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Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs
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Chan, James K-K., Aquilina, Alexander L., Lewis, Sharon R., Rodrigues, Jeremy N., Griffin, Xavier L. and Nanchahal, Jagdeep (2022) Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs. Cochrane Database of Systematic Reviews, 2022 (4). CD013555. doi:10.1002/14651858.CD013555.pub2
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Official URL: http://dx.doi.org/10.1002/14651858.CD013555.pub2
Abstract
Background
Open fractures of the major long bones are complex limb‐threatening injuries that are predisposed to deep infection. Treatment includes antibiotics and surgery to debride the wound, stabilise the fracture and reconstruct any soft tissue defect to enable infection‐free bone repair. There is a need to assess the effect of timing and duration of antibiotic administration and timing and staging of surgical interventions to optimise outcomes.
Objectives
To assess the effects (risks and benefits) of the timing of antibiotic administration, wound debridement and the stages of surgical interventions in managing people with open long bone fractures of the upper and lower limbs.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and clinical trial registers in February 2021. We also searched conference proceedings and reference lists of included studies.
Selection criteria
We included randomised controlled trials (RCTs) or quasi‐RCTs that recruited adults with open fractures of the major long bones, comparing: 1) timings of prophylactic antibiotic treatment, 2) duration of prophylactic antibiotic treatment, 3) timing of wound debridement following injury or 4) timing of the stages of reconstructive surgery.
Data collection and analysis
We used standard methodological procedures expected by Cochrane. We aimed to collect data for the following outcomes: limb function, health‐related quality of life (HRQoL), deep surgical site infection, delayed or non‐union, adverse events (in the short‐ and long‐term course of recovery), and resource‐related outcomes.
Main results
We included three RCTs of 613 randomised participants with 617 open fractures. Studies were conducted in medical and trauma centres in the USA and Kenya. Where reported, there was a higher proportion of men and a mean age of participants between 30 and 34 years old. Fractures were in the upper and lower limbs in one study, and were tibia fractures in two studies; where reported, these were the result of high‐energy trauma such as road traffic accidents. No studies compared the timing of antibiotic treatment or wound debridement.
Duration of prophylactic antibiotic treatment (1 study, 77 participants available for analysis)
One study compared antibiotic treatment for 24 hours with antibiotic treatment for five days. We are very uncertain about the effects of different durations of antibiotic treatment on superficial infections (risk ratio (RR) 1.19, 95% CI 0.49 to 2.87, favours 5 day treatment; 1 study, 77 participants); this was very low‐certainty evidence derived from one small study with unclear and high risks of bias, and with an imprecise effect estimate. This study reported no other review outcomes.
Reconstructive surgery: timing of the stages of surgery (2 studies, 458 participants available for analysis)
Two studies compared the timing of wound closure, which was completed immediately or delayed. In one study, the mean time of delay was 5.9 days; in the other study, the time of delay was not reported. We are very uncertain about the effects of different timings of wound closure on deep infections (RR 0.82, 95% CI 0.37 to 1.80, favours immediate closure; 2 studies, 458 participants), delayed union or non‐union (RR 1.13, 95% CI 0.83 to 1.55, favours delayed closure; 1 study, 387 participants), or superficial infections (RR 6.45, 95% CI 0.35 to 120.43, favours delayed closure; 1 study, 71 participants); this was very low‐certainty evidence. We downgraded the certainty of the evidence for very serious risks of bias because both studies had unclear and high risks of bias. We also downgraded for serious imprecision because effect estimates were imprecise, including the possibility of benefits as well as harms, and very serious imprecision when the data were derived from single small study. These studies reported no other review outcomes.
Authors' conclusions
We could not determine the risks and benefits of different treatment protocols for open long bone fractures because the evidence was very uncertain for the two comparisons and we did not find any studies addressing the other possible comparisons. Well‐designed randomised trials with adequate power are needed to guide surgical and antibiotic treatment of open fractures, particularly with regard to timing and duration of antibiotic administration and timing and staging of surgery.
| Item Type: | Journal Article | |||||||||
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| Subjects: | R Medicine > RD Surgery R Medicine > RM Therapeutics. Pharmacology |
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| Divisions: | Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Clinical Trials Unit Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School |
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| Library of Congress Subject Headings (LCSH): | Antibiotics, Debridement, Wound healing, Fractures, Open -- Treatment | |||||||||
| Journal or Publication Title: | Cochrane Database of Systematic Reviews | |||||||||
| Publisher: | John Wiley & Sons Ltd. | |||||||||
| ISSN: | 1469-493X | |||||||||
| Official Date: | 1 April 2022 | |||||||||
| Dates: |
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| Volume: | 2022 | |||||||||
| Number: | 4 | |||||||||
| Article Number: | CD013555 | |||||||||
| DOI: | 10.1002/14651858.CD013555.pub2 | |||||||||
| Status: | Peer Reviewed | |||||||||
| Publication Status: | Published | |||||||||
| Reuse Statement (publisher, data, author rights): | This is the peer reviewed version of the following article: Chan JK-K, Aquilina AL, Lewis SR, Rodrigues JN, Griffin XL, Nanchahal J. Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs. Cochrane Database of Systematic Reviews 2022, Issue 4. Art. No.: CD013555. DOI: 10.1002/14651858.CD013555.pub2., which has been published in final form at http://dx.doi.org/10.1002/14651858.CD013555.pub2. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. This article may not be enhanced, enriched or otherwise transformed into a derivative work, without express permission from Wiley or by statutory rights under applicable legislation. Copyright notices must not be removed, obscured or modified. The article must be linked to Wiley’s version of record on Wiley Online Library and any embedding, framing or otherwise making available the article or pages thereof by third parties from platforms, services and websites other than Wiley Online Library must be prohibited. | |||||||||
| Access rights to Published version: | Open Access | |||||||||
| RIOXX Funder/Project Grant: |
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