S. aureus carriage was performed with nares swabs and predebridement and postdebridement open fracture wound swabs . Patients underwent prospect i ve assessment for the development of SSI for no less than 30 days and up to 12 months . Results : Nasal colonization of methicillin-sensitive S. aureus and MRSA among the sample was 20 % and 3 % , respectively . No significant difference in the rates of SSI was observed between the study arms ( 15 % vs 19 % , respectively , P = 0.62 ) . Staphylococcus aureus caused 55 % of the deep incisional/organ space SSI , with 18 % attributed to MRSA . A significantly higher rate of MRSA SSIs was observed among MRSA carriers compared with noncarriers ( 33 % vs 1 % , respectively , P = 0.003 ) . Conclusions : Staphylococcus aureus nasal colonization in trauma patients with open fractures is similar to that of the general community . In this pilot study , the addition of vancomycin to st and ard antibiotic prophylaxis was found safe , but its efficacy should be evaluated in a larger multiinstitutional trial . Level of Evidence : Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence In a study of 200 patients scheduled for orthopedic surgery , prophylaxis with either ceftriaxone or cefotaxime was equally effective . No patient developed bacterial infection , either systemic or local , during the first 10 postoperative days . In the 1-year follow-up period , 2 patients developed deep wound infection ( 1 from each group ) . Ceftriaxone 1 g was given once only as a single preoperative dose , whereas cefotaxime was , in addition to the preoperative dose , also given postoperatively every 8 h for 3 days ( totally 9 doses of 1 g ) . Emphasis is placed on the practical advantage of the single dose of ceftriaxone , which facilitates nursing of the patient The value of prophylactic antibiotics in fracture surgery was studied in a series of 90 patients with open fractures of various bones and 180 patients with closed malleolar fractures treated by open surgery .  Dicloxacillin and benzyl penicillin were compared to saline ( placebo ) . The soft tissue lesions of the open fractures were divided into Grade I wounds and Grade II & III wounds . Of the patients with Grade I wounds , 17 received dicloxacillin , 21 benzyl penicillin and 17 saline . No major infections occurred . Twelve patients with Grade II & III wounds were treated with dicloxacillin , 10 with benzyl penicillin and 13 with saline . In the saline group , 2 patients developed a deep infection .  Fifty-eight patients with closed malleolar fractures received dicloxacillin , 59 benzyl penicillin and 63 saline . Two infections developed in the placebo group . A statistically significant difference was found between the number of infections in the antibiotic groups and the number in the placebo group . Superficial thromboplebitis following the antibiotic infusion occurred in 16 per cent of the dicloxacillin treated patients and in 1 per cent of those treated with benzyl penicillin or placebo A prospect i ve , r and omized , double-blind study was performed to evaluate the effects of antibiotic prophylaxis on the development of a wound infection in 239 patients who had immediate stabilization of a fracture of the proximal part of the femur with a dynamic hip screw . The effects of two perioperative doses of cefotiam , given twelve hours apart , were compared with those of two doses of a placebo .  Sixteen perioperative risk factors were evaluated to determine whether it was possible to identify patients who were at risk for a wound infection . All patients were followed for a minimum of six weeks . Antibiotic prophylaxis significantly reduced the prevalence of wound infection ( p < 0.05 ) : the rate of major wound infection decreased from 5 to 1 per cent and the rate of minor wound infection , from 11 to 4 per cent . The most powerful predictors of major wound infection were the duration of the operation , the interval between the accident and admission to the hospital , and the duration of postoperative urinary catheterization . The preoperative level of serum albumin and the absolute lymphocyte count were significant predictors ( p < 0.05 ) of minor wound infection and systemic infection , respectively The aim of this study was to investigate the controversial issue of the use of prophylactic antibiotics in open and basilar fractures of the skull . A series of 157 patients were r and omized to receive no antibiotics ( group A = 46 patients ) or ceftriaxone for 3 days ( group B = 50 patients ) , or the combination ampicillin/sulphadiazine for 3 days ( group C = 