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Intervention Review

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

  1. William J Gillespie1,*,
  2. Geert Walenkamp2

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 22 JAN 2001

Assessed as up-to-date: 25 NOV 2000

DOI: 10.1002/14651858.CD000244


How to Cite

Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD000244. DOI: 10.1002/14651858.CD000244.

Author Information

  1. 1

    University of Hull, Hull York Medical School, Hull, UK

  2. 2

    Academisch Ziekenhuis Maastricht, Orthopaedics, Maastricht , Maastricht, Netherlands

*William J Gillespie, Hull York Medical School, University of Hull, Cottingham Road, Hull, HU6 7RX, UK. bill.gillespie@hyms.ac.uk. bill.gillespie@yahoo.co.nz.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 22 JAN 2001

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This is not the most recent version of the article. View current version (17 MAR 2010)

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

The principles of prophylaxis against post-surgical infection were established in the laboratory in the early 1960s (Burke 1961). The administration of antibiotic prior to surgery is now widely accepted. The period of administration of prophylaxis has been reduced but the optimal duration remains uncertain. Antibiotic prophylaxis during the operative management of closed fractures has been claimed to reduce infection rates from around five per cent to less than one per cent (Bodoky 1993). As the pathogenesis of post-surgical infection is similar after osteosynthesis of any closed fracture, it has been suggested that combining data from similar prophylactic regimens used during different surgical procedures is quite appropriate (Platt 1991).

Closed hip fractures in the elderly are common, and surgical management is normal in the developed world. The majority of studies of the efficacy of antibiotic prophylaxis in closed fracture fixation have focused on this group of patients. Early randomised trials completed in the 1970s suggested a small but definite prophylactic effect. These trials were individually small, and some used prolonged courses of antibiotic. Many further trials have been reported over the following 25 years. These have addressed a range of issues: duration of administration, route of administration, and antimicrobial spectrum.

A number of descriptive reviews of antibiotic prophylaxis in orthopaedic surgery have been published (Doyon 1989; Norden 1991), in which some attempt has been made to assess methodological quality and include this in the interpretation of results. However, there is sufficient persisting uncertainty about the efficacy, optimal duration, and cost-effectiveness of antibiotic prophylaxis during the surgical treatment of hip and other long bone fractures to justify a systematic review of the evidence from randomised trials.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

The objective of this review is to determine whether the prophylactic administration of antibiotics in patients undergoing surgical management of hip or other closed long bone fractures reduces the incidence of wound and other hospital acquired infections.

The following hypotheses are tested:

1. Antibiotic prophylaxis leads to a reduction in the proportion of patients developing a wound infection, either deep or superficial, compared with those given a placebo or no prophylaxis.

2. 'Single dose' antibiotic prophylaxis leads to a significant reduction in the proportion of patients developing a wound infection compared with those given 'longer duration' prophylaxis.

3. There is a significant reduction in the proportion of patients with a post-operative wound infection who receive prophylaxis using broad-spectrum antibiotics when compared with those who receive narrow spectrum agents.

4. Antibiotic prophylaxis leads to a significant reduction in the proportion of patients developing septicaemia, respiratory or urinary tract infection, compared with those given a placebo or no prophylaxis.

5. 'Single dose' antibiotic prophylaxis leads to a significant reduction in the proportion of patients developing septicaemia, respiratory, or urinary tract infection after surgical management of a hip or other long bone fracture compared with those given three or more doses.

6. Oral administration of a prophylactic regimen leads to a significant reduction in the proportion of participants experiencing a wound infection, respiratory or urinary tract infection, or adverse drug effect, compared with those receiving parenteral prophylaxis.

7. There is a significant increase in the proportion of patients with conditions such as gastro-intestinal symptoms or skin reactions in those allocated antibiotic prophylaxis when compared with those receiving placebo or no prophylaxis.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
 

Criteria for considering studies for this review

 

Types of studies

The predetermined inclusion criteria were broad so as to include any controlled study testing a prophylactic antibiotic in closed fracture surgery.

1. The study must test some method of antibiotic prophylactic intervention aimed at reducing the wound infection rate in closed fracture surgery and compare it against a placebo or alternative intervention group.

2. The study must be a controlled study, randomised or quasi-randomised.

3. The study population must be defined to enable identification of the operative intervention, ideally with relevant subgroups given if more than one.

4. Wound infection must be one of the primary outcome measures.

 

Types of participants

Any person undergoing surgery for internal fixation or replacement arthroplasty as treatment for a closed fracture of the proximal femur, or any other long bone.

 

Types of interventions

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

 

Types of outcome measures

1. Wound infection. The reference definition of wound infection for quality assessment was:
Deep wound infection -
A surgical wound infection which occurs within one year, if an implant is in place and infection involves tissues or spaces at or beneath the fascial layer.
Superficial wound infection -
A surgical wound infection which occurs at the incision site within 30 days after surgery and involves the skin subcutaneous tissue, or muscle located above the fascial layer. In the assessment of methodological quality, more weight was given to studies in which wound infection had been confirmed by microbiological analyses.
2. Urinary tract infection
3. Respiratory tract infection
4. Adverse reaction to antibiotic (gastro-intestinal symptoms, skin reactions)
5. Cost-effectiveness outcomes - length of hospital stay
- reoperation due to infection.

 

Search methods for identification of studies

Trials were identified by searches up to the end of August 2000.

i. The Cochrane Central Register of Controlled Trials, The Cochrane Library, Issue 3, 2000 was searched.
ii. MEDLINE (1966-October 2000); OVID web (see Appendix 1)
iii. EMBASE (to October 2000), OVID web (see Appendix 1)
iv. LILACS, Current Contents, Dissertation Abstracts, and Index to UK Theses were searched to the end of August 2000.
v. The bibliographies of identified literature reviews, original articles, and relevant chapters of published books were examined for undetected articles.
vi. Contacts were made in person or by mail with identified trialists and other experts in the field.

No language restriction was applied.

