Rev. bras. ortop. vol.52 número5

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

Article

Infection

rate

in

adult

patients

with

open

fractures

treated

at

the

emergency

hospital

and

at

the

ULBRA

university

hospital

in

Canoas,

Rio

Grande

do

Sul,

Brazil

夽

Marcelo

Teodoro

Ezequiel

Guerra,

Fernando

Machado

Gregio

_,

Adriane

Bernardi,

Cyntia

Cordeiro

de

Castro

UniversidadeLuteranadoBrasil(Ulbra),HospitalUniversitário,Canoas,RS,Brazil

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Articlehistory:

Received26August2016 Accepted1September2016 Availableonline25August2017

Keywords:

Openfractures Infection Emergencies

a

b

s

t

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t

Objective:Toidentifytheinfectionrateinadultpatientswithopenfracturestreatedattwo tertiaryhospitalsinthecityofCanoas,RioGrandedoSul,Brazil.

Methods:ThisquantitativedescriptivestudywasconductedatHospitaldeProntoSocorro deCanoas.Eligibleparticipantswereadultsaged18–60yearswithopenfractureswhowere admittedtotheorthopedictraumaservicefromJanuarytoMay2014andfollowed-upfor oneyear.

Results:Atotalof133patientswithopenfractureswereincluded;mostweremen(92.48%), withameanageof36years.TherewasapredominanceofGustilo-AndersontypeIII frac-tures.Theinfection ratewas18.80%, beingmorefrequent inGustilo-Andersontype III fractures(72.00%).ThemostcommonlyobservedbacteriawereStaphylococcusaureusand

Enterobacteraerogenes.

Conclusion:Theinfectionrateinopenfracturesofpatientsinitiallytreatedattheemergency departmentofHPSCwas18.8%.TheinfectionsoccurredpredominantlyinGustilo-Anderson typeIIIfractures.ThebacteriawiththehighestincidenceininfectionswereStaphylococcus aureusandEnterobacteraerogenes.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽

PaperdevelopedatUniversidadeLuteranadoBrasil(Ulbra),HospitalUniversitário,DepartamentodeOrtopediaeTraumatologia, Canoas,RS,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](F.M.Gregio). http://dx.doi.org/10.1016/j.rboe.2017.08.012

Taxa

de

infecc¸ão

em

pacientes

adultos

com

fratura

exposta

atendidos

no

hospital

de

pronto

socorro

e

no

hospital

universitário

Ulbra

do

município

de

Canoas,

Rio

Grande

do

Sul

Palavras-chave:

Fraturasexpostas Infecc¸ão

Emergências

r

e

s

u

m

o

Objetivo: Identificarataxadeinfecc¸ãoempacientesadultoscomfraturaexpostaatendidos emdoishospitaisterciáriosnomunicípiodeCanoas,RioGrandedoSul.

Métodos: Estudoquantitativodescritivofeitono HospitaldePronto Socorrode Canoas (HPSC).Foramelegíveisospacientesentre18e60anosinternadoscomfraturaexposta nosetordetraumatologiaeortopediadaemergênciadoHPSC,dejaneiroamaiode2014,e queforamacompanhadosporumano.

Resultados: Foramincluídos133pacientescomfraturaexposta,amaioriadosexo mas-culino(92,48%),commédiade36anos.HouvepredomíniodefraturasdotipoIIIdeGustilo eAnderson.Ataxadeinfecc¸ãofoide18,80%,maisfrequenteemfraturasdotipoIIIde GustiloeAnderson(72%).Asbactériasmaisfrequentementeidentificadasnasinfecc¸ões foramStaphylococcusaureuseEnterobacteraerogenes.