61 patients ) . The incidence of meningitis was similar in both the antibiotic and non-antibiotic groups . However , the overall incidence of infectious complications in the non-antibiotic group was significantly higher than in the antibiotic group ( 8.7 per cent vs 0.9 per cent , P < 0.05 ) . There was no significant difference between the ceftriaxone group and the ampicillin/sulphadiazine group . The results of the study suggest that antibiotic prophylaxis has a role in the management of open and basilar fractures OBJECTIVE The purpose of this study was to compare the efficacy of a single agent , ciprofloxacin , with that of combination antibiotic therapy consisting of cefam and ole and gentamicin in all types of open fracture wounds . STUDY DESIGN A prospect i ve double-blind r and omized clinical trial . SETTING A Level 1 trauma center . PATIENTS One hundred ninety-five consecutive patients with 203 open fractures were enrolled over a twenty-month period . Twenty-nine fractures from low-velocity gunshot wounds were excluded , and three other patients were excluded because of protocol violations . Our final number of patients were 163 , with 171 open fractures . MAIN OUTCOME MEASUREMENT The infection rates for Type I and Type II open fractures for both antibiotic groups were calculated . The infection rate of Type III open fractures for both antibiotic groups was also calculated . Chi-square analysis with Yates correction was used to assess statistical significance of two treatment groups . RESULTS The infection rate for Types I and II open fractures in the ciprofloxacin group was 5.8 percent and 6 percent for the cefam and ole/gentamicin group ( p = 1.000 ) . The infection rate for Type III open fractures for the ciprofloxacin group was 31 percent ( 8 of 26 ) versus 7.7 percent ( 2 of 26 ) for the cefam and ole/gentamicin group ( p = 0.079 ) . There were no statistically significant differences in infection rate between the group treated with ciprofloxacin and that treated with cefam and ole/gentamicin for Types I and II open fracture wounds . However , there appeared to be a high failure rate for the ciprofloxacin Type III open fracture group , with patients being 5.33 times more likely to become infected than those in the combination therapy group . Although this difference was not statistically significant , possibly because of the small sample size , there was a definite trend toward statistical significance . CONCLUSION Single-agent antibiotic therapy with ciprofloxacin is effective in treatment of Type I and Type II open fracture wounds . However , on the basis of our results , we can not recommend ciprofloxacin alone for Type III wounds . Possibly one can use fluoroquinolones in combination therapy , specifically as an alternate to an aminoglycoside In 673 open fractures of long bones ( tibia and fibula , femur , radius and ulna , and humerus ) treated from 1955 to 1968 at Hennepin County Medical Center , Minneapolis , Minnesota , and analyzed retrospectively , the infection rate was 12 per cent from 1955 to 1960 and 5 per cent from 1961 to 1968 . In a prospect i ve study from 1969 to 1973 , 352 patients were managed as follows : débridement and copious irrigation , primary closure for Type I and II fractures and secondary closure for Type III fractures , no primary internal fixation except in the presence of associated vascular injuries , cultures of all wounds , and oxacillin-ampicillin before surgery and for three days postoperatively . In 158 of the patients in the prospect i ve study the initial wound cultures revealed bacterial growth in 70.3 per cent and the infection rate was 2.5 per cent . Sensitivity studies suggested that cephalosporin is currently the prophylactic antibiotic of choice . For the Type III open fractures ( severe soft-tissue injury , segmental fracture , or traumatic amputation ) , the infection rates were 44 per cent in the retrospective study and 9 per cent in the prospect i ve study Antibiotics were given for prophylaxis in hip-fracture patients to a r and omized group of patients with hip fractures ( 417 ) treated by operation at the Massachusetts General Hospital during three years . After excluding those patients with history of penicillin sensitivity , and those patients already receiving antibiotics at the time of fracture , 348 patients were r and omly assigned to a treatment ( sodium nafcillin ) or control ( glucose ) group . Either antibiotic or placebo was given before , during , and after operation . The incidence of postoperative wound infection was seven in 145 ( 4.8 per cent ) in the