 

Data collection and analysis

 

Selection of studies

All identified studies were read. We included all randomised or quasi-randomised controlled trials reporting the results of antibiotic prophylaxis in patients undergoing hip or other long bone fracture surgery with wound infection as one of the primary outcome measures. Reports in which participants were not allocated at enrolment in a randomised or quasi-randomised fashion into treatment or control groups were excluded.

 

Quality Assessment

Methodological assessment was undertaken by two raters, using the criteria described in Appendix 2, supplemented by a pre-designed coding manual. Disagreement was resolved by discussion between raters.

 

Data extraction

Data were independently extracted by two reviewers and adjudicated by a third using a data extraction tool which had undergone prior testing. We approached two groups of trialists for clarification of data relevant to the review.

 

Data synthesis

Using Review Manager, for each study, risk ratios and 95 per cent confidence intervals were calculated for dichotomous outcomes. For comparable groups of trials pooled odds ratios with 95 per cent confidence intervals were derived, and where appropriate absolute risk reduction was calculated.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification.

The search strategy identified 48 trials in which antibiotic prophylaxis had been compared with no treatment, a placebo, or another antibiotic regimen in orthopaedic surgery. Twenty-five of these were excluded either because the participants had sustained an open fracture prior to the administration of antibiotics, because participants had not sustained a fracture, or because no usable data were reported for a fracture fixation subgroup in a wider study. In 23 studies, data were available for patients undergoing closed fracture surgery. We were unable to assess one study (Chiu 1993), which has been reported only in abstract. The remaining 22 studies are described in detail in the 'Characteristics of included studies' table. Some reported more than one comparison.

The comparisons evaluated were:

1. A pre-operative dose and two or more post-operative doses of parenteral (injected) antibiotic compared with a placebo or with no treatment. There were 10 trials in this category, in seven of which the participants underwent hip fracture surgery (Ericson 1973; Boyd 1973; Tengve 1978; Burnett 1980; Hedstrom 1987; Buckley 1990; Bodoky 1993), and in three of which (Bergman 1982; Gatell 1984; Paiement 1994) other closed fracture fixation procedures were carried out.

2. A single preoperative dose of parenteral antibiotic compared with a placebo or no treatment. There were seven trials in this category, in five of which (Buckley 1990; Hjortrup 1990; Luthje 2000; McQueen 1990; Kaukonen 1995) the participants underwent hip fracture surgery, and in two of which a range of closed fracture fixation procedures were carried out (Hughes 1991; Boxma 1996).

3. A single dose of parenteral antibiotic compared with multiple doses of the same agent. There were two trials in this category, in one of which (Buckley 1990) the participants underwent hip fracture surgery, and in the other (Gatell 1987), a range of different closed fracture fixation procedures were carried out.

4. A single dose of parenteral antibiotic using an agent with a long half-life, compared with multiple doses of other agents with shorter half lives. There were three trials in this category, of which one (Garcia 1991) included both participants undergoing hip fracture surgery and others undergoing other closed fracture surgery. In Karachalios 1987 the participants underwent hip fracture surgery, and in Jones 1987 B a range of different closed fracture fixation procedures were carried out.

5. Multiple doses of parenteral antibiotic administered over 24 hours or less, compared with a longer period of administration. Two trials (Nelson 1983; Hedstrom 1987) whose participants underwent hip fracture surgery reported comparisons in this category.
6. Oral administration of antibiotic compared with parenteral administration. There was one trial (Nungu 1995) in this category.

 

Risk of bias in included studies

The quality of most studies as reported was poor to moderate. The score for each attribute is recorded for each trial in the 'Characteristics of included studies' table. Only four of the 22 published trials were adequately powered to test the research hypothesis with confidence. In seven trials the description of the randomisation process indicated that prior concealment of allocation was satisfactory, in 12 it was unclear, and in three assignment was inadequately concealed. Placebos were used appropriately in 12 trials, and were not employed where their use would have been appropriate in 10 trials. In trials with a short (inadequate) follow up, analysis by intention to treat was usually possible, but in those in which follow up would have been likely to identify late onset post-operative infection, losses were larger. The trialists' reported definitions of outcome measures varied. In most reports, the definition of wound infection was clinical and did not require microbiological confirmation, although it was often sought. Blinding of the outcome assessor was rarely mentioned, although it could be assumed in those studies which were fully placebo controlled.

 

Effects of interventions

Results in each comparison category are shown in the analyses. We accepted that there was variation between studies in the reported definition of the main outcome measures, but considered that these definitions were clinically sufficiently consistent to permit pooling. Also, although the regimens of antibiotic prophylaxis within each category also varied in respect of the agent and the details of timing, we found that all reported trials employed agents likely to be widely effective at the time of the study against Staphylococcus aureus, the principal organism implicated in post-operative wound infection.

1. A pre-operative dose and two or more post-operative doses of parenteral (injected) antibiotic compared with a placebo or with no treatment.

Data from 1896 participants from 10 trials (11 datasets) were pooled. Regimens in this category significantly reduced the incidence of deep wound infection (risk ratio (RR) 0.36, 95% confidence intervals (CI) 0.21, 0.65), and of superficial wound infection (RR 0.48, 95% CI 0.28 to 0.81), and reduced the incidence of infection of the urinary tract (RR 0.66, 95% CI 0.43 to 1.00). There was no significant reduction in the rate of respiratory infection (RR 0.81, 95% CI 0.41 to 1.63). Adverse effects were rarely reported but appeared more common in participants given antibiotics (RR 1.83, 95% CI 0.96 to 3.50). The absolute risk of deep wound infection in the control patients was 4.3% (0.043), and the risk difference -0.03, (95% CI -0.04 to -0.01).

