Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures

Infection of bone and soft tissues can result after bone fractures. Fractures which penetrate the skin are called 'open' or 'compound'. If the skin remains intact despite the fracture, it is called 'simple' or 'closed'. If a closed fracture is treated by a surgical operation, bacteria can contaminate the wound, and cause surgical site infection. This, and other hospital-acquired infections, can be life threatening in people following surgery for thigh and other closed long bone fractures. Antibiotics have been given routinely since the 1970s in an effort to reduce infections from bacteria such as staphylococcus. This review included 23 trials, involving a total of 8447 participants. The review found that antibiotics are effective in reducing the incidence of infection, both at the surgical-wound site and in the chest and urinary tract. The effect of a single dose of antibiotic is similar to that from multiple doses if the antibiotic chosen is active through the period from the beginning of surgery until the wound is sealed. There were too few data available to confirm the expected tendency for increased adverse drug-related events such as gut problems and skin reactions.

Authors' conclusions: 

Antibiotic prophylaxis should be offered to those undergoing surgery for closed fracture fixation.

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Background: 

Surgical site infection and other hospital-acquired infections cause significant morbidity after internal fixation of fractures. The administration of antibiotics may reduce the frequency of infections.

Objectives: 

To determine whether the prophylactic administration of antibiotics in people undergoing surgical management of hip or other closed long bone fractures reduces the incidence of surgical site and other hospital-acquired infections.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to November 2009), EMBASE (1988 to December 2009), other electronic databases including the WHO International Clinical Trials Registry Platform (December 2009), conferences proceedings and reference lists of articles.

Selection criteria: 

Randomised or quasi-randomised controlled trials comparing any regimen of systemic antibiotic prophylaxis administered at the time of surgery, compared with no prophylaxis, placebo, or a regimen of different duration, in people with a hip fracture undergoing surgery for internal fixation or prosthetic replacement, or with any closed long bone fracture undergoing internal fixation. All trials needed to report surgical site infection.

Data collection and analysis: 

Two authors independently screened papers for inclusion, assessed risk of bias and extracted data. Pooled data are presented graphically.

Main results: 

Data from 8447 participants in 23 studies were included in the analyses. In people undergoing surgery for closed fracture fixation, single dose antibiotic prophylaxis significantly reduced deep surgical site infection (risk ratio 0.40, 95% CI 0.24 to 0.67), superficial surgical site infections, urinary infections, and respiratory tract infections. Multiple dose prophylaxis had an effect of similar size on deep surgical site infection (risk ratio 0.35, 95% CI 0.19 to 0.62), but significant effects on urinary and respiratory infections were not confirmed. Although the risk of bias in many studies as reported was unclear, sensitivity analysis showed that removal from the meta-analyses of studies at high risk of bias did not alter the conclusions. Economic modelling using data from one large trial indicated that single dose prophylaxis with ceftriaxone is a cost-effective intervention. Data for the incidence of adverse effects were very limited, but as expected they appeared to be more common in those receiving antibiotics, compared with placebo or no prophylaxis.

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