Antibiotic prophylaxis for closed limb fractures – adapted from the Lancet 1996;347;1133-7

Antibiotic prophylaxis for closed limb fractures – adapted from the Lancet 1996;347;1133-7 – Tips from Other Journals

The controversy concerning antibiotic prophylaxis in the surgical treatment of closed limb fractures is longstanding. The 11 prospective, randomized, controlled trials published in the past 25 years have differed in design and have failed to resolve this issue. Boxma and colleagues report the results of a large, randomized, doubleblind, placebo-controlled trial of antibiotic prophylaxis in the surgical treatment of closed limb fractures.

The study included 2,195 patients who were seen at 14 trauma units in the Netherlands. Patients who were scheduled to undergo surgical treatment were randomly given either 2 g of ceftriaxone or identical placebo at the induction of anesthesia. The trial was double-blinded by use of prefilled syringes, and all aspects of patient care were identical in the two groups of patients. At five to 15 days after surgery, patients were evaluated for evidence of infection. This evaluation was repeated at 30 and 120 days after surgery. Bacteriologic cultures were obtained in cases suspected of serious infection.

At the time of the first evaluation, five superficial and deep wound infections were detected in the 1,105 patients who received ceftriaxone, compared with 41 infections in the 1,090 patients who received placebo. When the analysis took into account patients who violated protocol or had incomplete data, these differences remained significant (4 percent for placebo versus 0.5 percent for cefiriaxone) and were significant even if a worst-case scenario was applied. The rate of development of late infections was approximately the same in the two treatment groups. After four months, 79 (8.3 percent) of the patients treated with placebo and 36 (3.6 percent) of those treated with ceftriaxone had acquired either a superficial or deep wound infection. The most common organism isolated in 98 positive cultures was Staphylococcus aureus.

The authors conclude that a single 2-g dose of ceftriaxone substantially reduces the incidence of early wound infections in patients undergoing surgery for closed fractures of the limbs. They discuss the advisability of giving antibiotics to only selected groups of patients at particularly high risk of infection, but conclude that savings in morbidity and costs indicate that all patients should receive antibiotic prophylaxis at the time of surgery for closed fractures of the limbs. They emphasize that such prophylaxis is adjunctive to other measures to prevent infection, such as scrupulous surgical technique and supportive general care. (Boxma H, et al. Randomized controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial. Lancet 1996;347:1133 7.)

COPYRIGHT 1996 American Academy of Family Physicians

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