Date: Wed, 26 Nov 2003 17:20:25 -0500

Subject: Antibiotics - Critical Thinking

Bill:

Today I wanted to take one of my poly-trauma patients off antibiotics 48 hours after ORIF of an open humerus. The orthopedist told me that the patient had to be on antibiotics "until the drains came out". I challenged this belief as being totally unsupported by any evidence, and suggested that if he felt strongly about it we should subject the practice to prospective study. He replied that he couldn't ever study the problem ethically because of the risk to "his" patient.

Well, isn't that special ! After all, the use of drains at all in bone surgeries is of dubious value at best if you believe the 2001 Cochrane Group meta-analysis (Cochrane Database Syst Rev. 2001;(4):CD001825.)

Also, a MEDLINES search of "fractures / drains / antibiotics" yields (you guessed it) zero relevant hits. Adding "prospective / randomized " yielded zero hits, period. So frankly, I remain to be convinced that "covering the drains" is not just one more ruse used by surgical subspecialists who are antibiotic "believers" (ie orthopods, CV surgeons, neurosurgeons etc.) to prolong prophyllactic antibiotic use despite 1) the abundant evidence that it doesn't work, 2) the P&T committee, 3) the CDC and 4) the protests of the critical care specialists who have to treat the whole patient, including their multi-drug resistant pneumonias.

So post this on your ortho websites: I'm looking for some critical-thinking orthopedists who are willing to subject these unproven beliefs about the antibiotic "coverage" of wound drains to a prospective study. This should be a multicenter trial done under the aegis of the Surgical Infection Society. Come on all you budding orthopedic academics, don't you see that this is a NEJM paper??

CJH
Carl Hauser
UMDNJ

PS. - The antibiotic demanded was Ancef - the wound culture was MRSE
PPS - I bet I get zero hits from this, too!

From: Norman E. McSwain

Date: Wed, 26 Nov 2003 16:38:59 -0600

Actually drains are the problem - No drains=no need for antibiotics

See how that flies

Norman McSwain, MD, FACS
Tulane University School of Medicine
Charity Hospital Trauma Center
NASA

Date: Wed, 26 Nov 2003 18:34:58 -0500

From: carl hauser

Right Norm:

The problem here is the the assumption that orthopedic hardware requires 'coverage'. Now I'm not sure whether orthopedic hardware is Gram (+) or Gram (-), but I do agree that it needs coverage - with healthy, well perfused tissue.

The principle here is no different than a piece of mesh in a hernia or PTFE in a vessel. In fact stainless steel is probably less infectable than most surgical implants. Anyway, it's not the steel that gets infected, it's the nutritious dead stuff that we create in a wound that bacteria thrive on. The FB simply makes it harder to clear infections that we cause with imperfect technique.  Unfortunately though, many surgical specialties that don't focus on the modern, rational use of anti-infectives as part of their knowledge base still truly rely on the ancient traditions of 'Listerism' and truly believe that the bacterial innoculum is all that matters. For crying out loud - I had a spine surgeon ask to put one of our patients on Ancef the other day to "cover" the Gardner-Wells tongs. If that's not insanity then I don't know what is. Last, drains and antibiotics are often just crutches for surgeons who either can't or won't obtain ideal wound conditions.

  But that doesn't mean drains and antibiotics don't have valid uses. They do - we just need to know what they are.

CJH

Date: Thu, 27 Nov 2003 00:13:30 -0500

From: Bill Burman

Carl

See OTA Basic Fracture Course lecture by John Esterhai:

I have concerns that the belief system pertaining to antibiotic use may be based on one of those old time religions which featured drug festivals and human sacrifice.

In New York state all health care practictioners have recently received a CD-ROM called the "SASNY Information Toolkit" from a state funded coalition of major health plans and medical professional groups called "Save Antibiotic Strength New York" (http://www.sasny.org/). A snippet from the intro reads:

"The germ-killing power of antibiotics has saved many lives, but the overuse of antibiotics has created a growing public health problem. Deadly bacteria are becoming increasingly resistant to these very same antibiotics. The World Health Organization estimates that nearly two Americans an hour die from antibiotic resistant infections. Inappropriate and overuse of antibiotics has lead to this problem."

