Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures

Abstract

Background: Wound infection and other hospital-acquired infections cause significant morbidity after internal fixation of fractures (osteosynthesis). The administration of antimicrobial agents (antibiotics) may reduce the frequency of infections.

Objectives: To determine whether the prophylactic administration of antibiotics in patients undergoing surgical management of hip or other long bone fractures reduces the incidence of wound and other hospital acquired infections.

Search strategy: We searched the The Cochrane Library, Issue 3 2000; MEDLINE, EMBASE, LILACS, Current Contents, Dissertation Abstracts, and Index to UK Theses to August 2000. Bibliographies of identified articles were screened for further relevant trials. No language restriction was applied.

Selection criteria: Randomised or quasi-randomised controlled trials involving - Participants: Any patients with a hip or other closed long bone fracture undergoing surgery for internal fixation or replacement arthroplasty.

Interventions: Any regimen of systemic antibiotic prophylaxis administered at the time of surgery.

Outcome measures: Wound infection (deep and superficial), urinary tract infection, respiratory tract infection, adverse effects of prophylaxis, economic evaluations.

Data collection and analysis: Two reviewers independently screened papers for inclusion, assessed trial quality using an eight item scale, and extracted data. Additional information was sought from two trialists. Pooled data are presented graphically.

Main results: Data from 8307 participants in 22 studies were analysed. In patients undergoing surgery for closed fracture fixation, single dose antibiotic prophylaxis significantly reduced deep wound infection (relative risk 0.40, 95%CI 0.24, 0.67) superficial wound infections, urinary infections, and respiratory tract infections. Multiple dose prophylaxis had an effect of similar size on deep wound infection (relative risk 0.40, 95%CI 0.24, 0.67), but significant effects on urinary and respiratory infections were not confirmed. Economic modelling using data from one large trial indicates that single dose prophylaxis with ceftriaxone is a cost-effective intervention. There are limited data for the incidence of adverse effects, but as expected they appear to be more common in those receiving antibiotics, compared with placebo or no prophylaxis.

Reviewer's conclusions: Antibiotic prophylaxis should be offered to those undergoing surgery for closed fracture fixation. On ethical grounds, further placebo controlled randomised trials of the effectiveness of antibiotic prophylaxis in closed fracture surgery are unlikely to be justified. Trials addressing the cost-effectiveness of different effective antibiotic regimens would need to be very large.