Antibiotics for preventing infection in open limb fractures

  • Review
  • Intervention

Authors


Abstract

Background

Wound and bone infections are frequently associated with open fractures of the extremities and may add significantly to the resulting morbidity. The administration of antibiotics is routinely practised in developed countries as an adjunct to a comprehensive management protocol that also includes irrigation, surgical debridement and stabilisation when indicated, and is thought to reduce the frequency of infections.

Objectives

To review the evidence for the effectiveness of antibiotics in the initial treatment of open fractures of the limbs.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (26 July 2009), Clinical Trials (The Cochrane Library 2009, Issue 3), MEDLINE (1950 to July 2009), EMBASE (1980 to 2009 Week 30), LILACS (1992 to July 2009), International Pharmaceutical Abstracts (1970 to July 2009), and reference lists of articles. We handsearched proceedings of the American Academy of Orthopaedic Surgeons (1980 to 2001), the Orthopaedic Trauma Association (1990 to 2001) and the Société Internationale de Chirurgie Orthopedique et Traumatologique (1980 to 2001). We also contacted published researchers in the field.

Selection criteria

Randomised or quasi-randomised controlled trials involving: participants - people of any age with open fractures of the limbs; intervention - antibiotic administered before or at the time of primary treatment of the open fracture compared with placebo or no antibiotic; outcome measures - early wound infection, chronic drainage, acute or chronic osteomyelitis, delayed unions or non-unions, amputations and deaths.

Data collection and analysis

Two review authors independently screened papers for inclusion, assessed trial quality using an eight item scale, and extracted data. Additional information was sought from three trialists. Pooled data are presented graphically.

Main results

Data from 1106 participants in eight studies were analysed. The use of antibiotics had a protective effect against early infection compared with no antibiotics or placebo (risk ratio 0.43 (95% confidence interval (CI) 0.29 to 0.65); absolute risk reduction 0.07 (95% CI 0.03 to 0.10). There were insufficient data in the included studies to evaluate other outcomes.

Authors' conclusions

Antibiotics reduce the incidence of early infections in open fractures of the limbs. Further placebo controlled randomised trials are unlikely to be justified in middle and high income countries, except for open fractures of the fingers. Further research is necessary to the determine the avoidable burden of morbidity in countries where antibiotics are not used routinely in the management of open fractures.

摘要

背景

使用抗生素預防肢體開放性骨折所造成之感染

傷口和骨頭感染常見於肢體開放性骨折,可能顯著增加罹病率.已開發國家已經例行性使用抗生素,外加於完整的感染管理治療(傷口沖洗,手術清創穩定),抗生素被認為可降低感染頻率

目標

量化抗生素對開放性四肢骨折初始治療的療效

搜尋策略

搜尋the Cochrane Musculoskeletal Injuries Group specialised register (April 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 1, 2003), MEDLINE (1966 to April 2003), EMBASE (1988 to April 2003), LILACS (1992 to June 2002)和文章的參考文獻.手動搜尋American Academy of Orthopaedic Surgeons 的會議紀錄(1980 to 2001), the Orthopaedic Trauma Association (1990 to 2001)和 and the Society Internationale de Chirurgie Orthopedique et Traumatologique (1980 to 2001).也與發表文獻的作者聯繫.

選擇標準

隨機,半隨機對照試驗,對象微任何年齡層四肢開放性骨折病患;治療開放性骨折初級治療前或當下使用抗生素,比上安慰劑或沒有抗生素;結果變項:早期傷口感染,慢性排水,急性和慢性骨髓炎,延緩癒合或不癒合,截枝與死亡

資料收集與分析

兩位檢閱者獨立過濾論文是否應納入,以八項目量表評估品質,並擷取資料.向三位試驗執行者取得額外資料.以圖形表示匯整的資料

主要結論

分析來自7試驗913位受試者的資料,與沒有抗生素或安慰劑組相比,抗生素對早期感染有預防效果(RR = 0.41,95%CI = 0.27−0.63);絕對風險降低 0.08 (95% CI = 0.04−0.12);益一需治數為13 (95% CI = 8−25)).納入的試驗沒有提供足夠資料 評估其他結果變項.

作者結論

抗生素降低開放性四肢骨折早期感染的發生率,將來不應在中高收入國家,進行使用安慰劑為對照組的隨機試驗.未來應研究未常規於開放性骨折使用抗生素國家中,使用抗生素後可降低的罹病率.

翻譯人

本摘要由成功大學附設醫院尹子真翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

抗生素可有效預防開放性四肢骨折早期感染,骨感染是開放性四肢骨折常見的併發症.過去20多年來,已開發國家已經將抗生素納入標準療法,標準療法也包含傷口沖洗,手術清創穩定.本回顧發現,與沒抗生素或安慰劑相比,抗生素可有效降低傷口感染發生率.沒有發現研究骨感染或長期罹病率的試驗

Resumo

Antibióticos para prevenir infecção em fraturas expostas de membros

Introdução

As infecções das feridas e dos ossos são frequentemente associadas com fraturas expostas das extremidades e podem aumentar significativamente a morbidade. Nos países desenvolvidos, os antibióticos fazem parte da assistência habitual para esses casos, como parte de um protocolo que também inclui irrigação, desbridamento cirúrgico e imobilização, quando indicada. Acredita-se que o uso de antibióticos reduz a frequência de infecções.

Objetivos

Revisar as evidências sobre a efetividade dos antibióticos no tratamento inicial de fraturas expostas de membros.

