Bradley A Lloyd1, Clinton K Murray, Faraz Shaikh, M Leigh Carson, Dana M Blyth, Elizabeth R Schnaubelt, Timothy J Whitman, David R Tribble. 1. From the San Antonio Military Medical Center (B.A.L., C.K.M., D.M.B.), Fort Sam Houston, San Antonio, Texas; Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department (F.S., M.L.C.), Uniformed Services University of the Health Sciences and the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland; Landstuhl Regional Medical Center (E.R.S.), Landstuhl, Germany; Walter Reed National Military Medical Center (T.J.W.), Bethesda, Maryland; and Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department (D.R.T.), Uniformed Services University of the Health Sciences, Bethesda, Maryland.
Abstract
BACKGROUND: We examined combat-related open extremity fracture infections as a function of whether posttrauma antimicrobial prophylaxis included expanded Gram-negative (EGN) coverage. METHODS: Military personnel with open extremity fractures sustained in Iraq and Afghanistan (2009-2014) who transferred to participating hospitals in the United States were assessed. The analysis was restricted to patients with a U.S. hospitalization period of ≥7 days. Prophylaxis was classified as narrow (e.g., IV cefazolin, clindamycin, and/or amoxicillin-clavulanate) or EGN, if the prophylactic regimen included fluoroquinolones and/or aminoglycosides. RESULTS: The study population included 1,044 patients, of which 585 (56%) and 459 (44%) received narrow and EGN coverage, respectively (p < 0.001). Skin and soft-tissue infections (SSTIs) were more common among patients who received narrow prophylaxis compared to EGN coverage (28% vs. 22%; p = 0.029), whereas osteomyelitis rates were comparable between regimens (8%). Similar findings were noted when endpoints were measured at 2 and 4 weeks postinjury. There was no significant difference related to length of hospitalization between narrow and EGN regimens (median: 34 and 32 days, respectively) or operating room visits (median: 5 and 4). A higher proportion of EGN coverage patients had Gram-negative organisms isolated that were not susceptible to fluoroquinolones and/or aminoglycosides (49% vs. 40%; p < 0.001). In a Cox proportional model, narrow prophylaxis was independently associated with an increased risk of extremity SSTIs (hazard ratio: 1.41; 95% confidence interval: 1.09-1.83). DISCUSSION: Despite seeing a small benefit with EGN coverage related to a reduction of SSTIs, it does not decrease the risk of osteomyelitis, and there seems to be a cost of increased antibiotic resistance associated with use. Overall, our findings support the current post-combat trauma antibiotic prophylaxis guidelines, which recommend the use of cefazolin or clindamycin with open fractures. LEVEL OF EVIDENCE: Prognostic/Epidemiological, Level II; Therapy, level IV.
BACKGROUND: We examined combat-related open extremity fracture infections as a function of whether posttrauma antimicrobial prophylaxis included expanded Gram-negative (EGN) coverage. METHODS: Military personnel with open extremity fractures sustained in Iraq and Afghanistan (2009-2014) who transferred to participating hospitals in the United States were assessed. The analysis was restricted to patients with a U.S. hospitalization period of ≥7 days. Prophylaxis was classified as narrow (e.g., IV cefazolin, clindamycin, and/or amoxicillin-clavulanate) or EGN, if the prophylactic regimen included fluoroquinolones and/or aminoglycosides. RESULTS: The study population included 1,044 patients, of which 585 (56%) and 459 (44%) received narrow and EGN coverage, respectively (p < 0.001). Skin and soft-tissue infections (SSTIs) were more common among patients who received narrow prophylaxis compared to EGN coverage (28% vs. 22%; p = 0.029), whereas osteomyelitis rates were comparable between regimens (8%). Similar findings were noted when endpoints were measured at 2 and 4 weeks postinjury. There was no significant difference related to length of hospitalization between narrow and EGN regimens (median: 34 and 32 days, respectively) or operating room visits (median: 5 and 4). A higher proportion of EGN coverage patients had Gram-negative organisms isolated that were not susceptible to fluoroquinolones and/or aminoglycosides (49% vs. 40%; p < 0.001). In a Cox proportional model, narrow prophylaxis was independently associated with an increased risk of extremity SSTIs (hazard ratio: 1.41; 95% confidence interval: 1.09-1.83). DISCUSSION: Despite seeing a small benefit with EGN coverage related to a reduction of SSTIs, it does not decrease the risk of osteomyelitis, and there seems to be a cost of increased antibiotic resistance associated with use. Overall, our findings support the current post-combat trauma antibiotic prophylaxis guidelines, which recommend the use of cefazolin or clindamycin with open fractures. LEVEL OF EVIDENCE: Prognostic/Epidemiological, Level II; Therapy, level IV.
Authors: Clinton K Murray; William T Obremskey; Joseph R Hsu; Romney C Andersen; Jason H Calhoun; Jon C Clasper; Timothy J Whitman; Thomas K Curry; Mark E Fleming; Joseph C Wenke; James R Ficke Journal: J Trauma Date: 2011-08
Authors: Duane R Hospenthal; Clinton K Murray; Romney C Andersen; R Bryan Bell; Jason H Calhoun; Leopoldo C Cancio; John M Cho; Kevin K Chung; Jon C Clasper; Marcus H Colyer; Nicholas G Conger; George P Costanzo; Helen K Crouch; Thomas K Curry; Laurie C D'Avignon; Warren C Dorlac; James R Dunne; Brian J Eastridge; James R Ficke; Mark E Fleming; Michael A Forgione; Andrew D Green; Robert G Hale; David K Hayes; John B Holcomb; Joseph R Hsu; Kent E Kester; Gregory J Martin; Leon E Moores; William T Obremskey; Kyle Petersen; Evan M Renz; Jeffrey R Saffle; Joseph S Solomkin; Deena E Sutter; David R Tribble; Joseph C Wenke; Timothy J Whitman; Andrew R Wiesen; Glenn W Wortmann Journal: J Trauma Date: 2011-08
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