Effectiveness of Prophylactic Antibiotics in Infection Prevention in Closed Lower-Limb Fracture Surgery

doi:10.21203/rs.3.rs-1399484/v1

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Effectiveness of Prophylactic Antibiotics in Infection Prevention in Closed Lower-Limb Fracture Surgery

https://doi.org/10.21203/rs.3.rs-1399484/v1

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Background:‌ Postoperative infection is a major orthopedic problem that can be reduced by prescribing antibiotics to prevent surgical infection as an effective strategy. Therefore, the present study aimed to evaluate the effectiveness of prophylactic antibiotics to prevent infection in closed lower limb fracture surgery.

Methods:‌ The present study was conducted on all patients with closed lower limb fracture from hip to the ankle that underwent Open reduction and internal fixation ‌(ORIF)‌ by a surgeon and received antibiotics and prophylactic antibiotics. The patients who received cefazolin prophylactic antibiotics 1 hour before surgery and 24 hours after surgery were put into the first group. Those receiving cefazolin prophylactic antibiotics 1 hour before surgery and up to 72 hours after surgery were put into the second group. It should be noted that the criterion for the presence of infection was the physician’s clinical judgment based on clinical manifestations such as heat, redness and swelling, pain and infectious secretions, and laboratory tests.

Results:‌ Of 140 patients with closed lower limb fractures, two patients‌ (1.4%)‌were infected in each group. The culture of two patients with infection resulted in Staphylococcus aureus, and both patients showed fever and chill symptoms. Infection rates in patients, who received prophylactic antibiotics for 24 hours, had no significant difference with those who received antibiotics for 72 hours ‌(p=0.99).

Conclusion:‌ Based on the present study results, the 24-hour prophylactic antibiotic administration to reduce risks of postoperative infection of the closed lower limb fracture in patients can be a suitable alternative for the long-term use of antibiotics.

Fracture

Lower limb

Antibiotics

Prophylaxis

Infection

In about 1–5% of some orthopedic procedures, such as total hip replacement (THR) and total knee replacement (TKR) surgeries, a severe infection of surgical wound could be developed (1). Although preventable, they can be associated with increased long-term complications, morbidity, and mortality (2), emphasizing the importance of using appropriate preventive factors to reduce such postoperative infections. In general, disinfection and sterilization of the wound, the appropriate use of prophylactic antibiotics, and decreased postoperative recovery time have been considered as effective preventive methods against surgical site infections. Despite the extraordinary advances in the field of treatment and care of trauma patients in recent years, traumatic injuries are still one of the fundamental causes of mortality in the world (3, 4). During the past few decades, many efforts have been made to reduce the mortality of the patients in the accident scene and during the transfer to the hospital. Nevertheless, those who survive the traumatic injury itself have a 30–80% chance of death of infections (5, 6). Multiple factors make traumatic patients prone to infection, e.g., skin lesions that facilitate the entry of pathogens into the body and the presence of dead or damaged tissues with a limited blood supply that is easily susceptible to infections (1, 7). Traumatic injuries leading to bone fracture could be divided into 2 main categories: open and closed fractures (8).

A closed fracture can be defined as a bone fracture with no manifestation on the skin. In other words, the broken bone is not in contact with the outside environment, the skin is intact, and a mild-to-moderate swelling or redness may be present in the fracture site. It should be noted that soft tissue damage is possible in these fractures, but it is often partial rather than complete tissue deterioration. The incidence of infection is low after closed fracture surgeries, with a prevalence of 0.5-5% (8). Therefore, prophylactic antibiotics for preventing postoperative wound infections may be effective and indicated in certain situations. Advantages of an appropriate prophylactic antibiotic therapy are: 1) decreasing the rate of postoperative infection, resulting in faster wound healing and reduced postoperative complications; 2) lowering the burden of the disease on the health care system by decreasing the costs of the treatment; 3) reducing the risk of bacterial resistance. A previous study demonstrated that using prophylactic antibiotics to treat closed femoral neck fracture surgery effectively reduced the postoperative infection rate. However, it is of note that administering an inappropriate antibiotic could cause adverse drug reactions (ADRs), impose an unnecessary burden on the healthcare system, and create a resistant bacterial strain (9). Though various guidelines have been developed to reduce and modify this issue, the present data could not sufficiently and effectively address this major health problem (2). Therefore, the present study aimed to assess the efficacy of prophylactic antibiotic therapy in preventing pre-and-postoperative infections in closed lower extremity fracture surgeries.

