A deferred step: a decision attached to a person

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• Lack WD, Karunakar MA, Angerame MR, Seymour RB, Sims S, Kellam JF, Bosse MJ. Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma. 2015;29(1):1-6. Retrospective prognostic study at a level 1 trauma centre; 137 patients after exclusions, with deep infection within 90 days as the outcome. Age, smoking, diabetes, injury severity score, type IIIA versus IIIB/C injury, and time to surgical debridement were not associated with infection on univariate analysis. More than 5 days to wound coverage (p<0.001) and more than 66 minutes to antibiotics (p<0.01) were univariate predictors; on multivariate analysis wound coverage beyond 5 days (odds ratio 7.39; 95% CI 2.33-23.45; p<0.001) and antibiotics beyond 66 minutes (odds ratio 3.78; 95% CI 1.16-12.31; p=0.03) independently predicted infection. Immediate antibiotics with early coverage gave 1 infection in 36 (2.8%), against 6 in 59 (10.2%) with delay in one factor and 17 in 42 (40.5%) with delay in both. Prognostic level II. The authors note the therapeutic window is within an hour of injury.
• Roddy E, Patterson JT, Kandemir U. Delay of Antibiotic Administration Greater than 2 Hours Predicts Surgical Site Infection in Open Fractures. Injury. 2020;51(9):1999-2003. Consecutive open fracture patients at a level 1 trauma centre with a minimum 30-day follow-up, identified from an orthopaedic registry 2013-2017; surgical site infection within 90 days was the primary endpoint, with the threshold determined by receiver-operator analysis and a Cox model adjusted for age, smoking and drug use. Ten percent of 230 patients developed a surgical site infection. There was a trend for patients who did not develop infection to receive antibiotics earlier than those who did (median 61 minutes, IQR 33-107, versus 83 minutes, IQR 40-186; p=0.053). Intravenous antibiotic administration more than 120 minutes after presentation to the emergency department was significantly associated with a 2.4-fold increased hazard of surgical site infection within 90 days (p=0.036). Note that this study measures from arrival while the study above measures from injury.
• Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989;(243):36-40. Seventy-seven infections in 1,104 open fracture wounds were evaluated to identify factors predisposing to infection, grouped as increased risk, no effect, and inconclusive. The single most important factor in reducing the infection rate was the early administration of antibiotics providing activity against both gram-positive and gram-negative organisms. Surgical debridement was performed on all open fracture wounds in the study. No threshold time is reported in the indexed abstract, and none is quoted from it here.