Published on March 28, 2014
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 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
Calcification Inhibitors in CKD and Dialysis Patients
1. Arch Orthop Trauma Surg. 2002 Jun;122(5):259-61. Epub 2002 Apr 6. Efficacy of primary wound cultures in long bone open extremity fractures: are they of ...
Wound Closure Initial Wound Care of Tibial Fractures ... in Open Fractures Based on Cultures ... primary wound cultures in long bone open ...
... Efficacy of primary wound cultures in long bone open extremity fractures: are they of ... Wound management for severe open fractures: ...
Ganga Orthopaedic Research ... The management of open fractures includes ... to know whether primary wound cultures predict wound infection and ...
of primary wound cultures in long bone open extremity fractures: are they of any value?. ... gasabai R, et al. Predebridement wound culture in open fractures
tions in the treatment of open fractures ... wound cultures up ... Objective and absolute criterias for primary amputation in open tibia fractures were ...
Infection Risk and Wound Culture. 24-70% of open fractures ... Immediate primary wound closure ... Management of large open fracture wounds with ...
Efficacy of primary wound cultures in long bone open extremity fractures: Are they of any value? Arch Orthop Trauma Surg on ResearchGate, the professional ...
AADO/HKSSH Conjoint Scientific Meeting 2009 ... irrigation of lower extremity open fracture wounds. #352. ... Immediate primary skin closure