Clínical Audit of Primary Treatment of Open Fractures: Antibiotic Treatment and Tetanus Prophylaxis

doi:10.1055/s-0039-3402470

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Original Articles, Basic • Rev. bras. ortop. 55 (3) • May-Jun 2020 • https://doi.org/10.1055/s-0039-3402470 copy

Clínical Audit of Primary Treatment of Open Fractures: Antibiotic Treatment and Tetanus Prophylaxis^* * Study performed at Fundação Hospitalar de Minas Gerais (Fhemig), Hospital João XXIII, Belo Horizonte, Minas Gerais, Brazil.

About the corresp SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To evaluate whether the conducts involving antimicrobial treatment and prophylaxis against tetanus have been performed according to the Clinical Protocol of the Institution.

Methods

Descriptive and retrospective study conducted in patients of both genders, > 18 years old admitted to a public hospital specialized in emergency and trauma, to treat primary open fracture. The data of interest were surveyed in medical records, drug prescriptions, report of patients admitted in the Surgical Block and tetanus prophylaxis requests.

Results

A total of 241 patients were selected, mostly male (81.7%), young adults (64.3%), victims of motorcycle accidents (53.5%). Infectious complications were present in 18.7% of the fractures, the mean time for the surgical approach was 4 hours and 12 minutes, and 91.7% of the patients had preoperative antimicrobial prescription. The main inadequacies identified were: period of prescription of antimicrobial treatment (63.5%); choice of the antimicrobial scheme (59.3%) and antimicrobial dose (58.0%). Only 14.1% of the patients were immunized against tetanus.

Conclusion

The greatest divergences with the Clinical Protocol were observed in the issues involving the antimicrobial regimen used, doses and time of prescription, as well as in tetanus prophylaxis.

Keywords
open fracture; antibiotic prophylaxis; infection; tetanus

Variables	Patients primarily treated for open fractures
	(n = 241)
	n	(%)
Gender
Male	197	81.7
Female	44	18.3
Age group (37.2 ± 16.0 years old; 18-86 years-old)
18-39 years-old	155	64.3
40-59 years-old	62	25.7
≥ 60 years-old	24	10.0
Origin
Belo Horizonte Metropolitan Region	192	79.7
Minas Gerais State, except for RMBH	48	19.9
Not informed	1	0.4
Trauma mechanism
Car accident	15	6.2
Bicycle accident	5	2.1
Machinery accident	10	4.1
Motorcycle accident	129	53.5
Physical assault	5	2.1
Running over	33	13.7
Firearm or knife assault	8	3.3
Fall	32	13.3
Other	4	1.7
Affected anatomical segment
Lower limb	199	82.6
Upper limb	38	15.8
Lower + upper limbs	4	1.6

Variables	Patients with open fracture (n = 241)		Infectious complications				p-value ^* * χ2 test, significance level p < 0.05.
			YES (n = 45)		NO (n = 196)
	n	(%)	n	(%)	n	(%)
Open fracture classification
Type I	048	(20.0)	05	(10.4)	043	(89.6)	p = 0.0014
Type II	046	(19.0)	04	(08.7)	042	(91.3)
Type III	052	(21.6)	19	(36.5)	033	(63.5)
Unclassified	095	(39.4)	17	(17.9)	078	(82.1)
Time from patient admission to surgery
≤ 6 hours	199	(82.6)	37	(18.6)	162	(81.4)	p = 0.4621
> 6 hours	042	(17.4)	08	(19.0)	034	(81.0)
Time from patient admission to antimicrobial treatment start
Preoperative	221	(91.7)	38	(17.2)	183	(82.8)	p = 0.0362
Postoperative	020	(08.3)	07	(35.0)	013	(65.0)
≤ 3 hours after admission	172	(71.7)	27	(15.7)	145	(84.3)	p = 0.0350
> 3 hours after admission	069	(28.3)	18	(26.1)	051	(73.9)
TOTAL	241	(100)	45	(18.7)	196	(81.3)