The present study was conducted on patients with closed lower limb fractures referred to the Emergency Department of Shahid Beheshti Hospital, Babol, Iran, who underwent open reduction and internal fixation (ORIF), and received prophylactic treatment as well as postoperative antibiotics. All data were extracted from the patients’ files based on the following inclusion and exclusion criteria:

Inclusion criteria: Men and women aged 15–65 years; closed lower limb fractures (pelvic, hip, knee, leg, and ankle).

Exclusion criteria: Patients treated with external fixation or percutaneous fixation; those with open, compound, or multiple fractures; evidence of infection in the past week; history of cefazolin administration recently; antibiotic therapy for more than 3 days before randomization; history of allergy to penicillin and cephalosporins; history of osteoporosis, immunosuppression, rheumatoid arthritis (RA), diabetes mellitus (DM), ischemic heart disease (IHD), hypertension (HTN), or chronic obstructive pulmonary disease (COPD).

Then, patients who received one gram of intravenous cefazolin 1 hour before and up to 24 hours (every 6 hours) after the surgery were allocated to the first group, and patients who received one gram of intravenous cefazolin 1 hour before and up to 72 hours (every 6 hours) after the surgery were categorized in the second group. The patients’ demographics, including age and sex, past medical history, mechanism of trauma leading to limb fracture, duration between the trauma to hospital admission, type of fracture (upper and lower limbs), location and characteristics of the wound, indication of administered prophylactic antibiotic, types of administered antibiotics, drug dosage, drug administration method, time of antibiotic therapy initiation, intervals of antibiotic therapy, and duration of surgery were recorded. Washing, debridement, suture, and wound dressing were similarly done in all patients, if possible. Drains were removed within 24 hours after the operation, and patients were discharged if their nutrition tolerance and mobility were improved and did not have a fever.

Data were analyzed using SPSS v. 22 (IBM, NY, USA). Chi-square and student’s t-tests were performed for the statistical analysis, and p-values of less than 0.05 were considered statistically significant.

In the present study, 140 patients referred to the Emergency Department of Shahid Beheshti Hospital with closed lower limb fractures were included. The mean age of patients was 36.66 ± 14.42 years, ranging from 15–65 years, of which 106 patients (75.7%) were male. In total, two patients, one from each study group, were manifested with fever and chills, and their blood culture indicated Staphylococcus aureus infection. The infection rate was not significantly different between the two groups (p = 0.99). There was also no significant relationship between the two groups in the trauma etiology (p = 0.18) and the examined fraction sites (p = 0.31). The patients’ heights and weights indicated a significant difference between the two groups, while no significant difference was observed between the two groups in other demographics.

According to the relationship between infection and studied variables in patients who received antibiotics for up to 24 hours, only age was significantly associated with post-surgical infection (p = 0.01). There were no significant differences between clinical variables with post-surgical infection in the first group. On the other hand, there was no significant relationship between demographic and clinical variables with postoperative infection in patients who received antibiotics for up to 72 hours. There was no significant difference between the quantitative variables studied with postoperative infections in the second group.

The present study aimed to compare the efficiency of prophylactic antibiotics for different durations (up to 24 and 72 hours) after surgery in preventing infection in lower limb fractures. According to separate analyses on infection-dependent variables, the outcome of prophylactic antibiotics administration in the first and the second groups was not significantly different, and the infection rates were similar in both groups.

According to studied relationships of variables with the incidence of infection in the two groups, the indices, such as age, sex, and body mass index, and clinical variables, including the duration of surgery and the amount of blood loss during surgery, showed no relationship between the incidence of infection in either group. Nevertheless, it should be noted that one case of infection in the first group was observed in a patient older than 60 years of age, probably due to age-related factors as issues affecting the infection rate, such as osteoporosis, and underlying diseases were excluded in the study.

