Abstract
Objectives
The risk of infection after type III° open fractures is high (10–50%). Preemptive antibiotic therapy may prevent posttraumatic infection and improve the outcome. Recommendations about the type and duration of antibiotic vary among the institutions and it remains unclear whether gram-negative bacilli or anaerobs need to be covered.
In Europe, the most commonly recommended antibiotic is amoxicillin/clavulanic acid.
We retrospectively analyzed microbiology, characteristics and outcome of patients with open type III° fractures treated at our institution.
Methods
Between 01/2005 and 12/2009 we retrospectively included all type III grade open fractures of the leg at our institution classified after Gustilo (JBJS Am 1976) into type IIIA (adequate soft-tissue coverage of bone with extensive soft-tissue laceration or flaps), IIIB (extensive soft-tissue loss with periosteal stripping and bone exposure), and IIIC (requiring arterial injury repair). Demographic characteristics, clinical presentation, microbiology, surgical and antibiotic treatment and patient outcome were recorded using a standardized case-report form.
Results
30 cases of patients with type III° open fractures were included (25 males, mean age was 40.5 years, range 17–67 years). 27 fractures (90%) were located on the lower leg and 3 (10%) on the upper leg. 24 cases (80%) were high-energy and almost half of the patients (n=16, 53%) had a polytrauma. Microbiology at initial surgery was available for 19 cases (63%), of which 10 grew at least one organism (including 8 amoxicillin/clavulanic acid-resistant gram-negative bacilli [GNB], 7 amoxicillin/clavulanic acid-resistant Bacillus cereus), 11 were culture-negative. Preemptive antibiotics were given in all cases (100%) for an average duration of 8.5 days (range 1–53 days), the most common antibiotic was amoxicillin/clavulanic acid in 60 % (n=18). 11 cases just received preemptive antibiotic treatment, in 19 of 30 cases the antibiotic therapy was changed and prolonged. Microbiology at revision surgery was available for 25 cases and 22 grew at least one pathogen (including 32 amoxicillin/clavulanic acid-resistant gram-negative bacilli and 10 amoxicillin/clavulanic acid-resistant Bacillus cereus), 3 were culture-negative.
Conclusions
At initial surgery, most common isolated organisms were coagulase-negative staphylococci (43%), Bacillus cereus (23%), and gram-negative bacilli (27%), and others (7%) of which 48% were resistant to amoxicillin/clavulanic acid. At revision surgery, isolated organisms were gram-negative bacilli (64%), Bacillus cereus (20%), and others (16%) of which 88% were resistant to amoxicillin/clavulanic acid. The spectrum of amoxicillin/clavulanic does not cover the most common isolated organisms.
