Prehospital Emergency Care

ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20

Prehospital Antibiotic Prophylaxis for Open

Fractures: Practicality and Safety

William Lack, Rachel Seymour, Anna Bickers, Jonathan Studnek & Madhav
Karunakar

To cite this article: William Lack, Rachel Seymour, Anna Bickers, Jonathan Studnek & Madhav
Karunakar (2018): Prehospital Antibiotic Prophylaxis for Open Fractures: Practicality and Safety,
Prehospital Emergency Care, DOI: 10.1080/10903127.2018.1514089

To link to this article: https://doi.org/10.1080/10903127.2018.1514089

Accepted author version posted online: 24

Aug 2018.

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 Prehospital Antibiotic Prophylaxis for Open Fractures: Practicality and Safety

William Lack, MD
Corresponding Author
Loyola University Stritch School of Medicine
2160 S. First Ave., Maywood, IL 60153
wdlack@gmail.com

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Rachel Seymour, PhD
Carolinas Medical Center
1000 Blythe Blvd Charlotte, NC 28203

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Rachel.Seymour@carolinashealthcare.org

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Anna Bickers, BA
Carolinas Medical Center
1000 Blythe Blvd Charlotte, NC 28203
Annabickers1@gmail.com
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Jonathan Studnek, PhD
Carolinas Medical Center
1000 Blythe Blvd Charlotte, NC 28203
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jonst@medic911.com
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Madhav Karunakar, MD
Carolinas Medical Center
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1000 Blythe Blvd Charlotte, NC 28203

Madhav.Karunakar@carolinashealthcare.org
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Disclosure: No potential conflict of interest was reported by the authors.

Funding: No funding was received.
Introduction:

Infection remains a frequent complication of severe open fractures, greatly affecting patient

outcome and the cost of care. Despite a sustained overall research effort aimed at identifying

methods to decrease the risk of this complication, the rate of infection for these injuries has

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remained stable over the last several decades.1-4 Additionally, some existing methods of

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prophylaxis against infection have been demonstrated to be less efficacious than previously

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hypothesized. Although surgical debridement remains a critical component to the early treatment

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of an open fracture, emergent debridement (within several hours of injury) has not consistently

correlated with a decreased risk of infection relative to urgent (within 24 hours) debridement.1,3-6
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Although future research promises to provide new advances capable of altering the risk of
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infection for severe open fractures, such clinically relevant advances have been slow to develop.
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Given this, it is critical to optimize the delivery of those interventions that are currently available
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and known to be efficacious. One such intervention, antibiotic prophylaxis, has been associated
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with a significantly lower rate of infection for these injuries with recommendations for
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immediate antibiotic administration.1,7-8 Although debate remains regarding how sensitive

antibiotic efficacy is to timing, recent research has suggested the efficacy of this treatment may
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be particularly sensitive to the time that has elapsed since the injury.9-11 One study reported that

the infection rate was dramatically lower for patients receiving antibiotic prophylaxis within one

hour of injury, and also noted that this metric was unobtainable for the majority of patients given

they did not arrive at the hospital within a timeframe that would allow for such timely
administration.9 Notably, this was within a modern health delivery system with both its own

ambulance service and life-flight capability.

Given that time from injury to hospital arrival is only partially modifiable, transport time remains

a limiting factor in the delivery of antibiotic prophylaxis for open fractures. Antibiotics have

previously been delivered in the prehospital setting under a variety of circumstances. When the

clinical need and training permits, antibiotics have been incorporated into both military and

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civilian field operations. This includes administration for wounds sustained by service members

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of the U.S. and other militaries, through interventions of the Red Cross, and in a public health

program targeting early antibiotic therapy for bacterial meningitis.12-19 However, pre-hospital

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antibiotics are not currently the standard of care for civilian patients with open fractures in or

outside the United States.

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The objective of this study was to assess the safety and feasibility of prophylactic antibiotic

delivery in the prehospital setting. We hypothesized that patients with open fractures could be
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identified by ground transport paramedics and safely treated with prehospital antibiotics.
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Methods:
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Design and Setting

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This was an observational study performed in a single EMS agency. Data for this

analysis were collected from 1/1/2014 to 5/31/2015. Patients were included in this study if they

were ≥ 18 years of age, were transported to the single level one trauma center and had a

paramedic impression of an open fracture. Patients were excluded for known penicillin allergy.