Since this appears to be more deadly and costly than our investment in Iraq, there is more than a moral imperative to study the matter. The study of antibiotic duration after open fractures has been on the OTA multi-center "to-do" list for sometime now.

I'll cross-post your prompt to the OTA list.

Bill Burman, MD
HWB Foundation

Date: Thu, 27 Nov 2003 08:18:52 -0600

From: Obremskey, William T

Great idea. You could put together a protocol and post on this web-site for all interested to give feed back or begin IRB process. A potential problem is given relatively low infection rate even w/ open fxs of 3-7%.(OTA Open Fx immediate vs delayed closure and SPRINT studies preliminary data indicate it in this range) One would need 1000-2000 patients to show no difference in null hypothesis. (I have not run any stats for Power Analysis, but this is a guess). This is doable, but would need several sites.

Best data for drains and fractures is out of Charlotte:

Lang GJ. Richardson M. Bosse MJ. Greene K. Meyer RA Jr. Sims SH. Kellam JF. Efficacy of surgical wound drainage in orthopaedic trauma patients: a randomized prospective trial. [Clinical Trial. Journal Article. Randomized Controlled Trial] Journal of Orthopaedic Trauma. 12(5):348-50, 1998 Jun-Jul.

OBJECTIVE: To study the efficacy of closed suction drainage in clean nonemergent surgical fracture fixation or bone grafting on the extremities or pelvis. DESIGN: A prospective randomized trial.

SETTING: The orthopaedic trauma service of a Level I trauma hospital.

PATIENTS: Patients were older than age eighteen years and undergoing clean nonemergent surgical fracture fixation or bone grafting procedures on the extremities (excluding hands and feet) or pelvis.

INTERVENTION: The application of a surgical drain.

MAIN OUTCOME MEASUREMENTS: Wound drainage, edema, hematoma and erythema, dehiscence, infection, and need for surgery or readmission were followed for six weeks. A univariate analysis with Student's t test for continuous variables and chi-squared analysis for all categorical data were used, with a p value of < or = 0.05 considered statistically significant.

RESULTS: A total of 202 patients were randomized to 102 patients with no drain and 100 patients with a drain. There was no significant difference between the groups with regard to injury severity, systemic disease, age, body weight, physical status, or estimated blood loss. There was no significant difference between the drain and no-drain groups in any of the parameters evaluated.

CONCLUSION: There is no significant difference between drained and nondrained wounds in clean, nonurgent orthopaedic trauma surgery. It appears that drainage systems can be safely eliminated in this group.

This study was probably under powered for the null hypothesis, but best data I know of in literature. It does not address open fxs.

The OTA sponsored Immediate vs Delayed Closure of open fxs protocol requires only 24 hrs of antibiotics after wound closure w/ or w/o drain.

Good idea and could be good study w/ support from General Trauma Surgeons and Ortho trauma surgeons.

Bill

William T Obremskey MD MPH

Vanderbilt University

Orthopedic Trauma Division

131MCS 2100 Pierce Ave

Nashville, TN 37232-3450

From: Norman E. McSwain

Date: Thu, 27 Nov 2003 08:20:06 -0600

Just to add experience from Tulane ....We are seeing a lot of infected insect and spider bites for that last 3-4 weeks. There was another similar outbreak about 4-5 months ago. When cultured, these are found to be MRSA. We have been seeing 3-7 per day in the Tulane ED. These are coming off the street. They are mostly paying patients. I am personally seeing 4-5 similar patients in the Police officers that I personally treat. I&D without antibiotics seems to work but much slower that one would expect from the general skin type abscess. When treated with a cephalosporin, like cephalexin, when the infection does not initially clear after I&D, the cellulitis around the abscess does not respond. Bigger guns are necessary. With the big guns the infection is lasting 7-10 days.