control group , and one in 135 ( 0.8 per cent ) in the treatment group , a statistically significant difference ( P = 0.041 ) . The incidence of postoperative wound hematomas was high in each group , possibly because of the routine use of sodium warfarin . Subsequent infection developed in a few of these hematomas , with similar incidence in the control ( four in 145 ) and treatment ( six in 135 ) groups A double-blind prospect i ve study was done to assess the benefit of delaying closure of the wounds associated with open fractures . An additional double-blind study compared the effectiveness of clindamycin versus cefazolin for prophylactic antibiotic coverage . Quantitative cultures of the wounds were accomplished at the time of debridement and again at the time of closure if the wound was not closed initially . Almost half of the wounds were contaminated ( 46 % ) at the time of debridement , although the incidence of wound infection was low ( 6.5 % ) . Gram-negative organisms resistant to the prophylactic antibiotic were recovered initially only eight times , but four of these ( 50 % ) became infected . The contaminating organisms in each case were present in high concentration ( greater than 10(5 ) CFU/gm of tissue ) at initial culture . The time of wound closure , cefazolin versus clindamycin , and internal fixation of the fracture were not followed by significant differences in the development of clinical infection in this series The typical duration of hospitalization following major knee and hip surgeries may not provide adequate time for effective prophylaxis of venous thromboembolism ( VTE ) when inpatient therapy only is administered . Results from a clinical trial that extended the duration of VTE prophylaxis after hip fracture surgery are review ed . The risk of VTE after major knee and hip arthroplasty has been demonstrated to extend into the outpatient period . Although extending the duration of VTE prophylaxis has been demonstrated to decrease the incidence of VTE following total hip replacement , no r and omized , double-blinded assessment had demonstrated the effectiveness of this strategy following hip fracture surgery . A multicenter , r and omized , placebo-controlled , double-blind trial was conducted to assess prolonged prophylaxis of VTE in patients undergoing surgery for fracture of the upper third of the femur . Patients received an initial 7 + /- 1 day open period of treatment with subcutaneous fondaparinux ( 2.5 mg once daily ) ; 656 patients were subsequently r and omized to receive a 21 + /- 2-day double-blind treatment period of either the same fondaparinux regimen or placebo . Fondaparinux treatment produced statistically significant reductions in the incidence of all VTE events ( 1.4 % compared with placebo 35.0 % ) ; prolonged prophylaxis was associated with a 96 % relative risk reduction for VTE ( p < 0.001 ) . Also , no differences were observed in the incidence of other major endpoints such as bleeding or death . These results indicate that extended prophylaxis with fondaparinux significantly reduces the risk of VTE without increasing the risk of major bleeding Open fractures of the distal phalanx commonly present to the Accident and Emergency Department . Controversy surrounds the use of prophylactic antibiotics in treating this injury . A double-blind , prospect i ve , r and omized placebo-controlled study was undertaken comparing the use of prophylactic flucloxacillin to placebo in addition to meticulous wound toilet . One hundred and ninety-three adult patients with an open fracture of the distal phalanx were studied . Seven patients developed superficial infections , an overall infection rate of 4 % . No patient developed osteitis or a deep wound infection . There were three cases of infection in the 98 patients ( 3 % ) in the antibiotic group and four cases of infection in the 95 patients ( 4 % ) in the placebo group . A difference of proportion test confirmed no significant difference . It is concluded that the addition of prophylactic flucloxacillin to thorough wound toilet and careful soft-tissue repair of open fracture of the distal phalanx confers no benefit A prospect i ve r and omized study of severe open tibial fractures ( Type II and III ) was performed . Individual fractures were r and omized to treatment groups according to initial antibiotic therapy : One consisted of a first-generation cephalosporin , and the other consisted of a third-generation cephalosporin . Initial antibiotic therapy was given in all patients for 48 h and then specific antibiotic treatment was used as indicated by