Postoperative infection, especially in fracture surgery, is a main orthopedic problem that could severely affect the outcome of these operations (10, 11). Even though the impact of preventive administration of systemic antibiotics has been proven to prevent infection after the ORIF surgeries (9, 12), contradictory results have been reported regarding the duration of prophylactic antibiotic administration and its effectiveness. Minimizing the amount of post-surgical infection in these patients is vital in evaluating the effectiveness of prophylactic antibiotics. Due to the nature of this operation on tissues with low blood flow and external objects like metal plates, the antibiotic concentration would not be optimum in the surgical site. Thus, they might not help lower the possibility of postoperative infection (9, 13). Hence, various studies have been conducted on the efficacy of prophylactic antibiotics over different periods to reduce the risk of infection and its complications.

The prevalence of infection was reported as 1.42% in the present study, similar to Rahimi et al. [1], which reported an infection rate of 1.9%. The infection is a serious, difficult to treat complication of orthopedic surgeries, including the ORIF. It should be noted that the bone infection after surgery (Osteomyelitis) can lead to non-healing of the bone, and even amputation of the limb, in some cases (14). Balch et al. (15) found that prophylactic antibiotics can effectively reduce the risk of infection after orthopedic surgery. Infection treatment may be difficult, costly, and time-consuming for patients and physicians. Therefore, taking any measure to reduce the risk of infection after surgery is invaluable. There are many studies on finding preventive methods for reducing infection risk factors after surgery, among which antibiotic therapy has gained special attention. Mirza-Tolouei et al. (16) reported no significant difference between the 24- and 48-hour antibiotic therapy protocols for surgical site infection prevention, which was also confirmed in another study by Ondari et al. (17). These results were consistent with the present study. The present study also indicated that no significant difference was seen between the infection rate and duration of prophylactic antibiotic therapy.

Various studies have investigated surgical site infection risk factors, such as underlying infections, malnutrition, type of surgical procedures, and operating room conditions (18). Mathur et al. (19) found that prophylactic antibiotics for 24 hours were not significantly different from their use for a longer duration. This result was also consistent with the findings of the present study. Hawn et al. (20) reported that the probability of infection after orthopedic surgeries had no relationship with the duration of consumed prophylactic antibiotics, which confirmed the present study’s findings. The effectiveness of prophylactic antibiotics in reducing infections has been investigated in many studies (21), but the studied duration of consumed antibiotics was the strength of the present study. Significant points in the effectiveness of prophylactic antibiotics include the selection of antibiotics according to the type of surgery, the administration of the antibiotic 1 hour before surgery, and its discontinuation within 24 hours after the surgery. Suppose the prophylactic administration of antibiotics is not according to proper principles. In that case, it will lead to numerous complications, such as the disruption of the normal microbial flora of the body, the emergence of new antibiotic-resistant infections, increasing the risk of drug toxicity, and increasing unnecessary costs on the healthcare system (22). In a study by Rodriguez et al. (1), prophylactic antibiotics greatly reduced the infection. Prophylactic antibiotics can reduce the risk of wound infections and are routinely used in orthopedic surgeries. Despite their widespread use, there are still questions about the selection of prophylactic antibiotics in terms of duration and doses, and there is little evidence on the decision about prophylaxis duration (23).

Prophylactic antibiotics can reduce the risk of wound infections and are routinely used in orthopedic surgeries. Despite their widespread use, there are still questions about selecting prophylactic antibiotics for duration and doses. Based on the present study results, the 24-hour prophylactic antibiotic administration to reduce the risk of post-surgical infection of the lower limb fracture in patients can be a suitable alternative to the long-term use of antibiotics.

Funding

This study was funded by e Deputy of Research and Technology of Babol University of Medical Sciences.

