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Antibiotics for pelvic fracture

docrickfry at aol.com docrickfry at aol.com
Sat Apr 15 15:06:19 BST 2006


Claudia--
A nice overview of these principles.  One other exception to the use of prophylactic antibiotics in clean cases, or in cases in which no significant improvement in subsequent infection has been shown, is when foreign material is impanted such as heart valves, joint prostheses, vascular grafts, or hernia mesh, a convention on which there is widespread consensus. 
Remember that prophylactic antibiotics have only proven beneficial in reducing postop wound infections, and in some cases osteomyelitis in skeletal trauma, NOT sepsis, and not intra-abdominal abscess in contaminated cases, altho an awful lot of practitioners do not realize the latter--the only way to reduce infection in the latter is mechanical cleansing of the cavity or wound of all gross debris/cointaminants.  Thus, an abdomen full of stool following an acute injury--not an established infection so does not justify therapeutic Rx, and prophylaxis will do nothing--nothing ever shown--to reduce the incidence of intra-abdominal abscess, and by leaving the wound open there is no risk of wound infection, so actually has no indication for antibiotics at all--yet how many still give them in this setting while also leaving the wound open, and how many give them for prolonged periods in a thrapeutic rather than prophylactic regimen?  Most of us I assume, which is a clear divergence of practice from established evidence, and what is the result--increasing incidence of dangerous resistant bugs, intractable septic complications, and ever more expensive Gorilla-cillins with horrendous side-effects with less and less efficacy. Again--we the medical providers are our patients' own worst enemies on this issue.
ERF
 
-----Original Message-----
From: claudia <glamourcv at gmail.com>
To: Trauma &amp, Critical Care mailing list <trauma-list at trauma.org>
Sent: Sat, 15 Apr 2006 00:52:50 -0300
Subject: Re: Antibiotics for pelvic fracture


Dear all,

I agree on everything that Dr Reynolds pointed out.
However we must cristalize some concepts here.

First concept:
Prophylactic antibiotics - they are given with the aim to avoid post
surgical infectious complications - from wound superficial infections
to overwhelming sepsis.
They are not able to prevent colonization of devitalized tissue,
however, and if given for more than 5 days, good chances are they can
cause more harm (bacterial resistance ) than good in any setting.

Second concept: There is nothing in EBM to support their use in CLEAN
surgeries. This concept of CLEAN surgery many times  is a blurred one.
Most trauma surgeries are not clean, however, there are significant
outcome differences between a simple pelvic fracture with vascular
bleeding and severe open pelvic trauma with organ damage and lesions
to the sigmoid, genitals, or rectum, or even with extensive bone and
muscle lesions. If the gut is intact, outcomes usually are better.

Third concept: There are conflictant data in the literature regarding
whether prophylactic antibiotics in the contaminated pelvic trauma
surgeries will prevent deep tissue infection and sepsis, or even if it
can save people from a septic death... there is no controlled study
done comparing outcomes in patients who received prophylatic ATBs and
those who didn´t. Bacterial resistance does not appear to be a major
problem with prophylactic antibiotics in this particular setting of
pelvic trauma (it is not proven yet...however it is recognized for
other types of trauma...).It will become a problem, indeed, if  the
patient develops recurrent sepsis and is submitted to several courses
of therapeutic antibiotics or if you prolong too much your
"prophylactic" therapy.Current trends point to abandoning the
prophylactic ATBs, in face of the advances in surgical technicques and
necrectomy as the mainstem for wound management, as well as
improvement of blood cultures positivity and early access to the
adequate drug according with the isolated bug.

So, In the end, there is nothing to prove that some cefoxitin or
anything like that, before debridement will do any harm, but don´t
expect it to prevent your patient to die from severe sepsis, and if
you decide to administer it to your patient, please, do not turn it
into a therapeutic ATB regimen by extending the therapy for more than
24 -48 h.

After reading a bit this issue in the past years, I strongly believe
that most prophylactic ATB schemes are created to treat the doctors´
anxieties ;-) Exceptions are made to those patients who are recognized
as immunosupressed or with some sort of immune depression.

Unfortunately, this paper is in german, it´s very clear and treats
this issue with a lot of common sense.

Cheers,

claudia

Unfallchirurg. 1996 May;99(5):316-22.   Related Articles, Links     

Comment in:
Unfallchirurg. 1996 May;99(5):315.

