Perioperative cefamandole prophylaxis against infections. Antibiotic prophylaxis in proximal femoral fracture. Cloxacillin in the prophylaxis of postoperative infections of the hip. Antibiotic prophylaxis in operations on trochanteric femoral fractures. Prophylactic use of cephradine against postoperative infections of petrochanteric fractures. Cefuroxime prophylaxis in trochanteric hip fracture operations. A double-blind clinical trial of prophylactic antibiotics in hip fractures. Antibiotic prophylaxis of 1,036 patients undergoing elective surgical procedures. A prospective, randomized comparative trial of cefazolin, cefoxitin, and cefotaxime in a prepaid medical practice. Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial. Single-dose antibiotic prophylaxis in osteosynthesis for hip fractures. A clinical multicentre study in Finland. Antibiotic prophylaxis in surgery for hip fractures. Antibiotic prophylaxis in open and closed fractures: a controlled clinical trial. Antibiotic prophylaxis with two doses of cephalosporin in patients managed with internal fixation for a fracture of the hip. Prophylaxis with oral cefadroxil versus intravenous cefuroxime in trochanteric fracture surgery. A clinical multicentre study. Double-blind randomized prospective study of the efficacy of antibiotic prophylaxis for open reduction and internal fixation of closed ankle fractures. Single-dose prophylaxis of ceftriaxone versus standard dosage of cefotaxime in the prophylaxis of bacterial complications in orthopedic surgery. Is antibiotic prophylaxis necessary for internal fixation of low-energy fractures? One dose cefuroxime prophylaxis in hip fracture surgery. Prophylactic antibiotics in hip fractures. A double-blind, prospective study.
Seven hundred and seventeen patients were included in a prospective randomized double-blind trial comparing the efficacy of five doses of cefamandole (group I, 335 patients) with that of a single preoperative dose (group II, 382 patients) for prophylaxis against sepsis in patients who had an operation using either a Moore prosthesis, Ender or Küntscher nails, a bone plate, or another internal-fixation device. Patients who had an open fracture or total joint replacement were not included in the study. The two groups were similar in terms of mean age, sex ratio, duration of preoperative hospital stay, underlying risk factors, and type of surgical procedure. A wound infection developed in none of the seventy-four patients in group I and in five (6.6 per cent) of the seventy-six in group II (p = 0.03) who required a Moore prosthesis. A wound infection developed in three patients (1 per cent) in group I and in fifteen (5 per cent) in group II (p = 0.006) who required an internal fixation device other than a Moore prosthesis. Staphylococcus aureus, Staphylococcus epidermidis, and gram-negative bacilli were the most common infecting organisms. The rate of mortality was similar in both groups, while the percentage of postoperative urinary-tract infections was lower in group I (p = 0.04). No adverse side effects of the drug were encountered. A prospective randomized double-blind trial was carried out to assess the effectiveness of one dose of prophylactic cefuroxime versus placebo in 502 patients who underwent surgery for a proximal femoral fracture. With an overall deep infection rate of 2.2 per cent there was no significant difference in the superficial or deep wound infection rate between the two groups. However, there was a significant reduction in the incidence of postoperative bacteriuria in the cefuroxime group. A study of three doses of cefuroxime versus placebo is now proposed. nan Short-term prophylaxis against infection using cephalothin and cephalexin was studied in 140 patients operated on for trochanteric fractures of the femur. The group given the drug during preparation for anesthesia, intraoperatively, and for two days postoperatively had an infection rate of 1.8 per cent (one patient), whereas the group without prophylaxis had a rate of 16.9 per cent (twelve patients). The two groups were similar with regard to factors that may have influenced the infection rate, for example, age, time required for surgery, and blood loss. Staphylococcus aureus was the most common infecting organism, but several patients had mixed infections with intestinal bacteria. nan In a double-blind randomized study of antibiotic prophylaxis in trochanteric fractures operated on with a nail and plate, a 24-hour intravenous administration of cefuroxime 0.75 grams thrice daily (Group B) was compared with the previous regimen of cefuroxime for 24 hours plus 6 days of oral cephalexin (Group A). In each group, 56 (Group A) and 65 (Group B) patients could be evaluated. One deep infection occurred in Group B with growth of Staphylococcus aureus, and another 4 patients had discharge and cultures of which 2 showed S. aureus. In Group A, 6 patients had signs of an infection, and in 3 patients cultures were taken but were negative. There were no differences between the groups. We concluded that the prophylaxis time need not be longer than 3 days. nan nan The efficacy of prophylactic antibiotics in fracture surgery remains controversial for lack of well-documented prospective studies. We report here the findings of the Dutch Trauma Trial, a prospective, randomised, double-blind, placebo-controlled study of antibiotic prophylaxis in the primary operative treatment of limb fractures. Ceftriaxone was chosen because of its pharmacokinetic profile, including high serum levels, high tissue penetration, and long elimination half-life, makes it suitable for single-dose prophylaxis.