This study was approved by the Carolinas Healthcare System Institutional Review Board.
 The EMS agency under study is a single-tier advanced life support system that responds

to all 9-1-1 requests within the entire county (542 square miles). During the study period

annualized call volume was approximately 115,000 with over 105,000 transports. All first

responders functioned at the basic life support level and prehospital triage, treatment, and

transport protocols are uniform throughout the system.

Study Protocol

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In January of 2014 EMS patient care protocols were amended to allow for the intra-

venous (IV) administration of cefazolin in the presence of a suspected open fracture.

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Specifically, in patients weighing ≥ 70kg 2 grams over 10 minutes and patients <70 kg 1 gram

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over 10 minutes. Prior to implementation of this protocol all agency paramedics participated in a
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didactic and practical training session which lasted one hour. This training was provided by

educators employed by the EMS agency who had in turn received training materials and
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feedback from the study investigators. The didactic session covered the indications and

contraindications for the use of cefazolin, dosing and administration guidelines, and physical
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exam criteria for identifying an open fracture in the prehospital setting. The practical session
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involved hands on training related to reconstitution of cefazolin and assembling a buretrol to

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facilitate IV infusion. After training was completed the ambulances were stocked with cefazolin.

All patients who were administered cefazolin were enrolled in the study and follow up occurred
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by the orthopedic service. Further, any patients diagnosed with an open fracture and transported

by the EMS Agency with no cefazolin administration were also followed.

Outcome Measure
The primary outcome measure in this study was afety defined as the rate of adverse events

among both providers (eg, needlestick) and patients (eg, allergy including anaphylactic reaction).

Successful administration of prehospital antibiotics was determined by review of documentation

by prehospital personnel.

Other variables collected included age, gender, orthopaedic injuries; including diagnosis of open

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fracture, associated injuries, priority level as defined by the ambulance team, and total pre-

hospital time (Medic on scene time to hospital arrival). Definitive diagnosis of open fracture was

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made by the attending orthopaedic trauma surgeon during the index hospitalization.

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Statistical analysis included t-tests for continuous data and chi square analysis for categorical

data using Stata v12. For all tests, significance required a two-tailed p-value < 0.05.
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Results:
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There were no adverse events among patients or paramedics. Paramedics documented the
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potential occurrence of an open fracture in 70 patients. Of these, 49 were diagnosed by an

orthopaedic surgeon as having an open fracture upon presentation to the hospital (70%). The
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remaining 21 patients had a traumatic injury to an extremity and an open wound,but no open
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fracture..

Eight patients reported a penicillin allergy and were excluded from the pre-hospital antibiotic

prophylaxis protocol. A total of 32 patients received prehospital antibiotics, representing 51.6%

of the 62 patients identified by paramedics to be eligible for prophylaxis. During the hospital
stay, an additional 3 patients with allergy to antibiotics were identified. All three of these patients

received pre-hospital antibiotics, without an adverse event.

Age, gender, and ISS were not associated with the successful administration of antibiotics (p >

0.05). Total pre-hospital time was the only variable assessed that had a significant impact on

administration of prehospital antibiotics. When total pre-hospital time was 30 minutes or less, 7

of 24 patients (29.1%) received prehospital antibiotics and when transport time was greater than

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30 minutes, this increased to 25 of 38 patients (65.8%), p <0.001.

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Discussion:
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These results demonstrate that prehospital antibiotic administration is a practical and safe method

to speed the delivery of antibiotic prophylaxis in the setting of an open fracture. These findings
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are underscored by recent research demonstrating a strong association between the time from
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injury to antibiotic administration and the development of an infection in the setting of type III
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open tibia fractures.9

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It is noteworthy that longer total pre-hospital times were associated with an increased success
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rate in administering prehospital antibiotics, as it is these patients with longer transport times that
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prehospital administration may most benefit. Such patients are at increased risk of delayed

hospital-based antibiotic administration given an inherent delay to presentation.

Previous research outside of orthopaedics has demonstrated adaptation of Emergency Medical

Services (EMS) processes to be the most effective way to decrease delay to a time-dependent

treatment.20-22 Such adaptations may be particularly effective in expediting antibiotic delivery in

the setting of open fractures as the intervention has been successfully administered in the field

under a variety of conditions.12-16 Our results underscore this opportunity. This concept may be

even more powerful in expediting antibiotic delivery for open fractures as the intervention in

question can be effectively administered in the field under a variety of conditions.15-19,22

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