Conclusão: Ataxadeinfecc¸ãoemfraturasexpostasdepacientesatendidosinicialmentena emergênciadoHPSCfoide18,80%.Asinfecc¸õesocorrerampredominantementeemfraturas dotipoIIIdeGustiloeAnderson.Asbactériascommaiorincidêncianasinfecc¸õesforam

StaphylococcusaureuseEnterobacteraerogenes.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Traumaticpathologieshaveanincreasingincidencebothin diagnosesand hospitaladmissions,1 _{duetothe increasein}

violenceandcaraccidents,maincausesofthesetraumasin adults.Asaconsequence,thereisanincreaseinemergency expenses,whichisusuallymoreonerousthanmost conven-tionalprocedures.2,3

Openfractures,alsoknownascompoundfractures,areone ofthe consequencesoftrauma.Insuchcases,the fracture segmentscommunicatewiththecontaminatedenvironment throughskin4_{andadjacentsofttissues,}5_{nomatterhowsmall}

thesofttissuelesionis.6_{Theopenfracturemaybeanisolated}

injury,orcanoccurtogetherwithaseriesofmultiplewounds,4

andisusuallyassociatedwithalargenumberofcomorbidities. Itisestimatedthattheincidenceofopenfracturesoflong bones is 11.5 cases per 100,000 people per annum.7 _Open

fracturesaremorecommoninmenandhaveabimodalage distribution,withthetibiabeingthemostaffectedbone.6

Thepresenceofanopenfractureresultsinarangeof clin-icalsituations, amongwhich the mostcommon and most seriouscomplicationisinfection.8,9 _{Basedonthecriteriaof}

theBrazilianNational Health SurveillanceAgency (Anvisa), whichinvolveclinical,histologicalandimaging characteris-tics, the presence of one of the altered criteria is already determinantforthediagnosisofinfection.10_{Theprevalence}

ofinfectioniscloselyrelatedtotheseverityofthepatient’s fracture,11,12_{thatis,accordingtotheclassificationbyGustilo}

andAnderson,13_{thehigherthe lesiontype,the greaterthe}

likelihoodofinfection.14

Duetothelargenumberofvictimsofopenfractures,and totheircomplexity,itisnecessarytostudytheratesofopen

fractures intertiary hospitalstoallowbetter planning and careorganizationforthesepatients.Thus,thisstudyaimed toidentifytheinfectionrateinadultpatientswithopen frac-turestreatedattwohospitalsinthecityofCanoas,stateofRio GrandedoSul.

Material

and

methods

Thisisadescriptivestudy,basedon consecutivesampling, performedinanemergencyhospitalandinanothertertiary hospitalinthe city ofCanoas. Thestudy wasapprovedby the Research Ethics Committeeofbothinstitutions (proto-col#447594.15.2.0000.5349).Theanonymityoftheparticipants wasassured,aswellastheuseofdataonlybythemainauthor, exclusivelyforstudypurposes.

Allpatientsbetween18and60yearsofageattendedand admittedwithopenfracturesbythetraumaandorthopedics teaminthehospitalemergencyroom,fromJanuary1toMay 24,2014,wereeligibleforthestudyandwerefollowedupfor oneyearintheinstitutions.Thepatientswho couldnotbe evaluatedforaperiodofoneyear,fromthedateofadmission, andthepatientswhowerenotadmittedbythetraumatology andorthopedicsteamoftheinstitutionwereexcluded.

Patientdatawerecollectedfromthemedicalrecordsfrom JulytoAugust2015bythemainauthorwithaspecificform. Thepatientswereevaluatedbyage,gender,typeoffracture accordingtoGustiloandAndersonclassification,13_andforthe

presenceofinfectionattheopenfracture siteaccordingto Anvisa’scriteria10_{andbacteriologicalprofile.}

Table1–Relationbetweengenderandtypeoffracture,accordingtotheGustiloandAndersonclassification.

Type

I II IIIA IIIB IIIC

Gender n % n % n % n % n %

Female 1 3.10 1 2.60 3 8.10 3 17.60 2 25.00

Male 31 96.90 38 97.40 34 91.90 14 82.40 6 75.00

Fisher’sexacttest,p<0.065.

questionnaires;the consistency and coherence of the data wereanalyzed.DatawerethenstoredinadatabaseusingExcel software.