2. A single preoperative dose of parenteral antibiotic compared with a placebo or no treatment.

Data were pooled from seven trials, including one large multi-centre trial of good quality (Boxma 1996). Regimens in this category reduced the incidence of deep wound infection (RR 0.40, 95% CI 0.24 to 0.67), superficial wound infection (RR 0.69, 95% CI 0.50 to 0.95), urinary tract infection (RR 0.63, 95% CI 0.53 to 0.76), and respiratory infection (RR 0.46, 95% CI 0.33 to 0.65). The absolute risk of deep wound infection in the control patients was 3% (0.03), and the absolute risk reduction -0.02 (95% CI -0.03 to -0.01).

3. A single dose of short-acting parenteral antibiotic compared with multiple doses of the same agent.

Data were pooled from two trials, one of which (Gatell 1987) dominates the analysis by virtue of its size. This trial is of moderate quality. The analysis indicates that a single dose, in the circumstances described in Gatell 1987 was less effective (with marginal statistical significance) in preventing deep wound infection (risk ratio 7.89, 95% CI 1.01 to 61.98), superficial wound infection (RR 4.82, 95% CI 1.08 to 21.61) and urinary tract infection (RR 1.81 to 95% CI 1.01 to 3.23) after surgery for closed fracture than a multiple dose regimen (see 'Discussion').

4. A single dose of parenteral antibiotic using an agent with a long half-life, compared with multiple doses of other agents with shorter half life.

Data were pooled from three trials in this category. One of these (Garcia 1991) was a large trial of moderate quality, but despite its size, analysis of the pooled data failed to show a significant difference between the two types of regimen for the outcomes of deep wound infection (RR 0.57, 95% CI 0.20 to 1.64), superficial wound infection (RR 1.01, 95% CI 0.35 to 2.93), urinary tract infection (RR 0.69, 95% CI 0.37 to 1.32), or respiratory infection (RR 0.31, 95% CI 0.04 to 2.48).

5. Multiple doses of parenteral antibiotic administered over 24 hours or less, compared with a longer period of administration.

Data were pooled from the two small trials in this category. There was no evidence of difference between the two types of regimen for the outcomes of deep (RR 1.10, 95% CI 0.22 to 5.34) or superficial wound infection (RR 0.57, 95% CI 0.17 to 1.93).

6. Oral administration of antibiotic compared with parenteral administration.

Only one small trial (Nungu 1995) has evaluated this comparison for the outcomes of deep and superficial wound infection, and urinary infection. No significant difference between the routes was demonstrated (deep infection: RR 0.29, 95% CI 0.01 to 7.07; superficial infection: RR 0.17, 95% CI 0.02 to 1.47; urinary infection: RR 1.10, 95% CI 0.62 to 1.94). This trial was underpowered to identify any difference between oral and parenteral routes of administration.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

Antibiotic prophylaxis has been widely used in fracture surgery since the 1970s. The 22 trials reported span over quarter of a century. In the early studies, penicillins effective against gram positive cocci were used. As resistant organisms appeared, subsequent generations of penicillins, and then cephalosporins have been trialed in prophylaxis, both against placebo or no treatment, and against other agents. As cephalosporins have a wider antimicrobial spectrum than the penicillins used in the early studies, their efficacy in reducing the occurrence of infections of the urinary and respiratory tracts, which were secondary outcome measures in many of the included trials, may be superior.

Over time, shorter durations of prophylaxis have been used. For effective prophylaxis, the minimum inhibitory concentration (MIC) of the antibiotic in the tissues must be exceeded for at least the period from incision to wound closure (Burke 1961). In practice, this initially meant using regimens with several consecutive doses, and the pooled data support their effectiveness. The availability of agents with a long elimination half life has allowed single dose prophylaxis reliably to meet Burke's prerequisite. Amongst published trials the large multi-centre Netherlands trial (Boxma 1996), which used an antibiotic which provided concentrations exceeding MIC for 12-24 hours, dominates the analysis in this category. This trial supported the hypothesis that single dose intravenous prophylaxis is effective in reducing the incidence of deep wound infection, superficial wound infection, and urinary and respiratory tract infections. The effect sizes are similar to those of from multi-dose prophylaxis.

Despite the lack of power in many of the individual studies, pooling of the accumulated evidence supports the hypothesis of effectiveness of antibiotic prophylaxis. Boxma 1996 included an economic evaluation based on the effectiveness data which indicates a cost saving of a little under 500US dollars per patient given prophylaxis. This may be conservative as the evaluation does not appear to take into account the costs of urinary and respiratory infections prevented. Albers and colleagues (Albers 1994) have calculated that antibiotic prophylaxis for closed fracture surgery is cost effective if the absolute risk reduction is 0.25% or more; the pooled estimates for absolute risk reduction for single dose or multiple dose prophylaxis in this review exceed that. Therefore, without taking into account the effects of wide adoption of prophylactic regimens on the development of antibiotic resistance, antibiotic prophylaxis appears cost-effective.

Direct comparisons of multiple and single dose prophylaxis have also been conducted by Gatell 1987 and Buckley 1990. Buckley 1990 was underpowered to distinguish between the two regimens tested. Gatell 1987, a large single centre study, concluded that single dose prophylaxis was inferior , but the statistical significance is marginal. Also, the tissue MIC may not have been reliably exceeded throughout the procedure for all participants in Gatell 1987, in which an agent (cefamandole 2g) with a short half life was administered 30 minutes prior to the planned onset of surgery.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

 

Implications for practice

1. Antibiotic prophylaxis for closed fracture surgery is an effective intervention. Application of cost-modelling to the effectiveness data has indicated that it also appears to be cost-effective, in the absence of any data on the impact on the development of antibiotic resistance.
2. Single dose intravenous prophylaxis is effective if the agent used provides tissue levels exceeding the minimum inhibitory concentration over a 12 hour period.
3. If the antibiotic chosen has a short half-life which may not allow minimum inhibitory concentrations to be exceeded throughout the period from incision to wound closure, the use of multiple dose regimens using a 12 hour dosage schedule is a satisfactory alternative.