This seems to be a new phenomenon this year. One could speculate that in the past these bites did not get infected or the infection lasted just a day or two drained spontaneously (or with a little patient help) and it passed. That is not happening this year. Is MRSA now the usual skin contaminant? .....SCAREY

Norman McSwain, MD, FACS
Tulane University School of Medicine
Charity Hospital Trauma Center
NASA

Date: Thu, 27 Nov 2003 12:29:26 -0600

From: Andrew H. Schmidt

There are 2 issues here - the use of drains and the use of antibiotics. I think that there is already reasonable and well-accepted evidence that antibiotics only need to be given for 24 hours after each major operative procedure in patients with open fractures. The prolonged use of drains also seems out-dated. Bill Obremsky presented some of the relevant citations in his email.

I don't think that the greatest studies in the world will persuade every surgeon. Some will remain obstinate and do what they have always done - even if it it flies in the face of "evidence" and may be potentially - though not obviously - harmful to patients. In this particular case, the orthopedist's colleagues are probably the best people to try to change his ideas. At our center, we have had very good luck with the use of standardized orders that we agreed on as a department and that we use to make our practice patterns uniform with respect to such things as antibiotics, DVT prophylaxis, drains, etc.

Andrew H. Schmidt, M.D.

Faculty, Hennepin County Medical Center

Assoc. Professor, Univ. of Minnesota

Minneapolis, MN

Date: Thu, 27 Nov 2003 22:11:44 EST

From: Tadabq

Prophylactic antibiotics are likely overused in many orthopedic operations and we really don't know what is optimal but protocols that include stopping them after 24 hours do not seem to be associated with an appreciable increase in problems.

However, I don't understand the logic that anything but a random controlled double blind study is USELESS. All studies have limitations and flaws, especially clinical studies involving patients and doctors.

By the way, I ran a search for "prospective randomized" studies of appendectomy versus observation for appendicitis and got zero hits and, following this logic, would conclude that appendectomy is "totally unsupported by any evidence." I don't really believe that but am trying to make the point by hyperbole.

If medical publications were subjected to the standard of scientific method of say, physics, I doubt a single article would ever have been published. Would that make us better off? If physics used medicine's standards I suspect we would have gotten to the moon a lot sooner but lost a lot more astronauts along the way.

TD

Date: Thu, 27 Nov 2003 21:54:00 -0800

From: George Thomas

I do not think that anyone subscribes to the view that any study design other than prospective randomised control trials are USELESS. However, they are the closest approximation to a perfect design in appropriate situations. The question here: whether antibiotics need be given "till the drains are out" is definitely one where the RCT is appropriate. The other point of what practitioners will do with the evidence is in the realm of philosophy - after all there still exists a flat earth society whose members believe that the earth is flat!

George Thomas,
Chennai, India

From: KMATTOX

Date: Fri, 28 Nov 2003 09:34:43 EST

Norman:

One suggestion and observation. What you describe is common in brown recluse spider bites. Near you in Carville, La is the USA's only remaining hospital for Hansen's disease. Hansen's disease is treated with Dapsone and when given early Dapsone has been shown to decrease the reaction to the brown recluse spider bite. Just a thought.

k

Date: Fri, 28 Nov 2003 08:40:10 -0800 (PST)

From: Ben Reynolds

We have the same problem that Norm's been describing in the Memphis area. Community acquired MRSA is rampant. A pediatric ED physician in the community told me that she had cultured twenty consecutive "insect bites" and found that fifteen had MRSA (unpublished). Mind you, she was culturing children. My experience hasn't been as dramatic, but is alarming nonetheless.

I question the value of Dapsone, as no large study has looked objectively at it's efficacy in the face of it's side effect profile. In light of this, I've been making a habit of culturing ALL of my drained "insect bites" and waiting for the sensitivities in those patients without systemic symptoms or an expanding cellulitic component. I think that if anyone needed a reason to advocate frugality in the use of antibiotics, this is certainly it.