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Author Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Rahmatollah Jokar, Seyyed Mokhtar Esmaeilnejadganji and Ali Bijani. The first draft of the manuscript was written by Sekineh kamali Ahangar, Nahid Shafeei and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethics approval

This study was reviewed and approved by the Research Ethics Committees of Babol University of Medical Sciences.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent to publish

Not applicable

Acknowledgments

The authors are grateful to the Deputy of Research and Technology of Babol University of Medical Sciences and all colleagues in the Department of Orthopedics and Operative Room in Shahid Beheshti Hospital of Babol and the respectful expert of Clinical Research Development Department of Shahid Beheshti Hospital.

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Table 1

Evaluation of different variables in two studied groups

Variable	Total n (%)	Duration of antibiotic administration		P-value
Variable	Total n (%)	24 hours n (%)	72 hours n (%)	P-value
Sex				0.55
Male	106 (100)	51 (1.48)	55 (9.51)
Female	34 (100)	19 (9.55)	15 (1.44)
Age group (year)				0.23
Under 20	23 (100)	9 (1.39)	14 (9.60)
21-30	32 (100)	15 (9.46)	17 (1.53)
31-40	28 (100)	17 (7.60)	11(3.39)
41-50	24 (100)	9 (5.37)	15 (5.62)
51-60	32 (100)	19 (4.59)	13 (6.40)
61 and over	1 (0.7)	1 (100)	-
Marital status				0.25
Single	39 (100)	16 (0.41)	23 (0.59)
Married	101 (100)	54 (5.53)	47 (5.46)
Body mass Index (kg/m²)				0.01
Thin	1 (100)	-	1 (100)
Normal	85 (100)	50 (8.58)	35 (2.41)
Overweight	53 (100)	20 (7.37)	33 (3.62)
Obese	1 (100)	0 (0)	1 (100)
Job				0.55
Housewife	27 (100)	16 (3.59)	11 (7.40)
Self-employed	105 (100)	50 (6.47)	55 (4.52)
Employee	8 (100)	4 (0.50)	4 (0.50)
Fracture history (yes)	9 (100)	6 (7.66)	3 (3.33)	0.49
Smoking (Yes)	62 (100)	39 (9.62)	23 (1.37)	0.01
Alcohol consumption (yes)	5 (100)	2 (040)	3 (0.60)	0.99
Addiction history (yes)	12 (100)	5 (7.41)	7 (3.58)	0.76
Underlying Background (yes)	5 (100)	5 (100)	-	0.053
Operation room traffic				0.002
Low	113 (100)	64 (6.56)	49 (443)
Medium	27 (100)	6 (2.22)	21 (8.77)

Table 2

Comparison of quantitative variables between two group

Variable	Duration of antibiotic administration		P-value
Variable	24 hours Mean (deviation benchmark)	72 hours Mean (deviation benchmark)	P-value
Height (cm)	168.00 (5.12)	170.90 (7.00)	<0.001
Weight (kg)	65.86 (7.00)	72.06 (7.85)	0.006
Surgery Duration (min)	63.64 (17.51)	67.04 (17.75)	0.11
Tourniquet twisting time (min)	62.72 (3.95)	60.07 (3.27)	0.06
Frequency of applied suction	10.73 (4.95)	11.13 (5.36)	0.82
Bleeding (cc)	612.86 (131.23)	700.93(7136)	0.42

Table 3

Relationships pf different variables with infection in patients who received antibiotics for 24 hours

Variable	Infection		P-value
Variable	No n (%)	Yes n (%)	P-value
Sex			0.27
Male	51 (100)	0 (0)
Female	18 (94.7)	1 (5.3)
Age group (year)			0.01
Under 20	9 (100)	0 (0)
21-30	15 (100)	0 (0)
31-40	17 (100)	0 (0)
41-50	9 (100)	0 (0)
51-60	19 (100)	0 (0)
61-65	0 (0)	1 (100)
Marital status			0.99
Single	16 (100)	0 (0)
Married	53 (98.1)	1 (1.9)
Body mass Index (kg/m²)			0.28
Thin	0 (0)	0 (0)
Normal	50 (100)	0 (0)
Overweight	19 (95.0)	1 (5.0)
Obese	0 (0)	0 (0)
Job			0.28
Housewife	15 (93.8)	11 (6.2)
Self-employed	50 (100)	0 (0)
Employee	4 (100)	0 (0)
Fracture history (yes)	6 (100)	0 (0)	0.99
Smoking (Yes)	39 (100)	0 (0)	0.44
Alcohol consumption (yes)	2 (100)	0 (0)	0.99
Addiction history (yes)	5 (100)	0 (0)	0.76
Underlying Background (yes)	5 (100)	0 (0)	0.99
Operation room traffic			0.91
Low	63 (98.4)	1 (1.6)
Medium	6 (100)	0 (0)
Trauma mechanism			0.60
Car-car accident	28 (100)	0 (0)
Car-motorcycle accident	16 (100)	0 (0)
Fall from height	21 (95.5)	1 (4.5)