 
Implications for research

1. Further placebo controlled trials to evaluate the effectiveness of antibiotic prophylaxis in closed fracture surgery would be unlikely to be ethical.
2. Further trials comparing different antibiotic regimens would require to be very large to confirm differences between candidate regimens.
3. Modelling of cost effectiveness (purchase price, adverse effects) will be important in making choices as established agents lose their efficacy due to resistance, and new agents become available.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

The authors acknowledge the help of the following who assisted with searching, retrieval of studies, and methodological assessment: Dr Helen Handoll, Mrs Lesley Gillespie, Dr Chris Hoffman. We would also like to thank the following for useful comments from the initial editorial review in 1998: Dr Helen Handoll, Dr Rajan Madhok, Prof Gordon Murray and Dr Antony Berendt.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
Download statistical data

 
Comparison 1. Antibiotic agent (mulitple dose) versus placebo or no treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Deep wound infection101896Risk Ratio (M-H, Fixed, 95% CI)0.36 [0.21, 0.65]

    1.1 Hip fracture fixation
4526Risk Ratio (M-H, Fixed, 95% CI)0.22 [0.07, 0.75]

    1.2 Hip endoprosthesis
114Risk Ratio (M-H, Fixed, 95% CI)0.56 [0.03, 11.57]

    1.3 Unspecified hip fracture procedure
3770Risk Ratio (M-H, Fixed, 95% CI)0.47 [0.21, 1.04]

    1.4 Operative management of other or unspecified closed fracture
3586Risk Ratio (M-H, Fixed, 95% CI)0.35 [0.10, 1.24]

 2 Superficial wound infection71366Risk Ratio (M-H, Fixed, 95% CI)0.48 [0.28, 0.81]

 3 Urinary tract infection2500Risk Ratio (M-H, Fixed, 95% CI)0.66 [0.43, 1.00]

 4 Respiratory infection2500Risk Ratio (M-H, Fixed, 95% CI)0.81 [0.41, 1.63]

 5 Adverse drug effects2882Risk Ratio (M-H, Fixed, 95% CI)1.83 [0.96, 3.50]

    5.1 Gastro-intestinal symptoms
2441Risk Ratio (M-H, Fixed, 95% CI)2.05 [0.99, 4.25]

    5.2 Skin reactions
2441Risk Ratio (M-H, Fixed, 95% CI)1.26 [0.30, 5.22]

 
Comparison 2. Antibiotic agent (single dose) versus placebo or no treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Deep wound infection73500Risk Ratio (M-H, Fixed, 95% CI)0.40 [0.24, 0.67]

    1.1 Unspecified hip fracture procedure
51251Risk Ratio (M-H, Fixed, 95% CI)0.68 [0.28, 1.66]

    1.2 Operative management of other or unspecified closed fracture
22249Risk Ratio (M-H, Fixed, 95% CI)0.32 [0.17, 0.60]

 2 Superficial wound infection73500Risk Ratio (M-H, Fixed, 95% CI)0.69 [0.50, 0.95]

 3 Urinary tract infection42975Risk Ratio (M-H, Fixed, 95% CI)0.63 [0.53, 0.76]

 4 Respiratory infection42975Risk Ratio (M-H, Fixed, 95% CI)0.46 [0.33, 0.65]

 
Comparison 3. Single dose short-acting versus multiple dose - same agent

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Deep wound infection2921Risk Ratio (M-H, Fixed, 95% CI)7.89 [1.01, 61.97]

    1.1 Unspecified hip fracture procedure
1204Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    1.2 Operative management of other or unspecified closed fracture
1717Risk Ratio (M-H, Fixed, 95% CI)7.89 [1.01, 61.97]

 2 Superficial wound infection1717Risk Ratio (M-H, Fixed, 95% CI)4.82 [1.08, 21.61]

 3 Urinary tract infection1717Risk Ratio (M-H, Fixed, 95% CI)1.81 [1.01, 3.23]

 
Comparison 4. Single dose long acting versus any multiple dose regimen

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Deep wound infection31747Risk Ratio (M-H, Fixed, 95% CI)0.57 [0.20, 1.64]

    1.1 Unspecified hip fracture procedure
2505Risk Ratio (M-H, Fixed, 95% CI)0.66 [0.12, 3.59]

    1.2 Operative management of other or unspecified closed fracture
21242Risk Ratio (M-H, Fixed, 95% CI)0.52 [0.13, 2.02]

 2 Superficial wound infection21689Risk Ratio (M-H, Fixed, 95% CI)1.01 [0.35, 2.93]

 3 Urinary tract infection11489Risk Ratio (M-H, Fixed, 95% CI)0.69 [0.37, 1.32]

 4 Respiratory infection11489Risk Ratio (M-H, Fixed, 95% CI)0.31 [0.04, 2.48]

 
Comparison 5. Operative day only versus longer prophylaxis

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Deep wound infection2224Risk Ratio (M-H, Fixed, 95% CI)1.10 [0.22, 5.34]

    1.1 Unspecified hip fracture procedure
2224Risk Ratio (M-H, Fixed, 95% CI)1.10 [0.22, 5.34]

 2 Superficial wound infection1121Risk Ratio (M-H, Fixed, 95% CI)0.57 [0.17, 1.93]

 
Comparison 6. Oral versus parenteral administration of antibiotic agent

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Deep wound infection1452Risk Ratio (M-H, Fixed, 95% CI)0.29 [0.01, 7.07]

    1.1 Unspecified hip fracture procedure
1452Risk Ratio (M-H, Fixed, 95% CI)0.29 [0.01, 7.07]

 2 Superficial wound infection1452Risk Ratio (M-H, Fixed, 95% CI)0.17 [0.02, 1.47]

 3 Urinary tract infection1452Risk Ratio (M-H, Fixed, 95% CI)1.10 [0.62, 1.94]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
 

Appendix 1. Search strategies

 

MEDLINE (OVID Web)

