The Use of Prophylactic Antibiotics in Open Phalanx Fractures

Date First Published:
December 22, 2009
Last Updated:
July 28, 2010
Report by:
Neil Kellie, ST3 Emergency Medicine (Royal United Hospital, Bath)
Search checked by:
Neil Kellie, Royal United Hospital, Bath
Three-Part Question:
In [patients with open distal phalanx fractures] are [additional prophylactic antibiotics better than thorough wound toilet alone] in [decreasing risk of infection]?
Clinical Scenario:
A 42-year-old man presents to the emergency department following an injury to his right index finger. Whilst at work approximately 2 hours ago, he sustained a significant crush injury to his right index finger. Examination reveals a swollen, bruised and erythematous distal phalanx with a deep laceration proximal to the nail fold. Radiographs confirm the diagnosis of an open fracture of the distal phalanx. You wonder whether prescribing a course of oral antibiotics, in addition to thorough wound toilet, will reduce the likelihood of infection developing.
Search Strategy:
MEDLINE 1967-March 2010 using the OVID interface.
LIMIT to human AND English language.

Search Details:
Search 1: [exp Phalanx fracture OR phalanx fracture.mp] AND [Antibiotics OR antibiotic.mp].
Search 2: [exp Tuft fracture OR tuft fracture.mp] AND [Antibiotics OR antibiotic.mp].
Outcome:
46 papers were found, of which 3 were relevant and shown in the table below.
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
The use of flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial Stevenson J, McNaughton G, Riley J 2003 UK 193 adult patients (without diabetes, steroid treatment or peripheral vascular disease) with an open fracture of the distal phalanx

All wounds were thoroughly irrigated and debrided. 98 patients received antibiotics (flucloxacillin po) and the remaining 95 were in the placebo group
 Double-blind, prospective, randomised placebo-controlled clinical trial

Level 1b
 Follow up rates: Day4/5; Day 14; 8 weeks 100% follow up at day 4/5; 91% follow up at day 14; 67% follow up at 8 weeks
Compliance 84% compliant in antibiotic group; 91% compliant in placebo group
Infection rate 3% (3/98 patients) developed superficial infection in the antibiotic group; 4% (4/95 patients) in the placebo group; Overall 4% (7/193 patients) infection rate; A difference of proportion test confirmed no significant difference; No patients developed deep wound infection or osteitis
Positive bacterial swab 86% (6/7) of infections grew Staphylococcus aureus; 1/7 (14%) grew E.Coli, coliforms and enterococcus
Role of antibiotics in open fractures of the finger Suprock MD, Hood JM, Lubahn JD 1990 USA 91 patients with open fractures of the finger

Aggressive surgical irrigation and debridement with 45 patients receiving antibiotics and the remaining 46 in the control group
 Prospective randomised controlled clinical trial

Level 2a
 Number of infections 9% (4 patients) in each group developed clinical signs of infection; None developed osteomyelitis Small numbers

Not double blind trial

No exclusion criteria - patients with underlying diseases such as Diabetes or peripheral vascular disease were included
Positive bacterial swab 2.1% (2/91 patients) had cultures that grew Staphylococcus aureus
Antibiotics in open fractures of the distal phalanx? 3.tSloan JP, Dove AF, Maheson M, Cope AN, Welsh KR 1986 UK 85 adult patients with open fractures of the distal phalanx (<6 hours) treated by conventional surgery.

Patients were randomised to one of four treatment regimes:
1.tNo antibiotics
2.tCephradine 500mg PO QDS for 5 days
3.tCephradine 1gm pre-operatively and then 500mg PO QDS for 5 days
4.tCephradine 1gm IV pre-operatively and then 1 gm post-operatively
 Prospective randomised controlled clinical trial

Level 2a
 Signs of infection Group 1 (no antibiotics) was discontinued after first 40 patients. 30% (3/10 patients) developed infection - felt unethical to continue; no significant difference in the infection rate between Groups 2-4 with differing regimes of antibiotic treatment; overall infection rate 4.7%; no patient developed osteomyelitis Small numbers

Not double blind study

No long term follow up (only Day 2 & 5)
Positive bacterial swab 4/85 (5%) developed bacteriologically proven infections; 75% grew Staphylococcus aureus and 25% grew viridans-type streptococcus
Author Commentary:
The two most recent studies both emphasise the importance of meticulous initial wound management. In addition, the use of prophylactic antibiotics does significantly decrease the risk of infection developing. In contrast, the Sloan study demonstrated a significantly higher infection rate in the ‘no antibiotic group’. This study however also describes closure methods for amputations (skin grafts or V-Y flaps), which now do not reflect current and conventional practice within the Emergency Department. Finally, the 2 UK studies also highlighted that by far the most common organism cultured from those with infection was Staphylococcus aureus.
Bottom Line:
Current evidence suggests that all open finger fractures should be meticulously cleaned and debrided. The additional use of prophylactic antibiotics does not significantly reduce the risk of infection developing.
Level of Evidence:
Level 1: Recent well-done systematic review was considered or a study of high quality is available
References:
  1. Stevenson J, McNaughton G, Riley J. The use of flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial
  2. Suprock MD, Hood JM, Lubahn JD. Role of antibiotics in open fractures of the finger
  3. 3.tSloan JP, Dove AF, Maheson M, Cope AN, Welsh KR. Antibiotics in open fractures of the distal phalanx?