Prävention von Infektionen bei offenen Frakturen heute

Springer Science and Business Media LLC - Tập 41 - Trang 32-42 - 2012
S. Grote1, H. Polzer1, W.C. Prall1, S. Gill1, S. Shafizadeh2, M. Banerjee2, B. Bouillon2, H. Bäthis2
1Chirurgische Klinik und Poliklinik, Ludwig-Maximilians-Universität, Campus Innenstadt, München, Deutschland
2Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Klinikum Köln-Merheim, Universität Witten/Herdecke, Köln, Deutschland

Tóm tắt

Die Behandlung offener Frakturen stellt immer noch eine interdisziplinäre Herausforderung dar. Über den Erfolg insbesondere neuartiger Behandlungsmaßnahmen offener Frakturen ist kaum etwas bekannt. Die systematische Literaturanalyse erfolgte in den elektronischen Datenbanken für die Jahre 1974 bis September 2011. Eingeschlossen wurden klinische Studien mit >5 erwachsenen Patienten in deutscher, englischer und französischer Sprache. Die Bewertung der Studien erfolgte nach den Centre for Evidence-Based Medicine(CEBM)-Kriterien. Von über 855 analysierten Artikeln konnten nach den Einschluss-/Ausschluss Kriterien 49 in unsere evidenzbasierten Empfehlungen einfließen. Empfehlungsgrad A: Frühzeitige Antibiotikatherapie bei allen offenen Frakturen gegen grampositives Keimspektrum und ab offenen Frakturen Typ III zusätzliche Antibiotika gegen das gramnegatives Keimspektrum. Frühzeitiges radikales, operatives Débridement Empfehlungsgrad B: Antibiotikatherapie offener Frakturen Typ III für mindestens 72 bzw. bis 24 h nach Wundverschluss. Eine Vakuumtherapie sollte ab offenen Frakturen Typ III erwogen werden, sofern ein Wundverschluss nicht spannungsfrei möglich ist. Empfehlungsgrad C: Lokale Antibiotika können in Kombination mit systemischen Antibiotika eventuell die Infektrate reduzieren. Eine definitive Defektdeckung auch bei Vakuumtherapie soll möglichst innerhalb einer Woche erfolgen. Die evidenzbasierte Analyse der Behandlung offener Frakturen zeigt, dass v. a. im Bereich der Antibiotikatherapie und des operativen Débridements sehr gute Evidenz vorliegt. Neuartige Therapieverfahren wie die Vakuumtherapie können, falls Hautdefekte nach Débridement bestehen bleiben, empfohlen werden.