Métodos de busca

Pesquisamos as seguintes bases de dados: Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (26 julho de 2009), Clinical Trials (The Cochrane Library 2009, edição 3), MEDLINE (1950 a julho de 2009), EMBASE (1980 a 2009, semana 30), LILACS (1992 a julho de 2009), International Pharmaceutical Abstracts (1970 a julho de 2009), e listas de referências de artigos. Realizamos busca manual por resumos de estudos apresentados nos anais das seguintes sociedades: American Academy of Orthopaedic Surgeons (1980 a 2001), Orthopaedic Trauma Association (1990 a 2001) e Société Internationale de Chirurgie Orthopedique et Traumatologique, SICOT (1980 a 2001). Fizemos contato com pesquisadores que tinham publicações sobre o tema.

Critério de seleção

Incluímos ensaios clínicos randomizados ou quasi randomizados controlados, que preenchessem os seguintes critérios: participantes — pessoas de qualquer idade com fratura exposta nos membros; intervenção — antibiótico administrado antes ou no momento do tratamento primário da fratura exposta em comparação com placebo ou nenhum antibiótico; desfechos — infecção precoce da ferida, drenagem crônica, osteomielite aguda ou crônica, consolidação tardia ou ausência de consolidação amputações e mortes.

Coleta dos dados e análises

Dois autores fizeram o rastreamento das citações para possível inclusão, extraíram os dados dos estudos incluídos e analisaram a qualidade desses estudos utilizando uma escala com oito itens. Esse processo foi feito de forma independente pelos dois autores. Três autores de ensaios clínicos forneceram informações adicionais. Os dados obtidos foram apresentados graficamente.

Principais resultados

Foram analisados dados de 1.106 participantes incluídos em oito estudos. O uso de antibióticos teve efeito protetor contra a infecção precoce em comparação com não dar antibióticos ou placebo (razão de risco de 0,43, com intervalo de confiança de 95%, 95% CI, de 0,29-0,65); redução do risco absoluto de 0,07 (95% CI de 0,03 a 0,10). Não foi possível avaliar os outros desfechos devido à falta de dados nos estudos incluídos.

Conclusão dos autores

Os antibióticos reduzem a incidência de infecções precoces em fraturas expostas dos membros. Nos países de alta e média renda, não há justificativa para a realização de mais ensaios clínicos randomizados sobre essa questão, com exceção dos casos de fraturas expostas dos dedos das mãos. Nos países que não usam antibióticos de rotina nos casos de fratura exposta, mais pesquisas são necessárias para avaliar o peso da morbidade evitável decorrente dessa conduta.

Notas de tradução

Tradução do Centro Cochrane do Brasil (Igor Guerra Cheloni)

Plain language summary

Antibiotics for preventing infection in open limb fractures

Wound and bone infections are common complications following open fractures of the limbs. For more than 20 years in developed countries, the use of antibiotics has been a part of a standard management protocol that also includes washing the wound (irrigation), cleaning up the wound and fracture (surgical debridement), and stabilisation of the fracture, as required. This review, which included data from 1106 participants in eight trials, found that antibiotics are effective in decreasing the incidence of wound infections, as compared with no antibiotics or placebo. No studies reporting bone infection or long-term ill health (morbidity) were identified.

Resumo para leigos

Antibióticos para evitar infecção em casos de fratura exposta

As infecções da ferida e do osso são complicações comuns em pessoas que têm uma fratura exposta dos membros. Nos países desenvolvidos, há mais de 20 anos se usa antibiótico como parte do tratamento habitual desses casos. Além do antibiótico, esses casos são tratados com lavagem da ferida (irrigação), limpeza cirúrgica da ferida e da fratura (chamada de desbridamento cirúrgico) e imobilização da fratura, conforme necessário. Esta revisão sistemática, que incluiu dados de 1.106 pessoas que participaram de oito estudos, concluiu que os antibióticos são eficazes na redução da incidência de infecções de feridas, em comparação com nenhum antibiótico ou placebo. Não foram identificados estudos que avaliaram infecção óssea ou problemas de saúde a longo prazo (morbidade).

Notas de tradução

Tradução do Centro Cochrane do Brasil (Igor Guerra Cheloni)

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திறந்த கை கால் எலும்பு முறிவுகளின் நோய் தொற்றை தடுப்பதற்கான ஆண்டிபயாடிக்ஸ்

திறந்த கை கால் எலும்பு முறிவுகளைத் தொடர்ந்து, புண் மற்றும் எலும்பு தொற்றுகள் பொதுவாக ஏற்படும் சிக்கல்களாகும். புண்ணை கழுவுதல் (பாசனம்), புண்ணை மற்றும் எலும்பு முறிவை சுத்தப்படுத்துதல் (அறுவை சிகிச்சை மூலம் காயத் துப்புரவு), மற்றும் தேவைக்கேற்ப, எலும்பு முறிவு நிலைப்படுத்துதல் போன்றவற்றை உள்ளடக்கிய வழக்கமான மேலாண்மை திட்டத்தின் ஒரு பகுதியாக ஆண்டிபயாடிக்ஸ் பயன்பாடு 20 வருடங்களுக்கும் மேலாக முன்னேறிய நாடுகளில் இருந்து வருகிறது. ஆண்டிபயாடிக்ஸ் இல்லாமை அல்லது போலி மருந்துடன் ஒப்பிடுகையில், ஆண்டிபயாடிக்ஸ் புண் தொற்றுகளின் நிகழ்வை குறைப்பதில் திறன் மிக்கதாக இருக்கின்றன என்று எட்டு சோதனைகளில் 1106 பங்கேற்பாளர்களிடமிருந்து பெறப்பட்ட தரவை கொண்டிருக்கும் இந்த திறனாய்வு கண்டது. எலும்பு தொற்று, அல்லது நீண்ட-கால உடல்நல குறைவு (நோயுறுதல்) ஆகியவற்றை அறிக்கையிடும் எந்த ஆய்வுகளும் கண்டறியப்படவில்லை.

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