ANTIMICROBIAL TREATMENT	Patients (n = 167)
ANTIMICROBIAL TREATMENT	n	(%)
Type I
Adequate	20	(645)
Inadequate	11	(35.5)
Trauma occurred in rural environment and/or contamination with dirt with no coverage for anaerobic organisms	03	(27.3)
Increased coverage for gram-negative organisms is unrequired	03	(27.3)
Increased coverage for gram-negative and anaerobic organisms is unrequired	04	(36.3)
Alternative regimen: Clindamycin not associated with gentamycin	01	(09.1)
Type II
Adequate	24	(60.0)
Inadequate	16	(40.0)
Trauma occurred in rural environment and/or contamination with dirt with no coverage for anaerobic organisms	01	(06.3)
No increased coverage for gram-negative organisms	14	(87.4)
Coverage for anaerobic agents is not required	01	(06.3)
Type III and/or trauma over 6 hours before
Adequate	24	(25.0)
Inadequate	72	(75.0)
No coverage for gram-negative organisms	40	(55.5)
No increased coverage for gram-negative and anaerobic organisms	21	(29.2)
No increased coverage for gram-negative organisms	06	(08.3)
Use of not recommended antimicrobial agent (ceftriaxone)	05	(06.9)
Adequacies	68	(040.7)
Inadequacies	99	(059.3)

Variables	Length of stay (Days)
	Primary care hospital			Other unit from the hospital network			Total time at the hospital network
	Mean	Median	Range	Mean	Median	Range	Mean	Median	Range
Fracture classification
Type I	10	04	1-35	11	08	1-41	15	09	1-137
Type II	05	02	1-42	09	05	1-48	10	06	1-60
Type III	17	09	1-93	14	13	1-72	25	19	1-107
Unclassified	07	04	1-79	09	07	1-50	13	08	1-77
Infectious complication
Without infection	07	04	1-079	07	04	1-41	12	07	1-77
With infection o	21	15	1-135	16	12	1-72	37	30	4-137
Total	0 9	04	1-135	11	8	1-72	16	09	1-137

Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br

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[1] Address for correspondence Adriana Lúcia Ferris de Assunção, Rua João Donada, 453, Bairro Santa Terezinha, Belo Horizonte, MG, CEP: 31.360-190, Brasil (e-mail: adriana.ferris@hotmail.com).

ANTIMICROBIAL AGENTS	RECOMMENDATIONS
Starting time	Treatment must start at the preoperative period
Choice of antimicrobial agents	Type I fractures: cefazolin, 1 g IV every 6 hours
	Type II fractures: cefazolin, 1 g IV every 6 hours + gentamycin, 240 mg IV every 24 hours
	Alternative regimen for type I and II fractures: clindamicina 600 mg EV de 6/6 hours + gentamycin, 240 mg IV every 24 hours
	Type III fractures: cefazolin, 1 g IV every 6 hours + gentamycin, 240 mg IV every 24 hours + metronidazole, 500 mg every 6 hours
	For fractures occurring in rural environment and with gross contamination, add metronidazole, 500 mg every 6 hours
Treatment duration	Type I and II: 24 hours
	Type III: 72 hours
TETANUS PROPHYLAXIS	RECOMMENDATIONS
	Evaluate requirement based on the vaccination history of the patient
	In case of doubt regarding previous tetanus prophylaxis: add metronidazole, 500 mg every 6 hours

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Clínical Audit of Primary Treatment of Open Fractures: Antibiotic Treatment and Tetanus Prophylaxis* * Study performed at Fundação Hospitalar de Minas Gerais (Fhemig), Hospital João XXIII, Belo Horizonte, Minas Gerais, Brazil.

Abstract

Objective

Methods

Results

Conclusion

Clínical Audit of Primary Treatment of Open Fractures: Antibiotic Treatment and Tetanus Prophylaxis^* * Study performed at Fundação Hospitalar de Minas Gerais (Fhemig), Hospital João XXIII, Belo Horizonte, Minas Gerais, Brazil.