Primary wound culture in open fractures

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Information about Primary wound culture in open fractures
Health & Medicine

Published on March 28, 2014

Author: sitanshubarik

Source: slideshare.net

PRIMARY WOUND CULTURE IN OPEN FRACTURES DR ABIJIT RADHAKRISHNAN PROF JOHN GEORGE,PROF P S JOHN DEPARTMENT OF ORTHOPAEDICS MEDICAL COLLEGE, KOTTAYAM

GREETINGS FROM MEDICAL COLLEGE KOTTAYAM

INTRODUCTION  Sepsis occurring in open fractures leads to significant morbidity  Wound contamination as well as knowledge of the microbial flora is needed to administer a rational and effective antibiotic treatment for open fractures

 the amount of devitalization  the type and site of fracture  the time lapse between injury and debridement  the mode of fracture fixation  the timing of antibiotic administrations DETERMINANTS

AIM OF THE STUDY  The incidence of bacterial contamination in open fractures depending upon mode of trauma  The common bacterial flora contaminating open fractures  The sensitivity pattern of the isolated bacteria and effectiveness of antibiotic regimen

INCLUSION CRITERIA  Extremity open fractures of Gustilo Anderson* type I, II &III presenting within 8 hours  Haemodynamically stable patients for whom emergency debridement and fixation are possible

EXCLUSION CRITERIA  Open fractures with delayed presentation more than 8 hours  Prophylactic antibiotic therapy from the local hospital  Open fractures with mangled extremity requiring emergency amputation  Immunocompromised patients

MATERIALS AND METHODS  22 patients with open fractures of the extremities  December 2006 to October 2007 in Medical College, Kottayam

 Out of 22 patients, 2 were Gustilo Anderson* type I, 12 were type II& IIIa and 8 were type IIIb 0 2 4 6 8 10 12 GA 1 GA 2 & 3A GA 3B Series1

 14 sustained open fractures out of road traffic accidents, 3 at work site, 1of rail accident and 4 due to household accidents RTA FARM RAIL HOUSE

TRIPHASIC SAMPLING

TRIPHASIC SAMPLING  PRE-DEBRIDEMENT SAMPLE  DEBRIDEMENT SAMPLE  POST-DEBRIDEMENT SAMPLE

 Time of presentation  Before the administration of antibiotics PRE-DEBRIDEMENT SAMPLE

DEBRIDEMENT SAMPLE  Skin culture sample in all cases  Muscle tissue in GA type II & III  Samples of periosteum in type IIIB

 Tissues obtained from skin, muscle and periosteum kept separately in pre-sterilized weighted containers filled with normal saline  The average time between injury and surgical debridement was 11 hours (8-14 hours) DEBRIDEMENT SAMPLE

POST-DEBRIDEMENT SAMPLE  Wound sampling repeated on first postoperative day  Denotes the need for further debridement  High chance of persistent infection & warrants extended antibiotic therapy  Incidence of nosocomial infection

ANTIBIOTIC REGIMEN  Third generation cephalosporin and aminoglycosides after pre- debridement sample  Changed to sensitive antibiotics according to pre-debridement sampling report

 Parenteral antibiotics for 10 days  Oral antibiotics for another 7 days CULTURE NEGATIVE

CULTURE POSITIVE  Initial 3 weeks of parenteral antibiotics followed by oral antibiotics for 3 weeks  Extended antibiotic therapy for 10 weeks in positive Post-debridement cases

CULTURE POSITIVE Absence of infection confirmed with wound culture at the end of antibiotic therapy if the wound is not well healed

RESULTS Among a total of 94 samples from all tissues, 29 (30%) showed positive bacterial counts  14 of 66 skin (21%)  11 of 20 muscle (55%)  4 of 8 periosteum samples (50%)

 10 cases of mixed bacterial flora,7 of Staph Aureus,3 of Klebsiella, 7 Pseudomonas, 2 of group D streptococci 0 1 2 3 4 5 6 7 8 9 10 MIXED S. AUREUS KLEB PSEDO STREPT PATTERN OF BACTERIAL FLORA

 Patients with positive muscle and periosteum had 100% incidence of infection  Positive cultured organisms were treated with the sensitive antibiotics according to antibiotic protocol RESULTS

RESULTS  1 patient with type IIIb fracture showed positive contamination of all samples which went for persistent infection  Infection controlled with early detection and extended antibiotic therapy

 11 of 22 patients had soft tissue contamination  7 were GA type II & IIIA  4 were GA type IIIB 0 5 10 15 20 25 30 35 1 2 3 4

THE RATE OF CONTAMINATION WAS PROPORTIONATE TO THE SOFT TISSUE INJURY

0 2 4 6 8 10 12 14 16 18 20 GA 1 GA 2&3a GA 3b Series2 Series1 Grade III open fractures were more contaminated than grade II and grade I

 All the patients showed contamination were victims of RTA  Shows place at which fracture occurs determines the absence or presence of wound contamination ACCIDENT SITE

ADVANTAGES OF TRIPHASIC SAMPLING  Early detection & control of infection  Early predictor of persistent infection  Timely sensitive Antibiotic therapy  Detection of nosocomial infection denotes the quality of sterilization & chances of cross infection

RESULTS  No cases of uncontrolled infection  No incidence of chronic osteomyelitis  No incidence of nosocomial infections

CONCLUSION  50% of the open fractures are already contaminated upon the patient's arrival  Presence of contamination in muscle or periosteum is associated with very high incidence of infection

 Contaminating organisms are community acquired and infections can be controlled with early detection & adequate sensitive antibiotics  Persistence of the same organism in the Post- debridement sample implies the need for further debridement and a subsequent very high risk of infection CONCLUSION

PREVENTION IS BETTER THAN CURE

THANK YOU

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