Amanda Binkley, PharmD, AAHIVP
Clinical Pharmacy Specialist, Infectious Diseases
Penn Presbyterian Medical Center, United States
Disclosure information not submitted.
Jillian Baron, MD
Attending Physician, Infectious Disease
Penn Presbyterian Medical Center, United States
Disclosure information not submitted.
Niels Martin, MD, FCCM
Associate Professor of Surgery
University of Pennsylvania
Philadelphia, Pennsylvania
Disclosure information not submitted.
Lauren Schmidt, PharmD, BCCCP
Clinical Pharmacy Specialist, Critical Care
Penn Presbyterian Medical Center
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
Title: Characterization of antimicrobial prophylaxis and definitive repair in traumatic open fractures
INTRODUCTION/HYPOTHESIS: Traumatic open fractures are associated with an increased risk of infection secondary to soft-tissue damage and potential contamination with environmental elements. Societal guidelines provide conflicting recommendations for antimicrobial agent selection and duration of prophylaxis. Although a standardized guideline has been published at our health system, we hypothesized that evaluation of clinical outcomes in the setting of suspected noncompliance could lead to health system guideline optimization.
Methods: This retrospective, single center, quality improvement study included adult patients admitted with traumatic open fractures between July 1, 2017 and July 1, 2020. The primary outcome evaluated adherence to health system guideline recommendations for agent selection and duration prior to definitive operative repair. Secondary outcomes included time from hospital admission to prophylaxis initiation, incidence and timing of secondary infection(s) and those due to multi-drug resistant organisms (MDROs), incidence of acute kidney injury (AKI), and hospital and ICU lengths of stay. Continuous and categorical data were evaluated using Wilcoxon signed rank and chi-squared tests, respectively.
Results: Of 472 patients screened, 197 met inclusion criteria. Initiation of inappropriate antimicrobials occurred more frequently with type II/III fractures (29% vs. 8%; p=0.007). The prophylaxis duration across all fracture types exceeded current health system recommendations of less than 48 hours after operative repair (3.7 days [1-9] vs. 3.9 days [1-11]). Antimicrobial initiation occurred within 1 hour of admission for all patients (0.72 hours [0.5-1] vs. 0.75 hours [0.5-1.25]; p=0.57) and no infections were identified at the primary fracture site(s). A higher incidence of AKI was observed with both cefazolin and gentamicin compared to cefazolin alone (10.6% vs. 6.1%; p=0.28). The incidence of secondary and MDRO infections, as well as hospital and ICU lengths of stay, were similar between groups.
Conclusions: The results of this study led to health system guideline optimization to ceftriaxone monotherapy for type II and III fractures and prophylaxis duration of less than 72 hours’ post injury. Assessment of post-implementation adherence provides an opportunity for further evaluation.