PRIMARY WOUND PRIMARY WOUND CULTURE IN OPEN CULTURE IN OPEN

FRACTURESFRACTURESDR ABIJIT RADHAKRISHNANDR ABIJIT RADHAKRISHNAN

PROF JOHN GEORGE,PROF P S JOHNPROF JOHN GEORGE,PROF P S JOHN

DEPARTMENT OF ORTHOPAEDICS DEPARTMENT OF ORTHOPAEDICS

MEDICAL COLLEGE, KOTTAYAMMEDICAL COLLEGE, KOTTAYAM

GREETINGS GREETINGS

FROMFROM

MEDICAL COLLEGE KOTTAYAMMEDICAL COLLEGE KOTTAYAM

INTRODUCTIONINTRODUCTION

Sepsis occurring in open fractures Sepsis occurring in open fractures leads to significant morbidityleads to significant morbidity

Wound contamination as well as Wound contamination as well as knowledge of the microbial flora is knowledge of the microbial flora is needed to administer a rational and needed to administer a rational and effective antibiotic treatment for effective antibiotic treatment for open fracturesopen fractures

the amount of devitalizationthe amount of devitalization the type and site of fracturethe type and site of fracture the time lapse between injury and the time lapse between injury and

debridement debridement the mode of fracture fixation the mode of fracture fixation the timing of antibiotic the timing of antibiotic

administrations administrations

DETERMINANTSDETERMINANTS

AIM OF THE STUDYAIM OF THE STUDY

The incidence of bacterial The incidence of bacterial contamination in open fractures contamination in open fractures depending upon mode of traumadepending upon mode of trauma

The common bacterial flora The common bacterial flora contaminating open fractures contaminating open fractures

The sensitivity pattern of the isolated The sensitivity pattern of the isolated bacteria and effectiveness of antibiotic bacteria and effectiveness of antibiotic regimenregimen

INCLUSION CRITERIAINCLUSION CRITERIA

Extremity open fractures of Gustilo Extremity open fractures of Gustilo Anderson* type I, II &III presenting Anderson* type I, II &III presenting within 8 hourswithin 8 hours

Haemodynamically stable patients Haemodynamically stable patients for whom emergency debridement for whom emergency debridement and fixation are possible and fixation are possible

EXCLUSION CRITERIAEXCLUSION CRITERIA

Open fractures with delayed Open fractures with delayed presentation more than 8 hourspresentation more than 8 hours

Prophylactic antibiotic therapy from the Prophylactic antibiotic therapy from the local hospitallocal hospital

Open fractures with mangled extremity Open fractures with mangled extremity requiring emergency amputationrequiring emergency amputation

Immunocompromised patientsImmunocompromised patients

MATERIALS AND MATERIALS AND METHODSMETHODS

22 patients with open fractures of 22 patients with open fractures of the extremitiesthe extremities

December 2006 to October 2007 in December 2006 to October 2007 in Medical College, KottayamMedical College, Kottayam

Out of 22 patients, 2 were Gustilo Out of 22 patients, 2 were Gustilo Anderson* type I, 12 were type II& IIIa Anderson* type I, 12 were type II& IIIa and 8 were type IIIband 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 14 sustained open fractures out of road traffic accidents, 3 at work site, 1of rail traffic accidents, 3 at work site, 1of rail accident and 4 due to household accidents accident and 4 due to household accidents

RTA

FARM

RAIL

HOUSE

TRIPHASIC TRIPHASIC SAMPLINGSAMPLING

TRIPHASIC TRIPHASIC SAMPLINGSAMPLING

PRE-DEBRIDEMENT SAMPLEPRE-DEBRIDEMENT SAMPLE

DEBRIDEMENT SAMPLEDEBRIDEMENT SAMPLE

POST-DEBRIDEMENT SAMPLEPOST-DEBRIDEMENT SAMPLE

Time of presentation Time of presentation

Before the administration of Before the administration of antibioticsantibiotics

PRE-DEBRIDEMENT SAMPLEPRE-DEBRIDEMENT SAMPLE

DEBRIDEMENT SAMPLEDEBRIDEMENT SAMPLE

Skin culture sample in all casesSkin culture sample in all cases

Muscle tissue in GA type II & IIIMuscle tissue in GA type II & III

Samples of periosteum in type IIIBSamples of periosteum in type IIIB

Tissues obtained from skin, muscle and Tissues obtained from skin, muscle and periosteum kept separately in pre-periosteum kept separately in pre-sterilized weighted containers filled with sterilized weighted containers filled with normal salinenormal saline

The average time between injury and The average time between injury and surgical debridement was 11 hours (8-14 surgical debridement was 11 hours (8-14 hours)hours)

DEBRIDEMENT SAMPLEDEBRIDEMENT SAMPLE

POST-DEBRIDEMENT POST-DEBRIDEMENT SAMPLESAMPLE

Wound sampling repeated on first Wound sampling repeated on first postoperative daypostoperative day

Denotes the need for further Denotes the need for further debridementdebridement

High chance of persistent infection & High chance of persistent infection & warrants extended antibiotic therapywarrants extended antibiotic therapy

