1. PRIMARY WOUND CULTURE
IN OPEN FRACTURES
DR ABIJIT RADHAKRISHNAN
PROF JOHN GEORGE,PROF P S JOHN
DEPARTMENT OF ORTHOPAEDICS
MEDICAL COLLEGE, KOTTAYAM

2. GREETINGS
FROM
MEDICAL COLLEGE KOTTAYAM

3. INTRODUCTION
 Sepsis occurring in open fractures leads to
significant morbidity
 Wound contamination as well as
knowledge of the microbial flora is needed
to administer a rational and effective
antibiotic treatment for open fractures

4.  the amount of devitalization
 the type and site of fracture
 the time lapse between injury and
debridement
 the mode of fracture fixation
 the timing of antibiotic administrations
DETERMINANTS

5. AIM OF THE STUDY
 The incidence of bacterial contamination in
open fractures depending upon mode of
trauma
 The common bacterial flora contaminating
open fractures
 The sensitivity pattern of the isolated
bacteria and effectiveness of antibiotic
regimen

6. INCLUSION CRITERIA
 Extremity open fractures of Gustilo
Anderson* type I, II &III presenting
within 8 hours
 Haemodynamically stable patients for
whom emergency debridement and
fixation are possible

7. EXCLUSION CRITERIA
 Open fractures with delayed presentation
more than 8 hours
 Prophylactic antibiotic therapy from the local
hospital
 Open fractures with mangled extremity
requiring emergency amputation
 Immunocompromised patients

8. MATERIALS AND METHODS
 22 patients with open fractures of the
extremities
 December 2006 to October 2007 in
Medical College, Kottayam

9.  Out of 22 patients, 2 were Gustilo
Anderson* type I, 12 were type II& IIIa and
8 were type IIIb
0
2
4
6
8
10
12
GA 1 GA 2 & 3A GA 3B
Series1

10.  14 sustained open fractures out of road
traffic accidents, 3 at work site, 1of rail
accident and 4 due to household accidents
RTA
FARM
RAIL
HOUSE

11. TRIPHASIC SAMPLING

12. TRIPHASIC SAMPLING
 PRE-DEBRIDEMENT SAMPLE
 DEBRIDEMENT SAMPLE
 POST-DEBRIDEMENT SAMPLE

13.  Time of presentation
 Before the administration of antibiotics
PRE-DEBRIDEMENT SAMPLE

14. DEBRIDEMENT SAMPLE
 Skin culture sample in all cases
 Muscle tissue in GA type II & III
 Samples of periosteum in type IIIB

15.  Tissues obtained from skin, muscle and
periosteum kept separately in pre-sterilized
weighted containers filled with normal saline
 The average time between injury and surgical
debridement was 11 hours (8-14 hours)
DEBRIDEMENT SAMPLE

16. POST-DEBRIDEMENT SAMPLE
 Wound sampling repeated on first
postoperative day
 Denotes the need for further debridement
 High chance of persistent infection &
warrants extended antibiotic therapy
 Incidence of nosocomial infection

17. ANTIBIOTIC REGIMEN
 Third generation cephalosporin and
aminoglycosides after pre- debridement
sample
 Changed to sensitive antibiotics according
to pre-debridement sampling report

18.  Parenteral antibiotics for 10 days
 Oral antibiotics for another 7 days
CULTURE NEGATIVE

19. CULTURE POSITIVE
 Initial 3 weeks of parenteral antibiotics
followed by oral antibiotics for 3 weeks
 Extended antibiotic therapy for 10 weeks
in positive Post-debridement cases

20. CULTURE POSITIVE
Absence of infection confirmed with
wound culture at the end of antibiotic
therapy if the wound is not well healed

21. RESULTS
Among a total of 94 samples from all tissues,
29 (30%) showed positive bacterial counts
 14 of 66 skin (21%)
 11 of 20 muscle (55%)
 4 of 8 periosteum samples (50%)

22.  10 cases of mixed bacterial flora,7 of Staph
Aureus,3 of Klebsiella, 7 Pseudomonas, 2
of group D streptococci
0
1
2
3
4
5
6
7
8
9
10
MIXED S. AUREUS KLEB PSEDO STREPT
PATTERN OF BACTERIAL FLORA

23.  Patients with positive muscle and
periosteum had 100% incidence of
infection
 Positive cultured organisms were treated
with the sensitive antibiotics according to
antibiotic protocol
RESULTS

24. RESULTS
 1 patient with type IIIb fracture showed
positive contamination of all samples
which went for persistent infection
 Infection controlled with early detection
and extended antibiotic therapy

25.  11 of 22 patients had
soft tissue
contamination
 7 were GA type II &
IIIA
 4 were GA type IIIB
0
5
10
15
20
25
30
35
1 2 3 4

26. THE RATE OF CONTAMINATION WAS
PROPORTIONATE TO THE SOFT TISSUE
INJURY

27. 0
2
4
6
8
10
12
14
16
18
20
GA 1 GA 2&3a GA 3b
Series2
Series1
Grade III open fractures were more
contaminated than grade II and grade I

28.  All the patients showed contamination
were victims of RTA
 Shows place at which fracture occurs
determines the absence or presence of
wound contamination
ACCIDENT SITE

29. ADVANTAGES OF TRIPHASIC
SAMPLING
 Early detection & control of infection
 Early predictor of persistent infection
 Timely sensitive Antibiotic therapy
 Detection of nosocomial infection denotes the
quality of sterilization & chances of cross
infection

30. RESULTS
 No cases of uncontrolled infection
 No incidence of chronic osteomyelitis
 No incidence of nosocomial infections

31. CONCLUSION
 50% of the open fractures are already
contaminated upon the patient's arrival
 Presence of contamination in muscle or
periosteum is associated with very high
incidence of infection

32.  Contaminating organisms are community
acquired and infections can be controlled with
early detection & adequate sensitive antibiotics
 Persistence of the same organism in the Post-
debridement sample implies the need for
further debridement and a subsequent very
high risk of infection
CONCLUSION

33. PREVENTION IS BETTER
THAN CURE

34. THANK YOU