3.5 Antibiotics for Open Fracture

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Description of Indicator

Relationship to Quality  Medical care should be timely
Type of Indicator Hospital process, Hospital level
Proposed Data Source Hospital Medical Records
Definition Number of patients with an open fracture* receiving an antimicrobial agent within 1 hour of hospital arrival per 100 patients
Numerator All patients age 18 years and older admitted to hospital with a diagnosis of an open fracture* AND administered guideline recommended intravenous antimicrobial agent‡ within 1 hour of hospital arrival
Denominator All patients age 18 years and older admitted to hospital with a diagnosis of an open fracture*
Benchmark Not applicable
Risk Adjustment Not specified at present

 

* Open fracture is defined as a fracture with an associated overlying cutaneous wound50.
‡ Practice management guidelines for prophylactic antibiotic use in open fractures by the Eastern Association for the Surgery of Trauma is one potential source of guidelines for recommended intravenous antibiotics50.


Summary
This indicator is intended to monitor the timely administration of antibiotics for patients with open fractures.


Panel Review
Panelists were in agreement that this indicator is well supported by the evidence and should apply to all grades of fractures. Specification of antibiotics was deemed to be inappropriate by the panel and should instead be determined according to clinical practice guidelines. The panel indicated that because time from injury to initiation of antimicrobial agent is associated with risk of infection, administration of an antimicrobial agent should be performed as soon as possible and therefore proposed a 1 hour time frame for this indicator.


Trauma Center Review
The trauma centers had concerns regarding the limited evidence to support the proposed time threshold for antibiotic administration. They suggested that administration of antibiotics within the one-hour time frame may be difficult, particularly for patients with multiple injuries requiring emergent procedures and imaging.


Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: One study found no association between timing of antibiotic administration during acute phase and infection rates51.
Reliability: No studies identified.
Risk Adjustment: No studies identified.
Utilization: Antibiotics for Open Fracture related indicators are used by a small number of trauma centers: USA 2% (3/200), Canada 0% (0/35), Australasia 0% (0/12).
When a fracture is associated with an overlying cutaneous wound, prevention of wound infection remains the primary objective in the management of the soft tissue. There is universal agreement that these wounds require emergency treatment to minimize infectious complications. Multiple studies have documented the reduction in wound infections with the use of prophylactic antibiotics in the care of patients with open fractures52. Dellinger suggested that reduction in wound infection was best achieved by early, parenteral, short term (for less than or equal to 24 hours) administration of large dose antimicrobials53.

 

Source
The indicator was proposed by the Quality Indicator Consensus Panel.

 

References
50. Luchette F, Bone L, Born C, et al. EAST practice management guidelines for prophylactic antibiotic use in open fractures. 1998. http://www.east.org/research/treatment-guidelines/open-fractures-prophylactic-antibiotics. Accessed Sep 26 2011.
51. Al-Arabi YB, Nader M, Hamidian-Jahromi AR, Woods DA. The effect of the timing of antibiotics and surgical treatment on infection rates in open long-bone fractures: a 9-year prospective study from a district general hospital.[Erratum appears in Injury. 2008;39(3):381 Note: Nader, Michael [corrected to Nader, Maher]]. Injury. 2007;38(8):900-905.
52. Eastern Association for the Surgery of Trauma. EAST - The Eastern Association for the Surgery of Trauma. 2011; http://www.east.org. Accessed September 26, 2011.
53. Dellinger EP. Antibiotic prophylaxis in trauma: penetrating abdominal injuries and open fractures. Rev Infect Dis. 1991;13 Suppl 10:S847-857.