Article

Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds A Prospective, Randomized Study</sbt

Department of Orthopaedics, Indiana University, 541 Clinical Drive, Suite 600, Indianapolis, IN 46202-5111, USA.
The Journal of Bone and Joint Surgery (Impact Factor: 4.31). 08/2005; 87(7):1415-22. DOI: 10.2106/JBJS.D.02615
Source: PubMed

ABSTRACT Irrigation of open fracture wounds is a commonly performed procedure, and irrigation additives have been used in an attempt to reduce the risk of infection. In vitro and animal studies have suggested that irrigation with detergent solution is more effective than irrigation with a solution containing antibiotic additives. This study was performed to compare the efficacy of those two solutions in the treatment of open fractures in humans.
Adult patients with an open fracture of the lower extremity were prospectively randomized to receive irrigation with either a bacitracin solution or a nonsterile castile soap solution. The patients were followed clinically to assess for the development of infection, healing of the soft-tissue wound, and union of the fracture.
Between 1995 and 2002, 400 patients with a total of 458 open fractures of the lower extremity were entered into the study. One hundred and ninety-two patients were assigned to the bacitracin group (B), and 208 were assigned to the castile soap group (C). Outcomes were available for 171 patients with a total of 199 fractures in group B and 180 patients with a total of 199 fractures in group C. The mean duration of follow-up was 500 days. There was no difference between groups B and C in terms of gender, the Gustilo-Anderson grade of the open fracture, the time between the injury and the irrigation, smoking, or alcohol use. There were significant differences in the mean age (thirty-eight compared with forty-two years, p = 0.01), duration of follow-up (560 compared with 444 days, p = 0.01), prevalence of hypotension (23% compared with 14%, p = 0.04), and duration of treatment with intravenous antibiotics (eleven compared with nine days, p = 0.02). An infection developed at thirty-five (18%) of the 199 fracture sites in group B and at twenty-six (13%) of the 199 fracture sites in group C. This difference was not significant (p = 0.2). Bone-healing was delayed for forty-nine (25%) of the 199 group-B fractures and forty-six (23%) of the 199 group-C fractures (p = 0.72). Wound-healing problems occurred in association with nineteen group-B fractures (9.5%) and eight group-C fractures (4%). This difference was significant (p = 0.03).
Irrigation of open fracture wounds with antibiotic solution offers no advantages over the use of a nonsterile soap solution, and it may increase the risk of wound-healing problems.

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    • "The main causes of open fracture include road traffic injury (RTI), fall from a height, gunshots, assault, machine injury, and others (Ahmed and Chaka, 2006). Approximately 3 -4% of all fractures being open fractures (Anglen, 2005), and the development of infection favored by devitalization of bone and soft-tissue and loss of skeletal stability are a major complication, especially in grade III open fractures (Quinn and Macias, 2006). Deep fracture-site infections can lead to chronic osteomyelitis, non-union, loss of function, or even limb loss. "
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    ABSTRACT: Sixty to seventy percent of compound fractures are believed to be contaminated with bacteria at the time of injury from both skin and environment. Infection of open fractures depends on the environmental, microbial and host factors. In developing countries like Ethiopia, a high incidence of open fracture wound infection is suspected though the magnitude of the problem is not known. No documented report on bacterial isolates from open fracture wounds and their drug resistance pattern. In set-ups where immediate culture and sensitivity tests are difficult, sound epidemiological knowledge of microbes helps in rationally selecting antibiotics for prophylaxis and empiric treatment as well. To profile the antimicrobial susceptibility pattern (Culture and sensitivity) of the bacterial isolates from open fracture wounds to the commonly used antibiotics. Addis Ababa University, Black-Lion ('Tikur Anbessa') Hospital-BLH, is the country's highest tertiary level referral and teaching Hospital. The Hospital has a newly established separate ER to receive trauma patients. During a period of November, 2007 and May, 2008, a cross-sectional prospective study was conducted to determine the bacteriology of open fracture wounds of 191 informed and consented patients (200 wounds) who visited the orthopedic department of 'Tikur Anbessa' Hospital, -a tertiary University Hospital, Addis Ababa, Ethiopia. Wounds were graded using Gustilo-Anderson's classification. The detailed bacteriological profile of the wounds swabs collected by Levine's technique is documented. All of the wound specimens were processed for microscopic examination, culture and sensitivity testing. A total of 162 bacterial pathogens were isolated from the 200 open fracture wounds sampled. Staphylococcus aureus was the dominant isolate (14.8%) followed by Acinetobacter spp. (11.4%). Of the culture-positive wounds, 51.2% showed mono-microbial growth (single bacterial type) and 48.8% showed polymicrobial (more than one bacterial type) growth. The gram-positive and -negative bacteria accounted for 34.0 and 66.0%, respectively (p < 0.05). All gram-positive bacterial isolates showed low level of resistance (<60%) to all antibiotics tested except for ampicillin and penicillin to which they showed intermediate level of resistance (60 -80%). Most gram-positive isolates, 29/55 (52.7%) showed multiple drug resistance (resistance to three or more drugs). All Clostridium spp. were susceptible to tetracycline, doxycycline, and kanamycin and showed low level of resistance (<60%) against chloramphenicol, clindamycin and penicillin. All gram negative bacterial isolates showed low level of resistance (<60%) to all antibiotics tested except for ampicillin and amoxicillin (60 -80%, intermediate level resistance). Fifty-one percent of the gram negative bacterial isolates were identified as multiple drug resistants (MDR). Staphylococcus aureus was the commonest isolate associated with open fracture wound contamination. Gentamicin, ciprofloxacin and norfloxacin were the most effective drugs against the tested gram-positive and -negative bacteria and should be considered in empirical antibiotic selection. The findings underscore the need for routine microbiological investigation of open fracture wounds and monitoring antimicrobial resistance pattern for the use of prophylactic and therapeutic antibiotics.
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    • "A notable exception was a study by Dire and colleagues [79], who found neomycin sulfate/bacitracin/polymyxin B sulfate ointment to be efficacious . Recent work by Anglen [80] highlighted the therapeutic potential of addition of castile soap to irrigation solutions but also highlighted the difficulty in demonstrating efficacy even in injuries where the infection risk is relatively high. Many factors can be considered in the assessment of wounds for risk of infection, leading the decision to deploy topical antimicrobials to be idiosyncratic to the provider. "
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