                Patients aged 18 years or more, attending one of fourteen Dutch centres for acute treatment of closed fractures, were randomly allocated to a single preoperative dose of ceftriaxone 2 g or placebo, and evaluated for development of wound infection and nosocomial infection at 10 days, 30 days, and 120 days. To assess the effects of drop-outs and withdrawals, best-case and worst-case analyses were performed.
                A total of 2195 patients were included. The incidence of superficial and deep wound infections after placebo was 8.3%, compared with 3.6% in the ceftriaxone group (p < 0.001, Pearson chi 2-test). The rate of nosocomial infection in the first month was 10.2% with placebo and 2.3% with ceftriaxone (p < 0.001, Pearson chi 2-test). Gram-positive bacteria were found in 74.5% of wound infections and 13.4% of nosocomial infections.
                Adequate single-dose prophylaxis with a long-acting broad-spectrum antibiotic substantially reduces the incidence of wound infection and early nosocomial infection after surgery for closed fractures. The use of antibiotic prophylaxis in open reduction and osteosynthesis of closed hip fractures is still controversial. The aim of this study was to demonstrate the effect of antibiotic prophylaxis in osteosynthesis of these fractures.
                A total of 224 patients operated on between November 1994 and February 1998 in six hospitals by internal fixation for a fresh hip fracture were prospectively and randomly allocated to either a ceftriaxone antibiotic prophylaxis or no prophylaxis group and followed for one year.
                Within 6 weeks after the operation, 2.6% wound infections were recorded in the antibiotic group and 4.7% in the control group. Two (1.9%) of the five infections in the control group were deep infections (both sensitive to ceftriaxone). There were no statistically significant differences between the infection rates in both groups. However, when analyzing all complications recorded within 6 weeks, significantly more complications were found in the control group (p < 0.01). In the multivariate analysis the most important factor predicting postoperative complications was the lack of antibiotic prophylaxis.
                In this study the antibiotic prophylaxis group had significantly less postoperative complications than the control group within 6 weeks after the operation. Totally, 185 patients, operated on for a fresh hip fracture, were randomly allocated to either methicillin antibiotic prophylaxis or no prophylaxis and followed for 1 month. Two superficial wound infections were recorded in the prophylaxis group and one in the control group. Prophylactic use of antibiotics in surgery for hip fractures seems unnecessary provided strict aseptic routines in the operating room are followed. The value of prophylactic antibiotics in fracture surgery was studied in a series of 90 patients with open fractures of various bones and 180 patients with closed malleolar fractures treated by open surgery. Dicloxacillin and benzyl penicillin were compared to saline (placebo). The soft tissue lesions of the open fractures were divided into Grade I wounds and Grade II & III wounds. Of the patients with Grade I wounds, 17 received dicloxacillin, 21 benzyl penicillin and 17 saline. No major infections occurred. Twelve patients with Grade II & III wounds were treated with dicloxacillin, 10 with benzyl penicillin and 13 with saline. In the saline group, 2 patients developed a deep infection. Fifty-eight patients with closed malleolar fractures received dicloxacillin, 59 benzyl penicillin and 63 saline. Two infections developed in the placebo group. A statistically significant difference was found between the number of infections in the antibiotic groups and the number in the placebo group. Superficial thromboplebitis following the antibiotic infusion occurred in 16 per cent of the dicloxacillin treated patients and in 1 per cent of those treated with benzyl penicillin or placebo. A prospective, randomized, double-blind study was performed to evaluate the effects of antibiotic prophylaxis on the development of a wound infection in 239 patients who had immediate stabilization of a fracture of the proximal part of the femur with a dynamic hip screw. The effects of two perioperative doses of cefotiam, given twelve hours apart, were compared with those of two doses of a placebo. Sixteen perioperative risk factors were evaluated to determine whether it was possible to identify patients who were at risk for a wound infection. All patients were followed for a minimum of six weeks. Antibiotic prophylaxis significantly reduced the prevalence of wound infection (p < 0.05): the rate of major wound infection decreased from 5 to 1 per cent and the rate of minor wound infection, from 11 to 4 per cent. The most powerful predictors of major wound