By the way Dr McSwain, how many of your patients remember seeing the spider that bit them?

Ben

Date: Fri, 28 Nov 2003 11:13:01 -0600

From: Anglen, Jeffrey

I think most surgeons are aware of the problem of antibiotic resistance and that overuse of antibiotics contributes to that, but they are also aware of how painful an infection is to the individual patient and to the surgeon. While overuse of antibiotics is detrimental to "Patients" in general (a social problem), it is not likely to be harmful to an individual patient, and may help prevent an infection in an occasional patient through an effect too small or too idiosyncratic to be seen in a study. ("Can't hurt, might help") And it may afford some perceived medicolegal protection to the surgeon, if the patient does get an infection anyway. That, of course, is wrong - but nonetheless it is reality in the minds of many practitioners.

It is similar to the conflict in evolutionary theory between individual selection and group selection - benefit to the individual beats out benefit to the group (species) every time. Group selection forces only influence evolution when aligned with the dictates of individual selection. Individuals will not behave in a truly altruistic fashion (self sacrifice for the good of the group) because they will be quickly out-competed by individuals who act to enhance their own reproductive success, despite effects on the "fitness" of the species. The tendency toward truly altruistic behavior dies out rapidly.

Jeff

Jeffrey O. Anglen MD FACS
Boone Orthopaedic Associates
Clinical Professor of Orthopaedics
University of Missouri

Date: Fri, 28 Nov 2003 11:26:33 -0600

From: Zeev Glozman

I am interested in studies done regarding OR infection. I think, or at least I have been told that antibiotics reduce OR infection rate (not in open fractures) form 10 % to somewhat like 2%. Is this true?

Anyway I wonder what a result would be if no antibiotics were used but super serile OR (fast air conditioning, closed "space suits" serilshields suites with vacuum. OR limited to surgeons with nurse dressed in the same suite. Etc.

What are your thoughts?

Date: Fri, 28 Nov 2003 22:31:13 -0600

From: Obremskey, William T

a single dose $20-50 of antibiotics is probably just as if not more effective than all the other fancy technology described.

Bill

Date: Sat, 29 Nov 2003 11:42:44 -0600

From: Anglen, Jeffrey

An interesting question, but one which will never be answered.

Date: Fri, 28 Nov 2003 16:40:17 -0500

From: carl hauser

Gregory J Schmeling wrote:

The practice you cite is NOT universally held.

- No Greg, but it is widely practiced. I have 1 C-spine ORIF, one T-spine ORIF and 1 humerus ORIF in the SICU right now being "covered" that way by 3 different services, along with one patient where the spine service wanted to cover the Gardner-Wells tong pins with Ancef (I kid you not). Also, the routine practice of the CV surgeons here as well as at the last institution I worked at is to maintain patients on cephalosporins (often Mandol  [...don't go there!] ) "until the lines are out". The Neurosurgeons here want to keep patients on antibiotics "until the ICP bolt is out" [They want Vanco and Ceftazidime. We give them nafcillin, and want to study it prospectively. They refuse because a study "would be unethical."]  The plastics guys want to keep the patients on antibiotics ("make it something strong") until the drains under the flaps are out. [We don't, and they don't notice.] Do you see a pattern emerging here?

My patients are on antibiotics for 24 hrs after open wound manipulation and clean orthpaedic surgery.

- Wow! I'd send you my patients in a second. Now, how about those Gustillo I, II and IIIa open fractures? Howz about them IIIb's?

In fact, I use drains less and less as a relatively recent study that I read but can't quote showed no increase in compliations in patients with or without drains.

- Well, as I mentioned, there are a lot of conflicting studies on that, but they're all quoted in the recent Cochrane Group meta-analysis on the subject. Unfortunately, the studies were often stupidly constructed and gave stupid answers. The Cochrane people (whom I detest) actually said of the orthopedic drain studies used:

"Many of the studies had poor methodology and reporting of outcomes."