Tài liệu tham khảo

Bednar DA, Parikh J (1993) Effect of time delay from injury to primary manaegment on the incidence of deep infection after open fractures of the lower extremities caused by blunt trauma in adults. J Orthop Trauma 7:532–535 Bergman B (1982) Antibiotic prophylaxis in open and closed fractures: a controlled trail. Acta Orthop Scand 53:57–62 Bhattacharyya T, Mehta P, Smith M, Pomahac B (2008) Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg 121:1263–1266, (1210.1097/1201.prs.0000305536.0000309242.a0000305536) Birke-Sorensen H, Malmsjo M, Rome P et al (2011) Evidence-based recommendations for negative pressure wound therapy: treatment variables (pressure levels, wound filler and contact layer) steps towards an international consensus. J Plast Reconstr Aesthet Surg (doi: 10.1016/j.bjps.2011.06.001) Brem MH, Blanke M, Olk A et al (2008) The vacuum-assisted closure (V.A.C.) and instillation dressing. Limb salvage after III open fracture with massive bone and soft tissue defect and superinfection. Unfallchirurg 111:122–125 Claes L, Grass R, Schmickal T et al (2002) Monitoring and healing analysis of 100 tibial shaft fractures. Langenbecks Arch Surg 387:146–152 Clancey GJ, Hansen ST (1978) Open fractures of the tibia. A review of hundred and two cases. J Bone Joint Surg [Am] 60-A:118–122 Court-Brown CM, Rimmer S, Prakash U, McQueen MM (1998) The epidemiology of open long bone fractures. Injury 29:529–534 Crowley DJ, Kanakaris NK, Giannoudis PV (2007) Debridement and wound closure of open fractures: the impact of the time factor on infection rates. Injury 38:879–889 Dellinger EP, Caplan ES, Weaver LD et al (1988) Duration of preventive antibiotic administration for open extremity fractures. Arch Surg 123:333–339 DeLong WG, Born CT, Wei SY et al (1999) Aggressive treatment of 119 open fracture wounds. J Trauma 46:1049–1054 Franklin JL, Johnson KD, Hansen ST (1984) Immediate internal fixation of open ankle fraktures. J Bone Joint Surs [Am] 66:1349–1356 Gagey ODF, Dellamonica P, Carsenti-Etesse H et al (1999) Infection prophylaxis in open leg fractures. Comparison of a dose of pefloxacin and 5 days of cefazolin-oxacillin. A randomized study of 616 cases. Rev Chir Orthop Reparatrice Appar Mot 85:328–336 Gustilo RB (1979) Use of antimicrobials in the management of open fractures. Arch Surg 114:805–808 Gustilo RB, Anderson JT (1976) Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. J Bone Joint Surg [Am] 58:453–458 Gustilo RB, Grunninger RP, Davis T (1987) Classification of type III (severe) open fractures relative to treatment and results. Orthopedics 10:1781–1788 Gustilo RB, Mendoza RM, Williams DN (1984) Problems in the management of type III (severe) open fractures: a new class of type III open fractures. J Trauma 24:742–746 Hansraj KK, Weaver LD, Todd AO et al (1995) Efficay of ceftriaxone versus cefazolin in the prophylactic management of extra-articular cortical violation of bone due to low-velocity gunshot wounds. Orthop Clin North Am 26:9–17 Helgerson MD, Potter BK, Tucker CJ et al (2009) Antibiotic-impregnated calcium sulfate use in combat-related open fractures. Orthopedics 32:323 Henry SL, Ostermann PA, Seligson D (1993) The antibiotic bead pouch technique. The management of severe compound fractures. Clin Orthop Relat Res 295:54–62 Henry SL, Ostermann PA, Seligson D (1990) The prophylactic use of antibiotic impregnated beads in open fractures. J Trauma 30:1231–1238 Hoff WS, Bonadles JA, Cachecho R, Dorlac WC (2011) East practice management guidelines work group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma 70:751–754 Huddleston PM, Steckelberg JM, Hanssen AD et al (2000) Ciprofloxacin inhibition of experimental fracture healing. J Bone Joint Surg [Am] 82:161–173 Hulsker C, Kleinveld S, Zonnenberg C et al (2011) Evidence-based treatment of open ankle fractures. Arch Orthop Trauma Surg:1–9 Jadad AR, Moore RA, Carroll D et al (1996) Assessing the qality of reports of randomized cinical tails: is blinding necessary? Control Clin Trials 17:1–12 Johnson KD, Johnson DW (1986) Orthopedic experience with methicillin-resistant Staphylococcus aureus during a hospital epidemic. Clin Orthop Relat Res 212:281–288 Kaltenecker G, Wruhs O, Quaicoe S (1990) Lower infection rate after interlocking nailing in open fractures of femur and tibia. J Trauma 1990:4 Keating JF, O‚Brien PI, Blachut PA et al (1997) Reamed interlocking intramedullary nailing of open fractures of the tibia. Clin Orthop Relat Res 338:182–191 Khatod M, Botte MJ, Hoyt DB et al (2003) Outcomes in open tibia fractures: relationship between delay in treatment and infection. J Trauma 55:949–954 Kneser U, Leffler M, Bach AD et al (2006) Vacuum assisted closure therapy is an essential tool for treatment of complex defect injuries of the upper extremity. Zentralbl Chir 131:7–12 Krettek C (1998) Fraktur und Weichteilschaden. Chirurg 69:684–700 Labler L, Keel M, Trentz O (2004) Vacuum-assisted closure (V.A.C.