Antibiotic prophylaxis in proximal femoral fracture. M. M. McQueenl, M. A. LittleJohn', R. S. Mile2 and S. P. F. Hughes'. 'University Department of Orthopaedic ...
104
Injury (1990). 21,104-106 Printedin Great Britain
Antibiotic prophylaxis in proximal femoral fracture M. M. McQueenl, M. A. LittleJohn’,R. S. Mile2 and S. P. F. Hughes’ ‘University Wniversity
Department Department
of Orthopaedic Surgery, Princess Margaret Rose Orthopaedic of Bacteriology, Medical school, England, UK
Hospital, Edinburgh,
UK
A prospective randomized double-blind trial was carried out to clsspssthe effectiveness of one dose of prophylactic cefuroxime versus placebo in 50.2 patients who undaoent surgery for a proximal femoral fractwe. With an overall deep infection rate of 2.2 per cent there was no significantdifference in the supperfcial or deep wound infection rate behoeen the two groups. However, there was a significant reduction in the incidenceof postoperative bactwiuria in the ceftrroxime group. A study of three doses of cefuroxime versus placebo is now proposed.
Deep wound infection was defined as infection extending to the deep fascia with persistent wound discharge, positive or negative cultures from the deep tissues and a delay in wound healing. Bacteriuria was defined as positive bacteriological culture of the urine with z-- lo5 organisms/ml. Respiratory infection was defined as the production of purulent sputum with or without positive bacteriological culture or radiographic changes.
Introduction
Results
The value of antibiotic prophylaxis against infection in total joint replacement is now well established but remains controversial in fracture surgery. The prevention of infection after surgery for proximal femoral fractures is of prime importance for several reasons. The incidence of proximal femoral fracture is high, particularly in elderly patients who are susceptible to infection and its consequences. Reduction of the incidence of infection in these patients would improve their quality of life as well as reducing the costs of hospital care. This study was designed to assess the effect of a single administration of prophylactic cefuroxime before surgery for a fractured neck of femur.
Of the 502 patients there were 434 females and 68 males. The mean age was 79 years (range 36-99 years). An intracapsular fracture of the proximal femur had been sustained by 254 patients and 248 patients had an extracapsular fracture. The procedures performed are shown in Table 1. The approach to the hip was also recorded (Table II), with the majority being lateral. All but II operations lasted less than 2 hours. Of the 246 patients in the cefuroxime group there were 222 females and 24 males. The mean age was 79.7 years (range 47-98 years). Of these 127 patients had sustained an intracapsular fracture and 119 an extracapsular fracture. The types of operation carried out in this group are shown in Table I. The majority of patients had a lateral approach to the hip (Table II), and only seven operations lasted longer than 2 hours. Of the 256 patients in the placebo group there were 212 females and 44 males. The mean age was 78.7 years (range 36-99 years). Of these, 127 patients had sustained an intracapsular fracture and 129 an extracapsular fracture. The types of operation carried out are shown in Table I. Again the majority of approaches to the hip were lateral (Table II) and only four operations took longer than 2 hours. In the period of follow-up there were 58 superficial wound infections in the 502 patients (11.5 per cent). Twenty-five of these occurred in the cefuroxime group and 33 in the placebo group. This difference was not statistically significant, The mean age of these patients was 81.1 years. There were 51 females and 7 males. Superficial infections occurred in 37 patients with an intracapsular fracture and in 21 patients with an extracapsular fracture. Twenty-nine hemiarthroplasties were carried out and 29 patients were
Materials and methods During the 20-month period from March 1985 to November 1986 a prospective, randomized, double-blind trial was carried out on 502 patients who underwent surgery for a proximal femoral fracture. Of these, 246 patients were randomly assigned to a group which received a single intravenous dose of 1.5 g of cefuroxime at the induction of anaesthesia and the other 256 patients received a placebo intravenous injection, also at the induction of anaesthesia. Clinical details were recorded on each patient preoperatively and any evidence of infection was recorded for up to 4 weeks postoperatively. Superficial wound infection was defined as infection superficial to the deep fascia. The clinical diagnosis of superficial infection was made on the finding of a discharge from the wound, with erythema and either positive or negative bacteriological cultures, but no delay in wound healing. 0 1990Butterworth & Co (Publishers) Ltd 002O-1383/90/020104-03
McQueen et al.: Antibiotic prophylaxis in proximal femoral fracture
Discussion
Table 1. Types of operation performed
Hemiarthroplasty (cementless) Hemiarthroplasty (cemented) Internal fixation
Cefuroxime group
Placebo group
Total
87 8 151
72 7 177
159 15 328
Table II. Operative approaches used
Posterior Anterior Anterolateral Lateral Unrecorded
105
Cefuroxime group
Placebo group
31 3 24 180 8
18 1 19 213 5
Total 49 4 3:: 13
treated with internal fixation. No operation in this group lasted longer than 2 hours. There were II deep infections in the 502 patients (2.2 per cent). Four of these occurred in the cefuroxime group and seven in the placebo group. This difference was not statistically significant. The mean age of the patients with deep infections was 85.2 years and all were female. Five patients had sustained an intracapsular fracture which was treated with a cementless hemiarthroplasty, and six an extracapsular fracture treated with internal fixation. In 10 cases the approach to the hip was lateral and in one anterolateral. One of the II operations lasted longer than 2 hours. The commonest organism which was responsible for the deep infections was Staphylococcus aureus which was cultured in five patients, all of whom had received a placebo injection. All of these organisms were sensitive to cefuroxime. Coliform organisms sensitive to cefuroxime were cultured from one deep infection in the placebo group and the final deep infection in this group grew a combination of Proteus, Micrococcus and Pseudomonas. The Pseudomonas was resistant to cefuroxime. Of the four deep infections in the cefuroxime group, coliforms sensitive to cefuroxime were cultured from two and Pseudomonas pyocyanea in one. There were no organisms cultured in the fourth. Postoperative respiratory infections developed in 70 patients, 30 (12.1 per cent) in the cefuroxime group and 40 (15.6 per cent) in the placebo group. This difference was not statistically significant. Urinary tract infection developed in 234 patients postoperatively. Of these, 106 (42.9 per cent) had received cefuroxime and 128 (49.8 per cent) placebo. The cefuroxime group, however, had a higher proportion of females who are more susceptible to urinary tract infection. After adjusting for the sex imbalance between the two groups and using Co&ran’s test, the increase in urinary tract infection in the placebo group was found to be statistically significant (PC 0.02). Within the first 7 days after operation 63 patients in the cefuroxime group developed bacteriuria. In the same period 104 patients in the placebo group developed bacteriuria. Using the fourfold contingency table the difference is statistically significant (x2 := 11.4; P< 0.001).
