Authors/contributors
- Green, Cynthia L
(Author)
- Briggs, Damon V
(Author)
- Chari, Tristan
(Author)
- Therien, Aaron D
(Author)
- Aitchison, Alexandra Hunter
(Author)
- Lunn, Kiera
(Author)
- Zirbes, Christian F
(Author)
- Manohar, Tanvi
(Author)
- Rijo, Diana V
(Author)
- Hagen, Jennifer E
(Author)
- Talerico, Michael T
(Author)
- DeBaun, Malcolm R
(Author)
- Pean, Christian A
(Author)
- Certain, Laura
(Author)
- Nelson, Sandra B
(Author)
Abstract
Background
The optimal duration and choice of antibiotic for fracture-related infection (FRI) is not well defined. This study aimed to determine whether antibiotic duration (≤6 vs >6 weeks) is associated with infection- and surgery-free survival. The secondary aim was to ascertain risk factors associated with surgery- and infection-free survival.
Methods
We performed a multicenter retrospective study of patients diagnosed with FRI between 2013 and 2022. The association between antibiotic duration and surgery- and infection-free survival was assessed by Cox proportional hazard models. Models were weighted by the inverse of the propensity score, calculated with a priori variables of hardware removal; infection due to Staphylococcus aureus, Staphylococcus lugdunensis, Pseudomonas or Candida species; and flap coverage. Multivariable Cox proportional hazard models were run with additional covariates including initial pathogen, need for flap, and hardware removal.
Results
Of 96 patients, 54 (56.3%) received ≤6 weeks of antibiotics and 42 (43.7%) received >6 weeks. There was no association between longer antibiotic duration and surgery-free survival (hazard ratio [HR], 0.95; 95% CI, .65–1.38; P = .78) or infection-free survival (HR, 0.77; 95% CI, .30–1.96; P = .58). Negative culture was associated with increased hazard of reoperation or death (HR, 3.52; 95% CI, 1.99–6.20; P < .001) and reinfection or death (HR, 3.71; 95% CI, 1.24–11.09; P < .001). Need for flap coverage had an increased hazard of reoperation or death (HR, 3.24; 95% CI, 1.61–6.54; P = .001).
Conclusions
The ideal duration of antibiotics to treat FRI is unclear. In this multicenter study, there was no association between antibiotic treatment duration and surgery- or infection-free survival.
Publication
Open Forum Infectious Diseases
Notes
Key Question: The article investigates whether the duration of antibiotic treatment (≤6 weeks vs. >6 weeks) in patients with fracture-related infections (FRIs) is associated with surgery- and infection-free survival, and explores additional factors influencing these outcomes.
Findings:
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There was no statistically significant association between longer antibiotic treatment (>6 weeks) and improved surgery- or infection-free survival.
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Culture-negative infections were associated with worse outcomes, with a higher likelihood of reoperation, reinfection, or death.
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The need for flap coverage also increased the risk of reoperation or death.
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Hardware removal and the presence of staphylococcal infection were not significantly associated with outcomes.
Clinical Implications:
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Shorter antibiotic courses (≤6 weeks) may be as effective as longer courses in managing FRIs, supporting the idea of potentially reducing the duration of treatment in some cases.
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Negative cultures and the need for flap coverage are significant risk factors for poor outcomes, which may help guide clinical decision-making in managing complex infections.
Strengths:
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Multicenter Design: The study includes data from four academic medical centers, improving generalizability within similar settings.
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Propensity Score Weighting: The use of inverse propensity score weighting helped balance the covariates, improving the robustness of the findings despite the observational nature of the study.
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Focused Population: The study specifically addresses FRI, a clinically important and under-researched area.
Limitations:
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Retrospective Design: The study is retrospective, meaning that treatment was not randomized, and unmeasured confounding factors may have influenced the results.
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Small Sample Size: Despite being a multicenter study, only 96 patients were included, limiting the statistical power to detect differences between the treatment groups.
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Generalizability Issues: All participating centers were level 1 trauma centers, which may limit the applicability of the findings to less specialized settings.
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Variability in Treatment: There was considerable variability in antibiotic regimens, including differences in the use of adjunctive therapies (e.g., rifampin), which might have affected outcomes.
GRADE Assessment:
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Level of Evidence: Low
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Rationale: The retrospective nature of the study, small sample size, and lack of randomization introduce a risk of bias. Although the study is strengthened by its multicenter design and propensity score weighting, the overall certainty in the findings is reduced by the limitations. Randomized controlled trials or larger prospective studies would be needed to confirm these findings.
Citation
1.
Seidelman J, Ritter AS, Poehlein E, et al. Multisite Study of the Management of Musculoskeletal Infection After Trauma: The MMUSKIT Study. Open Forum Infectious Diseases. 2024;11(6):ofae262.