Well, having recently reviewed the entire published literature on "antibiotics for open fractures" for a Surgical Infection Society position paper, I can tell you that's no surprise! But it didn't stop the Cochrane people from pooling the results. After all, their primary methodology is to steal other people's mediocre data to create self-proclaimed definitive studies. Pooling doesn't make crappy primary data any better.  But no pooling - no paper ...Sooo.....  Anyway, they found that the data from about 3000 fractures reported in various...

"randomised or quasi-randomised trials comparing the use  of closed suction drainage systems with no drainage systems for all types of elective and emergency orthopaedic surgery"

(...Randomized or quasi-randomized... Oh, man! You can't make stuff like this up!!!)

"indicated no difference in the incidence of wound infection, haematoma or dehiscence between those allocated to drains and the un-drained wounds. There was a tendency to an increased risk of re-operation for wound complications in the group with drains (relative risk (RR) 2.25, 95% confidence intervals (CI) 0.95 to 5.33)."

Well, the problem here is quasi-academic self-fulfilling prophesy. Dirtier wounds and wounds where hemostasis was worse were drained more often. So they had more collections, and more infections (...DOH!)

But does that mean you shouldn't drain fractures? That's the Cochrane Group's conclusion, but I'm not so sure. The old general surgery literature made the same dumb error. Lots of retrospective studies showed that drained splenectomy beds were more likely (oh yeah, P<0.05) to get subphrenic abscesses. The problem was that the observations didn't hold up in prospective studies. In fact, what the retrospective studies really showed was that when surgeons were worried about hemostasis or about buggering the tail of the pancreas they were more likely to drain. Thus more infection prone wound sites were more likely to get a collection or an abscess  (...DOH!).

Does that mean we shouldn't drain if we bag the pancreas taking out a spleen? Hell no! That's how the Shah of Iran died (and you know what that led to... Ronald Regan!) The point is, we need to study these problems individually and prospectively, and the data to make a good decision just doesn't exist yet.

Alas, religious beliefs are hard to change.

We're in total agreement.

I could not ethically keep my patients on antibiotics longer unless they have an infection.

Look around, I think you'll actually find you're in the minority, my friend. Ask your residents.

Before you make statements like, "So frankly, I remain to be convinced that "covering the drains" is not just one more ruse used by surgical subspecialists who are antibiotic "believers" (ie orthopods, CV surgeons, neurosurgeons etc.)..." I would suggest you get better data than just your experience or all you have is your own unpublished case report.

You mean that we don't abuse antibiotics as a culture? You mean all those CDC studies and guidelines and the hospital formulary rules are misguided, irrelevant and unnecessary?  Wow. I guess New Jersey must really be on a different planet! Would anyone else on the list like to chime in on whether my experience is unique? I must be wrong (...NOT!)

CJH

Gregory J Schmeling wrote:

The practice you cite is NOT universally held. My patients are on antibiotics for 24 hrs after open wound manipulation and clean orthpaedic surgery. In fact, I use drains less and less as a relatively recent study that I read but can't quote showed no increase in compliations in patients with or without drains. Alas, religious beliefs are hard to change. I could not ethically keep my patients on antibiotics longer unless they have an infection. Before you make statements like, "So frankly, I remain to be convinced that "covering the drains" is not just one more ruse used by surgical subspecialists who are antibiotic "believers" (ie orthopods, CV surgeons, neurosurgeons etc.)..." I would suggest you get better data than just your experience or all you have is your own unpublished case report.