culture . The purpose of this study was to determine whether or not additional gram-negative coverage had an effect on the overall infection rate or the type of infection in severe open tibial fractures . Additional factors , such as the timing of bone grafts and soft tissue coverage , were evaluated in this study as well . Although there was no statistical difference in the rate of infection with the use of a first-versus a third-generation cephalosporin , there was a trend toward a decreased infection rate as well as toward less morbid infections with the use of a third-generation cephalosporin . The study also confirms that early bone graft should not be performed prior to 6 weeks post injury or after successful soft tissue coverage has been achieved . On the other h and , soft tissue coverage procedures should be performed at the earliest possible date to decrease the overall infection rate PURPOSE Patients with pneumonia often remain hospitalized after they are stable clinical ly , and the duration of intravenous antibiotic therapy is a rate-limiting step for discharge . The purpose of this study was to determine whether implementation of an evidence -based guideline would reduce the duration of intravenous antibiotic therapy and length of stay for patients hospitalized with pneumonia . METHODS In a seven-site , cluster r and omized clinical trial , we enrolled 325 control and 283 intervention patients who were admitted by one of 116 physician groups . Within site , physician groups were assigned r and omly to receive a practice guideline alone ( control arm ) or a practice guideline that was implemented using a multifaceted strategy ( intervention arm ) . The effectiveness of guideline implementation was measured by the duration of intravenous antibiotic therapy and length of stay ; differences in the rates of discontinuation and hospital discharge were assessed with proportional hazards models . Medical outcomes were assessed at 30 days . RESULTS Intravenous antibiotic therapy was discontinued somewhat more quickly in the intervention group ( hazard ratio [ HR ] = 1.23 ; 95 % confidence interval [ CI ] : 1.00 to 1.52 ; P = 0.06 ) than in the control group . Intervention patients were discharged more quickly , but the difference was not statistically significant ( HR = 1.16 ; 95 % CI : 0.97 to 1.38 ; P = 0.11 ) . Fewer intervention ( 55 % [ 157/283 ] ) than control ( 63 % [ 206/325 ] ) patients had medical complications during the index hospitalization ( P = 0.04 ) , with no differences in other medical outcomes , including mortality , rehospitalization , and return to usual activities , between treatment arms . CONCLUSIONS The multifaceted guideline implementation strategy result ed in a slight reduction in the duration of intravenous antibiotic therapy and a nonsignificant reduction in length of stay , without affecting patient outcomes PURPOSE To determine the efficacy of prophylactic intravitreal antibiotics in reducing the incidence of endophthalmitis after trauma . METHODS This was a prospect i ve , r and omised , case control study of 70 consecutive patients with open globe injury . The patients were prospect ively r and omised into group I ( 32 eyes ) and group II ( 38 eyes ) . Group I patients were given prophylactic intravitreal injection of vancomycin 1 mg and ceftazidime 2.25 mg at the conclusion of primary repair . Group II patients were not given prophylactic intravitreal antibiotics . All the patients received intravenous ciprofloxacin . RESULTS The incidence of endophthalmitis was higher in group II ( 7 of 38 eyes ; 18.42 % ) compared to group I ( 2 of 32 eyes ; 6.25 % ) . Both the patients who developed endophthalmitis despite prophylactic intravitreal antibiotics in group I had an initially undetected intraocular foreign body ( eyelash ) in the vitreous cavity . CONCLUSIONS Prophylactic intravitreal broad spectrum antibiotic injection decreases the risk of post-traumatic endophthalmitis
Results of r and omized controlled trials performed to date provide evidence that antibiotic prophylaxis reduces subsequent infection and that courses as short as one day are as effective as courses of three to five days , although the evidence warrants only low to moderate confidence .
BACKGROUND The purpose of the present study was to perform a systematic review and meta- analysis of the use of alternative antibiotic regimens-including ( A ) antibiotic prophylaxis versus no prophylaxis , ( B ) longer versus shorter duration of antibiotic prophylaxis , and ( C ) alternative drugs-for  patients with open fracture of the extremities .