1 randomized controlled trial.pt.
2 controlled clinical trial.pt.
3 random allocation/
4 double blind method/
5 single blind method/
6 exp Cross-Over Studies/
7 or/1-6
8 ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed) adj3 (trial or study)).tw.
9 (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw.
10 ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw.
11 (cross?over$ or (cross adj1 over$)).tw.
12 ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)).tw.
13 or/8-12
14 or/7,13
15 exp Orthopedic Procedures/
16 exp Orthopedic Equipment/
17 exp Orthopedics/
18 exp Fractures/
19 exp Fracture Healing/
20 exp Amputation, Traumatic/
21 exp Arm Injuries/
22 exp Athletic Injuries/
23 exp Dislocations/
24 exp Hand Injuries/
25 exp Leg Injuries/
26 exp Soft Tissue Injuries/
27 exp Contusions/
28 exp Contusions/
29 exp "Sprains and Strains"/
30 exp Tendon Injuries/
31 exp Arthroscopy/
32 or/15-31
33 (hip$ or femur$ or femoral$ or trochant$ or pertrochant$ or intertrochant$ or subtrochant$ or intracapsular$ or extracapsular$ or condyl$ or shaft$ or diaphys$).tw.
34 (pelvi$ or acetabul$ or knee$ or patell$ or tibia$ or fibula$ or pillon or malleol$ or ankle$ or calcan$ or tarsal$ or talus$ or talar$ or cuneiform$ or navicular$ or cuboid$ or metatars$ or phalang$).tw.
35 (leg$1 or (lower adj limb$) or arm$1 or (upper adj limb$) or shoulder$ or humer$ or radi$ or ulna$ or scapula$).tw.
36 (elbow$ or wrist$ or supracondyl$ or epicondyl$ or metacarpal$ or hand$ or finger$ or trapez$ or hamate$ or capitate$ or scaphoid$ or lunate$ or triquetral$ or pisiform$).tw.
37 ((styloid$ or coronoid$) adj2 process$).tw.
38 (ligament$ or tendon$ or menisc$).tw.
39 or/33-38
40 (fracture$ or injur$ or wound$ or dislocat$ or sublux$ or rupture$ or tear$ or torn).tw.
41 and/39-40
42 (fracture$ adj3 (open or closed)).tw.
43 or/41-42
44 or/32,43
45 14 and 44
46 Animal/ not Human/
47 45 not 46
48 exp Antibiotic Prophylaxis/
49 Surgical Wound Infection/ or Postoperative Complications/ or Wound Infection/
50 (antibiotic$ or antimicrob$).tw.
51 or/48,50
52 infect$.tw.
53 or/49,52
54 and/51,53
55 and/47,54

 

EMBASE (OVID Web)

1. exp Randomized Controlled trial/
2. exp Double Blind Procedure/
3. exp Single Blind Procedure/
4. exp Crossover Procedure/
5. or/1-4
6. ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed) adj3 (trial or study)).tw.
7. (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw.
8. ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw.
9. (cross?over$ or (cross adj1 over$)).tw.
10. ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)).tw.
11. or/6-10
12. or/10-11
13. Animal/ not Human/
14. 12 not 13
15. exp Orthopedic Surgery/
16. exp Orthopedics/
17. exp Orthopedic Equipment/
18. exp Fracture Healing/
19. exp Avulsion Injury/
20. exp Contusion/
21. exp Limb Injury/
22. exp Musculoskeletal Injury/
23. exp Pelvis Injury/
24. exp Traumatic Amputation/
25. exp Soft Tissue Injury/
26. exp Sport Injury/
27. or/15-26
28. (hip$ or femur$ or femoral$ or trochant$ or pertrochant$ or intertrochant$ or subtrochant$ or intracapsular$ or extracapsular$ or condyl$ or shaft$ or diaphys$).tw.
29. (pelvi$ or acetabul$ or knee$ or patell$ or tibia$ or fibula$ or pillon or malleol$ or ankle$ or calcan$ or tarsal$ or talus$ or talar$ or cuneiform$ or navicular$ or cuboid$ or metatars$ or phalang$).tw.
30. (leg$1 or (lower adj limb$) or arm$1 or (upper adj limb$) or shoulder$ or humer$ or radi$ or ulna$ or scapula$).tw.
31. (elbow$ or wrist$ or supracondyl$ or epicondyl$ or metacarpal$ or hand$ or finger$ or trapez$ or hamate$ or capitate$ or scaphoid$ or lunate$ or triquetral$ or pisiform$).tw.
32. ((styloid$ or coronoid$) adj2 process$).tw.
33. (ligament$ or tendon$ or menisc$).tw.
34. or/28-33
35. (fracture$ or injur$ or wound$ or dislocat$ or sublux$ or rupture$ or tear$ or torn).tw.
36. and/34-35
37. (fracture$ adj3 (open or closed)).tw.
38. or/36-37
39. or/27,38
40. and/14,39
41. antibiotic prophylaxis/ or infection prevention/
42. (antibiotic$ or antimicrobial$).tw.
43. or/41-42
44. hospital infection/ or infection complication/ or postoperative infection/ or surgical infection/ or wound infection/ or "bone and joint infections"/
45. infection$.tw.
46. or/44-45
47. and/43,46
48. and/40,47

 

Appendix 2. Quality assessment criteria

A. Was the assigned treatment adequately concealed prior to allocation?
1=states random, but no description, or quasi-randomisation (Category C)
2=small but real chance of disclosure of assignment (Category B)
3=method did not allow disclosure of assignment (Category A)

B. Were the outcomes of patients who withdrew described and included in the analysis (intention to treat)?
1=not mentioned
2=states numbers and reasons for withdrawal, but analysis unmodified
3=primary analysis based on all cases as randomised

C. Assessment of outcome. Were assessors of outcome blinded to treatment status?
1=not done or not mentioned
2=moderate chance of unblinding of assessors
3=action taken to blind assessors, or outcomes such that bias is unlikely

D. Comparability of treatment and control groups at entry
1=large potential for confounding or not discussed
2=confounding small; mentioned but not adjusted for
3=unconfounded; good comparability of groups or confounding adjusted for

E. Was a placebo treatment assigned as part of the randomisation?
1=No 3=Yes

F. Were exclusion criteria clearly defined?
1=not defined
2=poorly defined
3=well defined

G. Method of assessment of wound infection.
1=not stated
2= clinical decision, or definite criteria without a microbiological diagnosis
3=definite criteria including a microbiological diagnosis

H. Surveillance for wound infection
1=not stated, or not active
2=active, but less than three months
3=active, and at least one year

 

Feedback

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
 

Comment sent 12 January 1999

 

Summary

I very much enjoyed reading the new Cochrane review of antibiotic usage in fracture prosthetic surgery. This is full of fascinating information, and is a good marriage of high-quality statistical and clinical input. I have made our Orthopaedic surgeons aware of the review's findings, and have proposed a change to our agreed prophylactic protocols as a result.