Quantitative variables were presented by mean and standarddeviation(SD)andcategoricalvariablesbyabsolute (n)andrelative(%)frequencies.Theassociationbetweenthe categoricalvariableswasevaluatedusingFisher’sexacttest, anappropriatemethodforthis evaluationwhenmorethan 25%ofthevaluesarebelowthelevelofsignificance(p<0.05). Forthevariables withnormaldistribution,the meanswere comparedwiththevarianceanalysis(Anova).Thestatistical analysiswasperformedwiththeStatisticalPackagefortheSocial Sciences(SPSS)software,version18.0(SPSSInc.,IBMCompany, Chicago,IL,USA)andthelevelofsignificanceusedwas5% (p<0.05).

Results

FromJanuary1toMay24,2014,519patientswereattended andadmittedbythetraumatologyandorthopedicsteamof theemergencyhospital,withameanof1.08caseperday.Of these,154patientshadanopenfractureandwereanalyzed forinclusioninthestudy.Twenty-onepatientswereexcluded becausetheydidnothaveaone-yearfollow-up,countingfrom thedayofadmission,whichresultedin133patientswithan openfractureincludedinthestudy.

Themeanageofthepatientswithopenfractureswas36 years(SD:12.60years)andmostofthemweremale(n=123; 92.48%).Themeanagewas35.50years(SD:12.45years)among males,and41.60years(SD:14.50years)amongfemales.

ThemostprevalenttypeoffracturewastypeIII, account-ingfor46.70%ofallcases(62patients).Ofthese,59.70%(37 patients)weretypeIIIA,27.40%(17)IIIBand12.90%(eight)IIIC. TypeIwastheleastprevalent,with24.70%(32),followedby typeII,with29.30%(39).

TypeIIICfractureswerethemostfrequentamongfemales (25%),whiletypeIIfractureswerethemostfrequentamong males(97.40%).Therewasnoassociationbetweengenderand typeoffracture(p<0.065)(Table1).

Twenty-five patients(18.80%) developedan infection.Of these,one(4%)wasclassifiedastypeIfracture,six(24%)with typeIIfractures,and 18 (72%)withtypeIIIfractures. Frac-turesclassifiedastypeIIIBpresentedthehighestinfectionrate (36%),whilethoseclassifiedastypeIhadthelowestinfection rate(4%).Therewasasignificantassociationbetweenthetype offractureandtheoccurrenceofinfection(p<0.001)(Fig.1).

Twenty-sevenpositivecultureswerefoundin17infected patients (68%). In these cultures, 11 microorganisms were

100,00%

90,00%

80,00%

70,00%

60,00%

50,00%

40,00%

infection rate _30,00%

20,00%

10,00%

0,00%

I II IIIA IIIB IIIC

Tipo

No infection With infection

Fig.1–Relationbetweeninfectionrateandtypeoffracture, accordingtotheGustiloandAndersonclassification. Fisher’sexacttest,p<0.001.

identified,describedinTable2.Ofthese,33.30%were gram-positivebacteria,and66.70%weregram-negativebacteria.

Therelationshipbetweentheuse ofprophylactic antibi-oticsandtheoccurrenceofinfectionispresentedinTable3. Twenty-eightpatientswithtypeIIIfracturesusedtwoormore antibiotics,while13patientswithtypeIorIIfracturesused twoormoreprophylacticantibiotics.

Discussion

Thepresentstudyinvestigatedtheassociationbetweenthe incidence of infections and open fractures in two tertiary hospitalsinthecityofCanoas,inthesouthernregionofthe country.ItwasalsoevidentthelackofresearchinBrazilian

Table2–Prevalenceofmicroorganisms.

Bacteria n %

Enterobacteraerogenes 5 18.50

Staphylococcusaureus 5 18.50

Acinetobactersp. 3 11.10

Enterococcussp. 3 11.10

Pseudomonasaeruginosa 3 11.10

Mixedflora 2 7.40

Serratiasp. 2 7.40

Grambacillus–non-fermenting 1 3.70

Enterobactercloacae 1 3.70

Escherichiacoli 1 3.70

Table3–Relationbetweentheuseofprophylacticantibiotics(ATB)andtheoccurrenceofinfection.