Incidence of nosocomial infectionIncidence of nosocomial infection

ANTIBIOTIC REGIMENANTIBIOTIC REGIMEN

Third generation cephalosporin and Third generation cephalosporin and aminoglycosides after pre- aminoglycosides after pre- debridement sampledebridement sample

Changed to sensitive antibiotics Changed to sensitive antibiotics according to pre-debridement according to pre-debridement sampling reportsampling report

Parenteral antibiotics for 10 daysParenteral antibiotics for 10 days

Oral antibiotics for another 7 daysOral antibiotics for another 7 days

CULTURE NEGATIVECULTURE NEGATIVE

CULTURE POSITIVECULTURE POSITIVE

Initial 3 weeks of parenteral Initial 3 weeks of parenteral antibiotics followed by oral antibiotics followed by oral antibiotics for 3 weeksantibiotics for 3 weeks

Extended antibiotic therapy for 10 Extended antibiotic therapy for 10 weeks in positive Post-debridement weeks in positive Post-debridement cases cases

CULTURE POSITIVECULTURE POSITIVE

Absence of infection confirmed with Absence of infection confirmed with wound culture at the end of antibiotic wound culture at the end of antibiotic therapy if the wound is not well therapy if the wound is not well healedhealed

RESULTSRESULTS

Among a total of 94 samples from all Among a total of 94 samples from all tissues, 29 (30%) showed positive tissues, 29 (30%) showed positive bacterial counts bacterial counts

14 of 66 skin (21%)14 of 66 skin (21%)

11 of 20 muscle (55%)11 of 20 muscle (55%)

4 of 8 periosteum samples (50%)4 of 8 periosteum samples (50%)

10 cases of mixed bacterial flora,7 of 10 cases of mixed bacterial flora,7 of Staph Aureus,3 of Klebsiella, 7 Staph Aureus,3 of Klebsiella, 7 Pseudomonas, 2 of group D streptococci 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 Patients with positive muscle and periosteum had 100% incidence of periosteum had 100% incidence of infectioninfection

Positive cultured organisms were Positive cultured organisms were treated with the sensitive antibiotics treated with the sensitive antibiotics according to antibiotic protocolaccording to antibiotic protocol

RESULTSRESULTS

RESULTSRESULTS

1 patient with type IIIb fracture 1 patient with type IIIb fracture showed positive contamination of all showed positive contamination of all samples which went for persistent samples which went for persistent infectioninfection

Infection controlled with early Infection controlled with early detection and extended antibiotic detection and extended antibiotic therapytherapy

11 of 22 patients 11 of 22 patients had soft tissue had soft tissue contaminationcontamination

7 were GA type II & 7 were GA type II & IIIAIIIA

4 were GA type IIIB4 were GA type IIIB

THE RATE OF CONTAMINATION WAS THE RATE OF CONTAMINATION WAS PROPORTIONATE TO THE SOFT PROPORTIONATE TO THE SOFT TISSUE INJURYTISSUE INJURY

0

2

4

6

810

12

14

16

18

20

GA 1 GA 2&3a GA 3b

Series2

Series1

Grade III open fractures were more Grade III open fractures were more contaminated than grade II and grade I contaminated than grade II and grade I

All the patients showed All the patients showed contamination were victims of RTAcontamination were victims of RTA

Shows place at which fracture occurs Shows place at which fracture occurs determines the absence or presence determines the absence or presence of wound contaminationof wound contamination

ACCIDENT SITEACCIDENT SITE

ADVANTAGES OF TRIPHASIC ADVANTAGES OF TRIPHASIC SAMPLINGSAMPLING

Early detection & control of infection Early detection & control of infection

Early predictor of persistent infectionEarly predictor of persistent infection

Timely sensitive Antibiotic therapyTimely sensitive Antibiotic therapy

Detection of nosocomial infection denotes Detection of nosocomial infection denotes the quality of sterilization & chances of the quality of sterilization & chances of cross infectioncross infection

RESULTSRESULTS

No cases of uncontrolled infectionNo cases of uncontrolled infection

No incidence of chronic osteomyelitisNo incidence of chronic osteomyelitis

No incidence of nosocomial infectionsNo incidence of nosocomial infections

CONCLUSIONCONCLUSION

50% of the open fractures are 50% of the open fractures are already contaminated upon the already contaminated upon the patient's arrival patient's arrival

Presence of contamination in muscle Presence of contamination in muscle or periosteum is associated with very or periosteum is associated with very high incidence of infectionhigh incidence of infection

Contaminating organisms are community Contaminating organisms are community acquired and infections can be controlled acquired and infections can be controlled with early detection & adequate sensitive with early detection & adequate sensitive antibioticsantibiotics

Persistence of the same organism in the Persistence of the same organism in the Post-debridement sample implies the need Post-debridement sample implies the need for further debridement and a subsequent for further debridement and a subsequent very high risk of infection very high risk of infection

CONCLUSIONCONCLUSION

PREVENTION IS PREVENTION IS BETTER BETTER THAN THAN CURECURE

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