The review usefully examined the effects of long- and short-halflife agents, but another common point of debate is the choice of narrow-spectrum (mainly isoxazolyl penicillin) versus broad-spectrum (e.g. cefuroxime, or isoxazolyl penicillin plus gentamicin) prophylaxis. There is a suggestion in the classic Lidwell/MRC study reports that broad spectrum prophylaxis may reduce infection rates (by reducing deep Gram-negative infections), but others have been concerned about costs, side effects (principally Clost. difficile diarrhoea) and induction of resistance associated with broader-spectrum agents. Did the group consider this approach? Could it be examined in the future?

 

Reply

Many thanks for your interest in our review. We did not identify any trial which compared narrow and broad spectrum agents in the closed fracture population. There are in joint replacement (Pollard 1979, Vainionpaa 1988), and in open fracture management (Patzakis 1977); these studies were in our excluded trials table. If we have missed any that you know about, I would be most interested to hear of them. In Nelson 1983 (a study which we included comparing antibiotic versus placebo), the choice of antibiotic was at the discretion of the treating surgeon, but the trial did not compare these options. There seems to be evidence of a beneficial effect in limiting urinary tract infection when a cephalosporin was compared with a placebo (see the analyses in our review).

 

Contributors

Comment sent from:
Dr Mark Farrington, Cambridge, UK
Reply from:
Prof William Gillespie, Dunedin, New Zealand
Processed by:
Dr Helen Handoll, Edinburgh, UK
Dr Rajan Madhok, Hull, UK (criticism editor)

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

Last assessed as up-to-date: 25 November 2000.


DateEventDescription

5 November 2008AmendedConverted to new review format.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

Protocol first published: Issue 1, 1995
Review first published: Issue 4, 1998


DateEventDescription

26 November 2000New citation required but conclusions have not changedThis review was updated in Issue 2, 2001. This involved including data from a new randomised controlled trial (Luthje 2000) comparing a single dose antibiotic regimen with no prophylaxis. The conclusions of the review were unchanged.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

Both reviewers (WJ Gillespie and G Walenkamp) appraised and extracted data from all included papers. WJ Gillespie was respnsible for drafting and for entering modifications to the text. WJ Gillespie is the guarantor of the review.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms

None known

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Index terms
 

Internal sources

  • HealthCare Otago Endowment Trust, Dunedin, New Zealand.

 