G. Schmeling

Director, Division of Orthopaedic Trauma

Medical College of Wisconsin

Date: Mon, 1 Dec 2003 16:22:54 -0500

From: Michael S. Sirkin MD

I would like to re-ask the same question with the actual facts detailed instead of the current misrepresentation by our "Critical Thinking" trauma surgeon. First this patient had an open comminuted diaphyseal humerus fracture that could not be fixed for 2 weeks because he was too sick to have surgery. Three days before his ORIF he was taken from the ICU to the OR for a debridement due to continued drainage from his traumatic wound. In the OR he had some tissue that looked infected and cultures were taken. The tissue looked as though it really needed to be washed out before placing any hardware, so the fixation was deferred. Three days after the I & D he was taken for an ORIF( cultures all negative at this point). Later that day, after his ORIF, his initial cultures grew out gram positive cocci. Post I&D cultures from the same day were negative. We had started the patient on ancef initially after the initial wash out and again after the ORIF. The comment I had with Dr. Hauser was that I would like to keep him on antibiotics on a little longer because of the positive cultures and since he had a drain anyway which was still putting out significant fluid, we wanted to cover him at least until they came out. When the cultures finally came back MRSE, Dr. Hauser's service changed his antibiotics to Bactrim which was fine with me.

It was at this time the conversation turned to "critical thinking".

Personally, I almost never use drains and when I do they come out the next morning and antibiotics are only used for 24-48 hours.

But this case was not an acute open fracture, it was an open fracture with a treatment delay of 2 weeks that had poor quality tissue with positive cultures and significant drainage from the wound. Yes we can argue that maybe a plate was not as good as an ex-fix if I truly was concerned but this is a whole different discussion.

So the questions should have been? 1. Who would keep antibiotics on this patient after ORIF with a 14 hole large fragment plate, positive cultures and a drain. 2. Does the drain matter or does the positive cultures matter or neither? 3. Who would have used a drain on this case.

Unlike Dr. Hauser, Mark and I do not know everybody's specialty better than they do and we feel it is very self-serving irresponsible to post misleading and incorrect facts about a case to a national forum - not to mention the unprofessional inclusion of derogatory comments .

Michael Sirkin and Mark Reilly
Orthopaedic Trauma Service
New Jersey Medical School

Date: Mon, 1 Dec 2003 14:02:55 -0800

From: Chip Routt

Very well said.

"Literature" doesn't always touch each and every patient and his/her unique clinical scenario. It serves as a foundation to build your patient care on.

Do unto patients what you'd want for yourself...easy, golden rule stuff!

Answers-

1. Antibiotics are good in this situation.

2. The drain matters and makes good sense. Cultures do matter especially when they can direct appropriate therapy.

3. Yes, I would have used a drain.

Thanks for the facts.

Good luck with the entire situation.

It's best when friends play well together-

Chip

M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
Seattle, WA 98104-2499

Date: Mon, 1 Dec 2003 16:26:53 -0600

From: Steven Rabin

Amazing how the "facts" can change with the perspective.

I would suggest that we should be flexible. I use drains if there is likely to be a postop hematoma (difficulty maintaining hemostasis, anticoagulation, persistent deadspace etc.) or in the presence of infection. In your case, I think you should treat the open contaminated fracture with positive cultures and poor soft tissue envelope as you would treat an infection, not as you would treat an open wound. I would have used the drain in your case.

Good luck.

Steve Rabin
Co-Chief Ortho Trauma
Loyola

Date: Mon, 1 Dec 2003 16:28:04 -0600

From: Andrew H. Schmidt

Michael and Mark,

You're right, the history as described by you changes everything. The situation was of a possibly infected fracture with bad soft tissues and internal fixation. I would say that the issue of the drain was secondary to the other facts of the case.

As you know, we have a strong interest in implant-related infections and a dedicated musculoskeletal ID specialist. Whether it's a fracture implant or an infected total joint, whenever there are positive cultures about an implant we consider it imperative to treat with antibiotics for 4 - 6 weeks. This is not dogma, but is based on reasonable interpretation of the pathophysiology of infection (bacterial adherence, biofilms, etc) and on the existing (but sparse) literature.