infection were the duration of the operation, the interval between the accident and admission to the hospital, and the duration of postoperative urinary catheterization. The preoperative level of serum albumin and the absolute lymphocyte count were significant predictors (p < 0.05) of minor wound infection and systemic infection, respectively. A prospective, randomized study was performed in 559 patients to compare two doses of oral cefadroxil with three doses of intravenous cefuorxime as antibiotic prophylaxis in intra- and subtrochanteric hip fracture surgery. Antibiotic concentrations in the wound fluid were determined at the start and at the end of the operation. The first dose of cefadroxil was given about 2 h before surgery and cefuroxime about 30 min before operation. In 226/242 (93%) patients randomized to oral cefadroxil, the concentration in the wound during surgery was on average 15 micrograms/ml, i.e., well above the minimum inhibitory concentration (MIC-90) for Staphylococcus aureus. In the cefuroxime group, antibiotic levels in the wound exceeded the MIC-90 for S. aureus in 204/210 (97%) of the patients at the start and/or at the end of surgery. All patients were followed up for 4 months. One deep and five superficial infections occurred in the cefuroxime group and no deep but one superficial infection in the cefadroxil group (P = 0.07). S. aureus was cultured in three of the infected cases while cultures were negative in four patients. Four of the seven infected patients had adequate levels of antibiotic in the wound during surgery, and in three patients no antibiotic assay was performed. The infected patients did not differ in age, sex, operation time, bleeding or any other basic variable compared with patients who healed without complications. Two doses of cefadroxil seems to be practical and as effective as intravenously administered cefuroxime as antibiotic prophylaxis in trochanteric hip fracture surgery. Antibioprophylaxis has been proven to be efficient for some orthopaedic procedures. However, its efficacy for clean limited procedures with metallic implants is not clear. One hundred twenty-two closed ankle fracture patients undergoing open reduction and internal fixation were randomized, double-blindly, to receive either cephalothin (1 g i.v. every 6 h x four doses) or a placebo starting before tourniquet application. Mean trauma-surgery delay was 30.2 h, and average tourniquet duration was 65.4 min. Four patients (three of 62 on placebo and one of 60 on cephalothin) developed a superficial wound infection. One of the patients in the placebo group was hospitalized and treated with i.v. antibiotics. However, there was no osteomyelitis or premature hardware removal. The difference between the two groups was not statistically significant (chi 2 test of appreciation p = 0.33, two-tailed probabilities). Therefore, cephalothin prophylaxis does not seem justified in this patient population. A larger series is needed to avoid a type II error. nan A series of 54 patients who had low-energy, closed fractures requiring internal fixation were entered into a randomized prospective study comparing prophylactic antibiotics with no treatment. In five patients who did not have antibiotics a superficial wound infection or fever was recorded. In those who received antibiotics, no infection or fever was detected. However, there was no statistical difference between the two groups, and it is concluded that there is no need for prophylactic antibiotics when internally fixing low-energy fractures. One 3 g intravenous dose of cefuroxime during the induction of anaesthesia was administered randomly in a series of 162 consecutive hip fractures. The overall infection rate was 8.0%, and 2.4% for deep infections. The number of infections was seven in the prophylaxis group and six in the control group. The percentage of deep infections was 3.9 and 1.4, correspondingly. Antibiotic prophylaxis given did not seem to have an effect on the infection rate. Three hundred and seven patients, each of whom had a fracture of the proximal part of the femur, were studied in a randomized, double-blind fashion to determine whether perioperative administration of cephalothin would prevent postoperative infection. Major postoperative wound infections were significantly reduced in the cephalothin-treated group (4.7 per cent versus 0.7 per cent; p less than 0.05). There also was a reduction in the incidence of postoperative urinary-tract infections and a reduction in mean peak body temperatures. The duration of hospitalization was not affected and no hospital stay was prolonged by complications of antibiotic administration. However, in the cephalothin-treated group, a strong trend toward colonization by cephalothin-resistant organisms was noted.
Antibiotic prophylaxis should be offered to those undergoing surgery for closed fracture fixation.