Table 4

Association of quantitative variables with infection in patients who received antibiotics for 24 hours

Variable	Infection		P-value
Variable	No Mean (SD)	Yes Mean (SD)	P-value
Height (cm)	168.12 (5.06)	160.00	0.55
Weight (kg)	65.80 (7.03)	70.00	0.11
Surgery Duration (min)	63.41 (17.53)	80.00	0.51
Tourniquet twisting time (min)	62.75 (9.01)	60.00	0.77
Frequency of applied suction	10.65 (4.94)	16.00	0.51
Bleeding (cc)	614.49 (131.48)	500.00	0.45

Table 5

Relationships of different variables with infection in patients who received antibiotics for 72 hours

Variable	Infection		P-value
Variable	No n (%)	Yes n (%)	P-value
Sex			0.99
Male	54 (98.2)	1 (1.8)
Female	15 (100)	0 (0)
Age group (year)			0.34
Under 20	14 (100)	0 (0)
21-30	17 (100)	0 (0)
31-40	11 (100)	0 (0)
41-50	15 (100)	0 (0)
51-60	12 (100)	0 (0)
61-65	0 (0)	0 (0)
Marital status			0.67
Single	23 (100)	0 (0)
Married	46 (97.9)	1 (2.1)
Body mass Index (kg/m²)			0.50
Thin	1 (100)	0 (0)
Normal	35 (100)	0 (0)
Overweight	32 (97.0)	1 (3.0)
Obese	1 (100)	0 (0)
Job			0.99
Housewife	11 (100)	0 (0)
Self-employed	54 (98.2)	1 (1.8)
Employee	4 (100)	0 (0)
Fracture history (yes)	3 (100)	0 (0)	0.99
Smoking (Yes)	22 (95.7)	1 (4.3)	0.32
Alcohol consumption (yes)	3 (100)	0 (0)	0.99
Addiction history (yes)	7 (100)	0 (0)	0.64
Operation room traffic			0.70
Low	48 (98.0)	1 (2.0)
Medium	21 (100)	0 (0)
Trauma mechanism			0.22
Car-car accident	28 (100)	0 (0)
Car-motorcycle accident	26 (100)	0 (0)
Fall from height	11 (91.7)	1 (8.3)
Motorcycle accident	2 (100)	0 (0)
Beat	2 (100)	0 (0)

Table 6

Relationship of quantitative variables with infection in patients who received antibiotics for 72 hours

Variable	Infection		P-value
Variable	No Mean (SD)	Yes Mean (SD)	P-value
Height (cm)	170.94 (7.05)	168.00	0.70
Weight (kg)	72.01 (7.90)	75.00	0.68
Surgery Duration (min)	66.68 (17.62)	92.00	0.057
Tourniquet twisting time (min)	60.07 (17.62)	60.00	0.94
Frequency of applied suction	11.04 (5.35)	17.00	0.57
Bleeding (cc)	700.22 (718.66)	750.00	0.25

No competing interests reported.

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You are reading this latest preprint version

Effectiveness of Prophylactic Antibiotics in Infection Prevention in Closed Lower-Limb Fracture Surgery

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Version 1

Abstract

Figures

Introduction

Methods

Results

Discussion

Conclusion

Declarations

Funding

Competing Interests

Author Contributions

Ethics approval

Consent to participate

Consent to publish

Acknowledgments

References

Tables

Competing Interests

Status:

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