This study has not shown a significant reduction in either superficial or deep wound infection using one prophylactic dose of cefuroxime administered immediately preoperatively. These are directly opposite findings to those in the recent literature. Burnett et al. (1980) undertook a similar study using cephalothin but continuing treatment or placebo for 72 h. There was a significant reduction in major wound infections in the treated group (0.7 per cent) versus the placebo group (4.7 per cent). Similar results of 0.8 per cent wound infection in a group treated with nafcillin compared with 4.8 per cent infection in a placebo group were reported by Boyd et al. (1973). The study of Tengve and Kjellander (1978) revealed an infection rate of 16.9 per cent in the placebo group compared with 1.8 per cent in the treated group. This study was carried out in general surgical wards and in a central operative suite with no special arrangements for ventilation. This is presumably the reason for the high overall infection rate of over 9 per cent. Burnett et al. (1980) and Boyd et al. (1973) have similar overall infection rates to our rate of 2.2 per cent. The only major difference between these studies and ours was the length of time for which the antibiotic was administered-72 h by Burnett et al. (1980) 48 h by Boyd et al. (1973) and Tengve and Kjellander (1978). It may be that one dose of cefuroxime is insufficient to reduce wound infection rates in proximal femoral fractures, although it has been shown by Hughes et al. (1982) that after 1.5 g of cefuroxime given at induction of anaesthesia for total joint replacement, the antibiotic concentration in bone rises above the minimal inhibitory concentration for most pathogenic organisms. However, it must be considered that lengthy periods of antibiotic prophylaxis may induce the emergence of resistant organisms (Burnett et al., 1980). Development of resistance in infecting organisms has been cited as a reason to avoid antibiotic prophylaxis in No resistance to cefuroxime orthopaedic surgery. developed in any of the wound infections as a result of antibiotic prophylaxis in this study. Burnett et al. (1980) noted a strong trend towards colonization by cephalosporin resistant organisms, but their prophylaxis extended for 72 h postoperatively. It is possible that short-term administration avoids the problem of developing bacterial resistance. It is of interest that a single dose of cefuroxime at induction of anaesthesia was sufficient to reduce the incidence of urinary tract infection postoperatively. Burnett et al. (1980) found that their prophylactic antibiotic regimen eliminated preoperative asymptomatic bacteriuria. This may be an added advantage of the use of prophylactic antibiotics. A study of the effectiveness of three doses of cefuroxime is now proposed.
Acknowledgements We would like to thank Mr J. Chalmers, Mr C. Court-Brown, Mr M. McMaster and Mr J. Christie for allowing their patients to be included in this study. We are grateful to Miss Elizabeth Brown of Glaxo Pharmaceuticals Ltd for her help and for supplying the antibiotic.
References Boyd R. J., Burke J. F. and Colton T. (1973) A double-blind clinical trial of prophylactic antibiotics in hip fractures. J Bonejoint Surg.
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Injury: the British Journal of Accident Surgery (1990) Vol. Zl/No.
Burnett J. W., Gustilo R. B., Williams D. N. et al. (1980) Prophylactic antibiotics in hip fractures. J. BoneJoint Surg. 62A, 457. Hughes S. P. F., Want S., Darrell J. H. et al. (1982) Prophylactic cefuroxime in total joint replacement. Inf. Otthop. 6, 155. Tengve B. and Kjellander J. (1978) Antibiotic prophylaxis in operations on trochanteric femoral fractures. J. Bow Joint Surg. 6OA, 97.
Paper accepted 24 August
2
1989.
Reqwsts forreprints should be addressed fo: M. M. McQueen, Senior Lecturer, University Department of Orthopaedic Surgery, Princess Margaret Rose Orthopaedic Hospital, Fairmilehead, Edinburgh EHlO 7ED, UK.