[Prophylactic and therapeutic use of antibiotics in trauma surgery]

[Article in German]

Hansis M, Arens S.

Klinik und Poliklinik fur Unfallchirurgie, Bonn.

Antibiotic treatment in traumatology (either for prophylactic or
therapeutic purposes) can reduce the local bacterial contamination and
can therefore improve the balance in favor of the host defence
capacity. Above all, its value has to be measured depending on the
local bacterial colonization in the individual case and to what extent
this is the essential pathogenetic factor for development of the
infection or for resistance to infection. In situations where local
host damage (either traumatic or iatrogenically/surgically induced) is
the predominant cofactor for the development or persistence of
infection, the antibiotic or other pharmacological reduction of the
bacterial colonization is of secondary or no importance at all. In
view of this, the indications for routine antibiotic prophylaxis or
therapy, which so far have been accepted as valid, should be
reconsidered. On the one hand, excellent hygienic conditions have
increasingly reduced the relative importance of bacterial
contamination in aseptic procedures. On the other hand, the
surgical-technical evolution in the last 5 years (such as biological
osteosynthesis, unreamed intramedullary nailing, stepwise definite
stabilization in complex fractures, initial open wound treatment and
very early plastic reconstruction in open fractures, as well as
radical necrectomy in chronic infection of bones and soft tissues)
could create a significant improvement in the conditions concerning
prevention and treatment of infection. Therefore, the relative
importance of adjuvant antibiotic treatment is considerably less.
Based on previous studies, the publications of the past 3 years
focusing on this aspect are examined critically. Finally, detailed
recommendations are defined and advice given for well-aimed,
controlled continuation studies.

Publication Types:

On 4/14/06, Ben Reynolds <aneurysm_42 at yahoo.com> wrote:
> Having read everyone's posts, I just want to clarify a
> few issues for the readers in such a way which doesn't
> drag me into this discussion.  It seems that the
> debating parties aren't speaking the same language:
>
> 1.  Surgery within the pelvis as performed by an
> OB/GYN and surgery on a fracture of the pelvis as
> performed an orthopedic surgeon are not the same
> thing.
>
> 2.   Perioperative antibiotic prophylaxis for pelvic
> surgery as performed by an OB/GYN and for fractures of
> the pelvis as performed by an orthopedic surgeon
> aren't the same.  The organisms you are trying to
> cover for in those two situations aren't the same,
> ergo they mandate different coverage.
>
> 3.  Pelvic fractures are sterile unless they are open
> or penetrate a hollow viscus (not including the
> bladder which is sterile) an event which occurs at a
> rate not exceeding 1%; this is why we do rectal and
> vaginal exams to ensure that a suspicious fracture
> hasn't violated those areas.  When open pelvic
> fractures do occur it is rare that they aren't
> heralded by OBVIOUS clinical stigmata.
>
> 4.  When open pelvic fractures occur, just as with ANY
> open fracture (femur, humerus, etc.) no amount of
> antibiotics will prevent infection or decrease the
> risk of sepsis.  Immediate irrigation and debridement
> of the open fracture is mandated and depending on the
> situation, repeated and serial irrigation and
> debridements may be necessary.  Massive doses of
> antibiotics do not aid in mechanically removing
> infectious burden, debris, or devitalized muscle and
> bone which are the nidus of sepsis in these
> situations; similarly, massive doses of antibiotics
> cannot STERILIZE this debris either.
>
> I hope this helps.
>
> Ben Reynolds, PA-C
> Pittsburgh, PA
>
> --- Krin135 at aol.com wrote:
>
> >
> > In a message dated 14-Apr-06 11:19:56 Central
> > Daylight Time,
> > docrickfry at aol.com writes:
> >
> > SIGHHHHH...
> > Do you not get it yet?  Of course, once again,
> > listen to this----yes,
> > prophylactic antibiotics DO work to reduce the
> > incidence of postop wound
> > infections--they have NOT ever been shown to prevent
> >  infictuous complications of pelvic
> > fractures--it seems pretty simple a concept  to me
> > to get your arms around
> > ERF
> >
> >
> >
> > OK...I must have missed something, because I was
> > under the impression that
> > the question involved a pelvic fracture needing some
> >  sort of OPERATIVE
> > management....
> >
> >
> > Charles S. Krin, DO  FAAFP
> >
> > --
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