®) for temporary coverage of soft-tissue injury in type III open fracture of lower extremities. Eur J Trauma 30:305–312 Lenarz CJ, Watson JT, Moed BR et al (2010) Timing of wound closure in open fractures based on cultures obtained after debridement. J Bone Joint Surg [Am] 92:1921–1926 Luchette FA BL, Born CT et al (2000) EAST Practice management workinggroup: practice management guidelines for prophylactic antibiotic use in open fractures. Eastern Association for the Surgery of Trauma. http://www.east.org/tgp/openfrac.pdf Merritt K (1988) Factors increasing the risk of infection in patients with open fractures. J Trauma 28:823–827 Moehring HD Gravel C, Chapman MW, Olson SA (2000) Comparison of antibiotic beads and intravenous antibiotics in open fractures. Clin Orthop Relat Res 372:254–261 Muth CM, Mutschler W (2004) Einfluss von hyperbarem Sauerstoff (HBO) auf die Wundheilung. Trauma Berufskrankh 6:16–20 Mutschler W, Haas NP (Hrsg) (1998) Praxis der Unfallchirurgie. Thieme, Stuttgart Okike K, Bhattacharvva T (2006) Trends in the management of open fractures: a critical analysis. J Bone Joint Surg [Am] 88:2739–2748 Olerud S, Karlstrom G, Danckwardt-Lillieström G (1978) Treatment of open fractures of the tibia and ankel. Clin Orthop Relat Res 136:212–224 Ostermann PA, Henry SL, Seligson D (1993) The role of local antibiotic therapy in the management of compound fracture. Clin Orthop Relat Res 295:102–111 Ostermann PA, Henry SL, Seligson D (1994) Timing of wound closure in severe compound fractures. Orthopedics 17:397–399 Ostermann PAW, Seligson D, Henry SL (1995) Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases. J Bone Joint Surg [Br] 77-B:93–97 Patzakis MJ, Harvey JP, Ivler D (1974) The role of antibiotics in the management of open fractures. J Bone Joint Surg [Am] 56:532–541 Patzakis MJ, Wilkins J (1989) Factores influencing infection rate in open fracture wounds. Clin Orthop Relat Res 243:36–40 Patzakis MJ, Wilkins J, Moore TM (1983) Use of antibiotics in open tibial fractures. Clin Orthop Relat Res 178:31–35 Patzakis MJ, Bains RS, Lee J et al (2000) Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma 14:529–533 Perry AC, Prpa B, Rouse MS et al (2003) Levofloxacin and trovafloxacin inhibition of experimental fracture-healing. Clin Orthop Relat Res 414:95–100 Pollak AN, Jones AL, Castillo RC et al (2010) The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma. J Bone Joint Surg [Am] 92:7–15 Robinson D, On E, Hadas N et al (1989) Microbiological flora contaminating open fractures: its significance in the choice of primary antibiotic agents and the liklihood of deep wound infection. J Orthop Trauma 3:283–286 Russell G, Henderson R, Arnett G (1990) Primary or delayed closure for open tibial fractures. J Bone Joint Surg [Br] 72-B:125–128 Sangha KS, Miyagawa CI, Healy DP, Bjornson HS (1995) Pharmacokinetics of once-daily dosing genatmycin in surgical intensive care unit patients with open fractures. Ann Pharmacother 29:117–119 Savelli CC, Belknap RW, Morgan SJ, Price CS (2011) The role of prophylactic antibiotics in open fractures in the era of community acquired methicillin-restistant Staphyloccocus aureus. Orthopedics 34:611–616 Schwabe P, Haas NP, Schaser KD (2010) Extremitätenfrakturen mit schwerem offenem Weichteilschaden. Unfallchirurg 113:647–672 Seligson D, Ostermann PA, Henry SL, Wolley T (1994) The management of open fractures associated with arterial injury requiring vascular repair. J Trauma 37:938–940 Sloan JP, Dove AF, Maheson M et al (1987) Antibiotics in open fractures of the distal phalanx? J Hand Surg [Br] 12:123–124 Sorger JI, Kirk PG, Ruhnke CJ et al (1999) Once daily, high dose versus divided, low dose gentamicin for open fractures. Clin Orthop Relat Res 366:197–204 Stannard JP, Volgas DA, Stewart R et al (2009) Negative pressure wound therapy after severe open fractures: a prospective randomized study. J Orthop Trauma 23:552–557 Steiert AE, Partenheimer A, Schreiber T et al (2004) The V.A.C. system as bridging between primary osteosynthesis in conjuction with functional reconstructed of soft-tissue – open fractures type 2 and type 3. Zentralbl Chir 129:98–100 Stinner DJ, Noel SP, Haggard WO et al (2010) Local antibiotic delivery using tailorable chitosan sponges: the future of infection control? J Orthop Trauma 24:592–597 Stinner DJ, Waterman SM, Masini BD, Wenke JC (2011) Silver dressings augment the ability of negative pressure wound therapy to reduce bacteria in a contaminated open fracture model. J Trauma 71:147–150 Swiontokowski MF (1989) Criteria for bone debridement in massive lower limb trauma. Clin Orthop Relat Res 243:41–47 Tscherne H, Oestern HJ (1982) Die Klassifizierung des Weichteilschadens bei offenen und geschlossenen Frakturen. Unfallheilkunde 85:111–115 Vasenius J, Tulikoura I, Vainionpää S, Rokkanen P (1998) Clindamycin versus cloacillin in the treatment of 240 open fractures. A randomized prospective study. Ann Chir Gynaecol 87:224–228 Windolf J (2005) Aktuelle Konzepte zur Prophylaxe posttraumatischer Infekte. Trauma Berufskrankh 7:100–104 Wirth CJ, Mutschler W, Bischoff HPet al (Hrsg) (2010) Komplikationen in Orthopädie und Unfallchirurgie. Vermeiden – erkennen – behandeln. Thieme, Stuttgart Wisniewski TF, Radziejowski MJ (1996) Gunshot fractures of the humeral shaft treated with external fixation. J Orthop Trauma 10:273–278 Zalavras CG, Patzakis MJ, Holtom P (2004) Local antibiotic therapy in the treatment of open fractures and osteomyelitis. Clin Orthop Relat Res 427:86–93