Infection p

No(n=108) Yes(n=25)

n % n %

ProphylacticATB 0.615

No 5 4.60 2 8.00

Yes 103 95.40 23 92.00

NumberofprophylacticATB <0.001

0 5 4.60 2 8.00

1 76 70.40 7 28.00

2 24 22.20 12 48.00

3 3 2.80 4 16.00

literature. An infection rate of 18.80% was found in open fractures ofpatientsseen initially inthe emergency room, and followed up for a year in the hospitalsin which the studieswere conducted.Infectionsoccurred predominantly inGustiloandAndersontypeIIIfractures.

Thestudyhasthreelimitations.Firstly,theshortperiod, becauseonMay25,2014,aprotocolofantibioticprophylaxis andantibiotictherapywasinstitutedintheemergencyroom, whichcouldinterferewiththeresultsoftheresearch.Thus, thestudywasinterruptedonMay24,2014.Secondly,patients withanopenfracturewhowerenotadmittedtothe hospi-tal bythe traumaand orthopedicsteam ofthe emergency roomwereexcludedfromthestudy.Thesehospitalsare refer-enceinOrthopedicsandTraumatologyfor140municipalities inthestateofRioGrandedoSul.However,somepatientshave privatehealthcareplansandprefertobecaredforin hospi-talsoftheirchoice.Inaddition,patientsfromcitiesthatare notareferenceofthemunicipalityofCanoasareoftentaken bytheEmergencyMobileCareService(SAMU)tooneofthe twohealthinstitutionstoreceivefirstcare,thentheyreturn totheirhomemunicipalityforfollow-up.Thirdly,arelevant numberofpatientswithopenfractures(n=21)wereexcluded fromthestudybecausetheyweretransferredorbecausethey lostthelinkwiththehealthinstitutions,makingit impossi-bletoanalyzethesepatientsforafullyearfromthedateof admission.

Inthe present study,mostpatients withopen fractures weremale,withameanageof36years,consistentwiththe lit-erature,whichestimatesthehighestprevalenceamongmen inthefourthdecade.6_{Thefemaleagegrouppresentedinthe}

literatureisover60yearsofage,6_{differentfromthatfoundin}

thepresentstudy,whichwas41.60years,mostprobablydue totheagerangestipulatedasinclusioncriterion(18–60years). TypeIIIfracturesofthe GustiloandAnderson classifica-tionwereprevalent(46.70%),datathatiscommoninprevious studiesofopenfractures.15,16_{Fortheotherfracturetypes,the}

valuesfoundwerealsosimilartothosereportedinthe litera-ture,of15.80%fortypeI,and29.50%fortypeII.15

Theinfectionratefound(18.80%)washigherthanthe10% rate described insimilar international studies,17 _{but lower}

thanthatreportedinnationalstudies,withrateshigherthan 20%.16_{TheestimatedrateofinfectionfortypeIfracturesis}

0–2%,fortypeIIis2–7%,andfortypeIIIis10–25%,valueslower thanthosefoundinthepresentstudy(typeI:4%,typeII:24%, andtypeIII:72%).

Regarding themicroorganismspresent intheinfections,

StaphylococcusaureusandEnterobacteraerogeneshadthehighest incidence,whichisinagreementwiththeliterature.17_In

addi-tion,therewasahigherincidenceofgram-negativeagents, whichmaybejustifiedbythepresenceofthesebacteriainthe openfracturesinfections,17,18_{andbytheprevalenceof}

bacte-riaineachinstitution.17_{ThestudybyCollingeetal.,}19_inwhich

onlyintravenouscefazolinwasusedinthepatients,showed thattimewasdirectlyassociatedwiththeinfectionrate,but theamountofantibioticsdidnotpresentastatistically signif-icantimpactontheinfectionrate.

Conclusion

Thepresentstudyaimedtoidentifytherateofinfectionin open fractures in two tertiary hospitals, HPSC and HU, by meansofthevariablesgender,age,severityofopenfractures, infectionandinfectiousagents.Therateofinfectioninopen fracturesfoundinpatientsadmittedthroughtheHPSC emer-gency was 18.80%, and the mostfrequent microorganisms wereEnterobacteraerogenesandStaphylococcusaureus.Itshould benotedthattheinfectionisnotdirectlylinkedtothenumber ofantibioticsused.Inviewofthedataobtained,the impor-tanceofthefollow-upofthestudiesisemphasized,sothat therecanbeaconstantimprovementinpatientcare.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1.deCastroRR,RibeiroNF,deAndradeAM,JaquesBD. Orthopedicsnursingpatients’profileofapublichospitalin Salvador-Bahia.ActaOrtopBras.2013;21(4):191–4.