External sources

  • Chief Scientist Office, Department of Health, The Scottish Office (Original Review), UK.
  • Health Research Council of New Zealand (Update), New Zealand.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. Additional references
Bergman 1982 {published data only}
Bodoky 1993 {published data only}
  • Bodoky A, Neff U, Heberer M, Harder F. Antibiotic prophylaxis with two doses of cephalosporin in patients managed with internal fixation for a fracture of the hip. Journal of Bone and Joint Surgery. American Volume 1993;75A:61-65.
  • Bodoky A, Neff U, Heberer M, Harder F. Preoperative assessment of at-risk patients in traumatology [Praoperative erfassung von risikopatienten in der traumatologie]. Helvetica Chirurgica Acta 1989;56:91-5.
Boxma 1996 {published data only}
Boyd 1973 {published data only}
  • Boyd RJ, Burke JF, Colton T. A double-blind clinical trial of prophylactic antibiotics in hip fractures. Journal of Bone and Joint Surgery. American Volume 1973;55A:1251-8.
Buckley 1990 {published data only}
  • Buckley R, Hughes GNF, Snodgrass T, Huchcroft SA. Perioperative cefazolin prophylaxis in hip fracture surgery. Canadian Journal of Surgery 1990;33:122-5.
  • Buckley RE, Hughes GNF. Perioperative cefazolin prophylaxis in hip fracture surgery. Journal of Bone and Joint Surgery. British Volume 1989;71B:343.
Burnett 1980 {published data only}
  • Burnett JW, Gustilo RB, Williams DN, Kind AC. Prophylactic antibiotics in hip fracture. A double-blind, prospective study. Journal of Bone and Joint Surgery. American Volume 1980;62:457-62.
Ericson 1973 {published data only}
  • Ericson C, Lidgren L, Lindberg L. Cloxacillin in the prophylaxis of post-operative infections of the hip. Journal of Bone and Joint Surgery. American Volume 1973;55A:808-13, 843.
Garcia 1991 {published data only}
  • Garcia S, Lozana ML, Gatell JM, Soriana E, Ramon R, Sanmiguel JG. Prophylaxis against infection. Single-dose cefonicid compared with multiple dose cefamandole. Journal of Bone and Joint Surgery. American Volume 1991;73A:1044-8.
Gatell 1984 {published data only}
  • Gatell JM, Riba J, Lozana ML, Mana A, Ramon R, SanMiguel JG. Prophylactic cefamandole in orthopaedic surgery. Journal of Bone and Joint Surgery. American Volume 1984;66A:1219-24.
Gatell 1987 {published data only}
  • Gatell JM, Garcia S, Lozano L, Soriano E, Ramon R, SanMiguel JG. Perioperative cefamandole prophylaxis against infections. Journal of Bone and Joint Surgery. American Volume 1987;69A:1189-93.
Hedstrom 1987 {published data only}
Hjortrup 1990 {published data only}
  • Hjortrup A, Sorensen C, Mejdahl S, Horsneas M, Kjersgaard P. Antibiotic prophylaxis in surgery for hip fractures. Acta Orthopaedica Scandinavica 1990;61:152-3.
  • Kjersgaard P, Hjortrup A, Moesgaard F, Horsnaes M. [Profylaktiske antibiotika ved operation for hoftefraktur]. Ugeskrift for Laeger 1987;149:713-4.
Hughes 1991 {published data only}
Jones 1987 B {published data only}
  • Jones RN, Wojeski W, Bakke J, Porter C, Searles M. Antibiotic prophylaxis of 1036 patients undergoing elective surgical procedures. A prospective randomized comparative trial of cefazolin, cefoxitin and cefotaxime in a prepaid medical practice. American Journal of Surgery 1987;153:341-6.
Karachalios 1987 {published data only}
  • Karachalios T, Lyritis G, Hatzopoulos E, Sapkas G. Single dose prophylaxis of ceftriaxone versus standard dosage of cefotaxime in the prophylaxis of bacterial complications in orthopaedic surgery. Chemioterapia: international journal of the Mediterranean Society of Chemotherapy 1987;6:573-5.
  • Karachalios Th, Lyritis GP, Hatzopoulos E. Antibiotic prophylaxix in the surgical treatment of trochanteric fractures: a comparative trial between two cephalosporins. Chemotherapy 1990;36:448-53.
Kaukonen 1995 {published data only}
  • Kaukonen JP, Kemppainen E, Makijarvi J, Touminen T. One dose cefuroxime prophylaxis in hip fracture surgery. Annales Chirurgica et Gynaecologiae 1995;84:417-9.
Luthje 2000 {published data only}
  • Lüthje P, Nurmi I, Aho H, Honkanene P, Jokipii P, Kataja M, et al. Single dose antibiotic prophylaxis in osteosynthesis for hip fractures. A clinical multicentre study in Finland. Annales Chirurgiae at Gynaecologiae 2000;89:125-30.
McQueen 1990 {published data only (unpublished sought but not used)}
Nelson 1983 {published data only}
  • Heydemann JS, Nelson CL. Short-term preventive antibiotics. Clinical Orthopaedics and Related Research 1986;205:184-7.
  • Nelson CL, Green TG, Porter RA, Warren RD. One day versus seven days of preventive antibiotic therapy in orthopaedic surgery. Clinical Orthopaedics and Related Research 1983;176:258-63.
Nungu 1995 {published data only}
  • Nungu KS, Larsson S, Wallinder L, Holm S. Bone and wound fluid concentrations of cephalosporins. Oral cefadroxil and parenteral cefuroxime compared in 52 patients with a trochanteric fracture. Acta Orthopaedica Scandinavica 1995;66:161-5.
  • Nungu KS, Olereud C, Rehnberg L, Larsson S, Nordell P, Alvin I, Bengtsson S, Wallinder L, Hedin G. Prophylaxis with oral cephadril versus intravenous cefuroxime in trochanteric fracture surgery. A clinical multicentre study. Archives of Orthopaedic and Trauma Surgery 1995;114:303-7.
Paiement 1994 {published data only}
  • Paiement GD, Renaud E, Dagenais G, Gosselin RA. Double-blind randomized prospective study of the efficacy of antibiotic prophylaxis for open reduction and internal fixation of closed ankle fractures. Journal of Orthopaedic Trauma 1994;8:64-6.
Tengve 1978 {published data only}
  • Tengve B, Kjellander J. Antibiotic prophylaxis in operations on trochanteric femoral fractures. Journal of Bone and Joint Surgery. American Volume 1978;60A:97-9.