So, to answer your questions, Yes - the positive cultures matter and we would consider keeping the patient on antibiotics for 4 - 6 weeks. Bactrim is great for this if the patient tolerates, and we often use rifampin as well (depending on the organism). Obviously, with this duration of therapy "covering" the drain is a moot point. Of course, there are unanswered questions about the effect of long-term antibiotics on fracture healing etc, etc. Personally, I rarely use drains, and probably would not have in this case, but that is my "style" and there is no evidence on the use of drains in this type of circumstance to say one way or the other if they are beneficial or not.

You seem to be managing the case very appropriately - thanks for clarifying the story.

Andy Schmidt

Andrew H. Schmidt, M.D.
Faculty, Hennepin County Medical Center
Assoc. Professor, Univ. of Minnesota
Minneapolis, MN

Date: Tue, 2 Dec 2003 07:13:27 -0500

From: James Carr

Glad I sat on the sidelines for this one- It seems to me the diagnosis is wound infection, and therefore antibiotics/drain are supported by evidence based medicine. I will commonly leave antibiotics coverage going until cultures return to clarify things.

Jim

Date: Tue, 02 Dec 2003 10:49:31 -0500

From: carl hauser

Guys:

Well, I didn't bring up all the facts of that particular case because they didn't bear on the issue of "covering the drains" which was the first reason I was told Ortho wanted the antibiotics to stay on (by the resident).  This patient in fact, is on the mend and out of his high-risk period for systemic sepsis. So when Michael called me up and asked, and I said "sure" to prolonging the course of Bactrim. But "covering the drains" (as I said) remains a commonly used and (as far as I can tell) unproven practice with a significant potential downside in sick trauma patients. The fact that the value of drains in general is highly controversial (at best) in the orthopedic surgery literature as well as the public health literature (ie Cochrane Group meta-analyses) makes drain "coverage" with antibiotics even less rational.

But I'd agree in a heartbeat that the issue of empiric antibiotic treatment of orthopedic hardware deliberately placed into a colonized field is different and should be considered completely separately - both as to whether it needs to be used at all, and if so for how long. These issues have also (to the best of my knowledge) never been subjected to prospective study. So I'd agree that there is scant (or zero) data on the appropriate length of such empiric antibiotic treatment. In the case of isolated fractures I think the OTA should study this issue directly. The basic research on "the pathophysiology of infection (bacterial adherence, biofilms, etc)" is very important and should be considered critically for hypothesis generation. But whether you consider your "reasonable interpretation"  of this basic work to be "dogma" or not, it is hardly a substitute for prospective outcomes research. But these are your patients and their treatment is ultimately your responsibility. So do it any way you like, although I haven't seen the OTA rushing to do the PRCT and I remain personally skeptical.

On the other hand, multiple trauma patients are the trauma/critical care surgeon's primary responsibility, at least in the USA. So if this problem is to be studied in multiple trauma patients, it must be our primary responsibility. In my patients, survival with osteomyelitis or even an amputation is often a great result. That might be hard for you to believe, but I think you'll admit that death from resistant pneumonia or subsequent MOF is a pretty bad result. Maybe even worse than osteo!  And there's no question that inappropriate or just unsubstantiated antibiotic use in the setting of subspecialty surgeries, is a major demographic factor in the overgrowth of trauma/SICU patients with resistant flora. The trauma surgical societies and the Surgical Infection Society all want to move toward prospective trials in these areas, but doing it as a collaborative PRCT with an orthopedic society would be most welcome.

My responsibility for the present is to weigh the risks and benefits of antibiotic use at the fracture site and in the patient as a whole for every multiple trauma case I care for. That's what I'd do if I were caring for my own child, and I hope it's what you'd do if you were caring for my child. But until prospective clinical data supports prolonged empiric use of systemic antimicrobials in any fracture surgery,  I will find it very difficult to expose my patients to the lethal, pan-resistant MRSA, pseudomonal, E. Clocae and A. Baumanii pneumonias that inevitably follow the unproven, prolonged empiric treatment of fracture sites with antimicrobial agents.

CJH