2.MinayoMC.ViolênciaeSaúde.RiodeJaneiro:Fiocruz;2006. 3.MalvestioMA,SousaRMC.Sobrevivênciaapósacidentesde trânsito:impactodasvariáveisclínicasepré-hospitalares. RevSaúdePública.2008;42(4):639–47.

4.HoffWS,BonadiesJA,CachechoR,DorlacWC.EastPractice ManagementGuidelinesWorkGroup:updatetopractice managementguidelinesforprophylacticantibioticusein openfractures.JTrauma.2011;70(3):751–4.

epidemiológicoeprospectivo.ActaOrtopBras. 2009;17(6):326–30.

6. GumJL,SelignoD.Updateonthemanagementofopen fractures.AmAcadOrthopaedicSurgeonsWebsite: OrthopaedicKnowledgeOnlineJ.2012;10(9).Availablein: www.aaos.org/jaaos/.

7. Court-BrownCM,RimmerS,PrakashU,McQueenMM.The epidemiologyofopenlongbonefractures.Injury.

1998;29(7):529–34.

8. OkikeK,BhattacharyyaT.Trendsinthemanagementofopen fractures.Acriticalanalysis.JBoneJointSurgAm.

2006;88(12):2739–48.

9. PatzakisMJ,WilkinsJ,MooreTM.Useofantibioticsinopen tibialfractures.ClinOrthopRelatRes.1983;(178):31–5. 10.AgênciaNacionaldeVigilânciaSanitária.Critérios

diagnósticosdeInfecc¸õesrelacionadasàassistênciaàsaúde. Brasilia,2013.Availablein:http://www20.anvisa.gov.br/ segurancadopaciente/images/documentos/livros/Livro2-CriteriosDiagnosticosIRASaude.pdf.

11.SungaranJ,HarrisI,MouradM.Theeffectoftimetotheatre oninfectionrateforopentibiafractures.ANZJSurg. 2007;77(10):886–8.

12.BartonCA,McMillianWD,CrookesBA,OslerT,BartlettCS3rd_.

CompliancewiththeEasternAssociationfortheSurgeryof Traumaguidelinesforprophylacticantibioticsafteropen extremityfracture.IntJCritIllnInjSci.2012;2(2):57–62.

13.GustiloRB,AndersonJT.Preventionofinfectioninthe treatmentofonethousandandtwenty-fiveopenfracturesof longbones:retrospectiveandprospectiveanalyses.JBone JointSurgAm.1976;58(4):453–8.

14.PatzakisMJ,WilkinsJ.Factorsinfluencinginfectionratein openfracturewounds.ClinOrthopRelatRes.1989; (243):36–40.

15.MatosMA,NascimentoJM,SilvaBVP.Estudoclínico

demográficodasfraturasexpostascausadasporacidentesde motocicleta.ActaOrtopBras.2014;22(4):214–8.

16.MüllerSS,SadenbergT,PereiraGJC,SadatsuneT,KimuraEE, NovelliFilhoJLV.Estudoepidemiológico,clínicoe

microbiológicoprospectivodepacientesportadoresde fraturasexpostasatendidosemhospitaluniversitário.Acta OrtopBras.2003;5:158–69.

17.ChenAF,SchreiberVM,WashingtonW,RaoN,EvansAR. Whatistherateofmethicillin-resistantStaphylococcusaureus andGram-negativeinfectionsinopenfractures?ClinOrthop RelatRes.2013;471(10):3135–40.

18.GoldmanL,AusielloD.CecilMedicina.RiodeJaneiro: Elsevier;2009.Traduc¸ãoAdrianaPittelaSudré. 19.CollingeCA,McWilliam-RossK,KellyKC,DombroskiD.