References to studies excluded from this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. Additional references
Benson 1983 {published data only}
Braun 1987 {published data only}
  • Braun R, Enzler MA, Rittmann WW. A double blind clinical trial of prophylactic cloxacillin in open fractures. Journal of Orthopaedic Trauma 1987;1:12-17.
Centulio 1988 {published data only}
  • Centulio F, Conticello A. [Antimicrobial chemoprophylaxis with ceftriaxone in surgical implantation of a non-cemented hip prosthesis: comparison of 2 dosage schemes]. [Italian]. Chirurgia Degli Organi di Movimento 1988;73(4):357-61.
De Benedictis 1984 {published data only}
  • De Benedictis KJ, Rowan NM, Boyer BL. A double-blind study comparing cefonicid with cefazolin as prophylaxis in patients undergoing total hip or knee replacement. Reviews of Infectious Diseases 1984;6:S901-4.
Dellinger 1988 {published data only}
Evrard 1988 {published data only}
  • Evrard J, Doyon F, Acar JF, Salord JC, Mazas F, Flamant R. Two day cefamandole versus five-day cephazolin prophylaxis in 965 total hip replacements. Report of a multicentre double blind randomised trial. International Orthopaedics 1988;12:69-73.
Gunst 1984 {published data only}
  • Gunst JP, Deletang S, Rogez JM, Blanloeil Y, Baron D, Dixneuf B. Prophylactic antibiotic therapy with cefamandole in total hip surgery replacement using Charnley's tent. A randomized study [Antibiotherapie prophylactique par le cefamandole dans la chirurgie de la prosthese totale de hanche sous tente de Charnley. Etude randomisee]. Pathologie et Biologie 1984;32(5 Pt 2):567-9.
Henley 1986 {published data only}
  • Henley MB, Jones RE, Wyatt RWB, Hofmann A, Cohen RL. Prophylaxis with cefamandole nafate in elective orthopaedic surgery. Clinical Orthopaedics 1986;209:249-54.
Hill 1981 {published data only}
Johnson 1988 {published data only}
  • Johnson KD, Bone LB, Scheinberg R. Severe open tibial fractures: a study protocol. Journal of Orthopaedic Trauma 1988;2:175-80.
Jones 1985 {published data only}
  • Jones S, DiPiro JT, Nix DE, Bhatti NA. Cephalosporins for prophylaxis in operative repair of femoral fractures; levels in serum, muscle, and hematoma. Journal of Bone and Joint Surgery. American Volume 1985;67A:921-4.
Jones 1987 A {published data only}
  • Jones RN, Wojeski WV. Single dose cephalosporin prophylaxis of 929 surgical procedures in a prepaid group practice: a prospective randomized comparison of cefoperazone and cefotaxime. Diagnostic Microbiology and Infectious Disease 1987;6:323-34.
Knapp 1996 {published data only}
  • Knapp TP, Patzakis MJ, Lee J, Seipel PR, Abdollahi K, Reisch RB. Comparison of intravenous and oral antibiotic therapy in the treatment of fractures caused by low-velocity gunshots. A prospective, randomized study of infection rates. Journal of Bone and Joint Surgery. American Volume 1996;78:1167-71.
Lidwell 1984 {published data only}
  • Lidwell OM, Lowbury EJL, Whyte W, Blowers R, Stanley SJ, Lowe D. Infection and sepsis after operations for total hip of knee joint replacement: influence of ultraclean air, prophylactic antibiotics and other factors. Journal of Hygiene 1984;93:505-29.
Mauerhan 1994 {published data only}
  • Mauerhan DR, Nelson CL, Smith DL, Fitzgerald RH, Slama TG, Petty RW, et al. Prophylaxis against infection in total joint arthroplasty. One day of cefuroxime compared with three days of cefazolin. Journal of Bone and Joint Surgery. American Volume 1994;76A:39-45.
Mollan 1994 {published data only}
  • Mollan RAB, Haddock M, Webb CH. Teicoplanin vs cephamandole for antimicrobial prophylaxis in prosthetic joint implant surgery; preliminary results. European Journal of Surgery 1992, (Suppl 567):19-21.
Patzakis 1977 {published data only}
Pavel 1974 {published data only}
  • Pavel A, Smith RL, Ballard A, Larson IJ. Prophylactic antibiotics in elective orthopaedic surgery: a prospective study of 1,591 cases. Southern Medical Journal 1977;70(Suppl 1):50-5.
  • Pavel A, Smith RL, Larsen IJ. Prophylactic antibiotics in clean orthopaedic surgery. Journal of Bone and Joint Surgery. American Volume 1974;56A:777-82.
Periti 1989 {published data only}
  • Periti P, Jacchia E. Ceftriaxone as short-term antimicrobial chemoprophylaxis in orthopedic surgery: a 1-year multicenter follow-up. European Surgical Research 1989;21(Suppl 1):25-32.
Periti 1992 {published data only}
  • Periti P, Stringa G, Donati L, Mazzei T, Mini E, Novelli A. Teicoplanin- its role in systemic therapy of burns infections and as prophylaxis for orthopaedic surgery. European Surgical Research 1992, (Suppl 567):3-8.
Pollard 1979 {published data only}
Schulitz 1980 {published data only}
  • Schulitz KP, Winkellman W, Schoening B. The prophylactic use of antibiotics in alloarthroplasty of the hip joint for coxarthrosis. A randomized study. Archives of Orthopaedic Trauma and Surgery 1980;96:79-82.
Vainionpaa 1988 {published data only}
  • Vainionpaa S, Wilppula E, Lalla M, Renkonen OV, Rokkanen P. Cefamandole and isoxazolyl penicillins in antibiotic prophylaxis of patients undergoing total hip or knee-joint arthroplasty. Archives of Orthopaedic Trauma and Surgery 1988;107:228-30.
Van Meirhaeghe 1989 {published data only}
  • Van Meirhaeghe J, Verdonk R, Vershraegen G, Myny P, Paeme G, Claessens H. Flucloxacillin compared with cefazolin in short-term prophylaxis for clean orthopaedic surgery. Archives of Orthopaedic Trauma and Surgery 1989;108:308-13.
Visuri 1976 {published data only}
  • Visuri T, Antila P, Laurent LE. A comparison of dicloxacillin and ampicillin in the antibiotic prophylaxis of total hip replacement. Annales Chirurgiae et Gynaecologiae 1976;65:58-61.
Wymenga 1992 {published data only}
  • Wymenga A, van Horn J, Theeuwes A, Muytjens H, Slooff T. Cefuroxime for prevention of post-operative coxitis. One versus three doses tested in a randomized multi-center study of 2651 arthroplasties. Acta Orthopaedica Scandinavica 1992;63:19-24.

References to studies awaiting assessment

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. Additional references
Chiu 1993 {published data only}
  • Chiu KY, Ng KH, Fung B, Lau SK, Chow SP. A prospective randomized study on four regimes of antibiotic prophylaxis for hip fracture operations. Journal of Bone and Joint Surgery. British Volume 1993;75B(Suppl III):230.

Additional references

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Characteristics of studies
  19. References to studies included in this review
  20. References to studies excluded from this review
  21. References to studies awaiting assessment
  22. Additional references
Albers 1994
  • Albers BA, Patka P, Haarman HJTM, Kostense PJ. Cost effectiveness of antibiotic prophylaxis for closed fractures [Kosteneffektivat einer Antibiotikaprophylaxe bei Senkung des Infectionsrisikos um 0,25%]. Unfallchirurgie 1994;97:625-8.
Burke 1961
Doyon 1989
  • Doyon F, Evrard J, Mazas F. Evaluation of therapeutic trials published apropos of antibiotic prophylaxis in orthopedic surgery [Evaluation des essais therapeutiques publies sur l'antibioprophylaxie en chirugie orthopedique]. Revue de Chirurgie Orthopedique et Reparatrice de l Appareil Moteur. 1989;75:72-6.
Norden 1991
  • Norden CW. Antibiotic prophylaxis in orthopaedic surgery. Reviews of Infectious Diseases 1991;13(10 Suppl):842S-6S.
Platt 1991
  • Platt R. Methodological aspects of clinical studies of perioperative antibiotic prophylaxis. Reviews of Infectious Diseases 1991;13(10 Suppl):810-4.