• 
• 

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 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].

Search Outcome

46 papers were found, of which 3 were relevant and shown in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Stevenson J et al 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
Suprock MD et al 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
Sloan JP et al, 1986, UK3 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. No antibiotics 2. Cephradine 500mg PO QDS for 5 days 3. Cephradine 1gm pre-operatively and then 500mg PO QDS for 5 days 4. Cephradine 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

Comment(s)

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.

Clinical 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 Journal of Hand Surgery (Br) 2003; 28/5: 388-94
2. Suprock MD, Hood JM, Lubahn JD Role of antibiotics in open fractures of the finger Journal of Hand Surgery (Am) 1990;15:761-4
3. 3. Sloan JP, Dove AF, Maheson M, Cope AN, Welsh KR Antibiotics in open fractures of the distal phalanx? Journal of Hand Surgery (Br) 1987; 12/1: 123-124