Antimicrobial prophylaxis in fracture surgery

• following fracture surgery, infection can present as deep or superficial infection involving the wound and adjacent tissues, non-union of the fracture, bony instability and osteomyelitis
  
  
• infections occur at a rate of around 3-4% after repair of a closed fracture of a long bone. The infecting organisms resulting in infection following operative intervention of a closed fracture are similar to those following prosthetic joint implantation (see menu item)
  
  
• there is a higher risk of infection after surgery for open fractures. Before operation of an open fracture there is a high incidence of bacterial contamination (50-70%) and there may be extensive soft tissue damage - these factors contribute to the increased risk of infection which may be up to 55% for the most severe fractures. The spectrum of infecting organisms is greater for open rather than closed fractures - there is an increased proportion of infections involving anaerobic and gram-negative infections
• Preventive measures include: Traditionally, a first- or second-generation cephalosporin (e.g. cefuroximine) or, alternatively, a penicillinase - resistant penicillin (e.g. flucloxacillin) have been used as antimicrobial prophylaxis for orthopaedic implant surgery. However, the precise regimen should be based on local information about pathogens in orthopaedic surgical site infections and their susceptibility to antibiotics.
  • general measures (see menu item 'prevention of infection in orthopaedics')
  • for closed fractures:
    • intravenous antibiotics given 30-60 minutes before skin incicision, and continued for at most 24 hours (1)
  • for open fractures: thorough debridement, wound irrigation, early parenteral administration of high dose antibiotics; optimum duration of prophylaxis is not established

Reference:

• (1) Drug and Therapeutics Bulletin (2001), 39 (6), 43-6.