Pre-hospital antibiotics for open fractures: Is there time? A descriptive study

Infection is a complication of open fractures. Early administration of intravenous (IV) antibiotics providing cover against gram positive and negative organisms has been shown to be the single most important factor in reducing infection rate in patients with open (compound) fractures. A delay of more than three hours from injury (open fractures or war wounds including fractures) to antibiotic administration is associated with a significantly higher infection rate. The purpose of this study is to identify the proportion of patients in a suburban sample that experience delay of more than 3 hours in antibiotic administration after open fracture. The authors hope to clarify if there would be opportunity and value in pre-hospital antibiotic administration in significantly shortening the delay. Methods: A retrospective and prospective descriptive study was conducted of all patients with open fractures of the limbs or girdles arriving via ambulance at a single district hospital in a suburban area in KwaZulu-Natal, South Africa from May to December 2012. Data analysed with descriptive statistics using STATA 11. Results: 38 patients were identified from May to December 2012. The median total time from injury to antibiotics was 465 min (7.5 h) (Q1 = 230 min, Q3 = 615). Administration of antibiotics was delayed beyond 3 h in 78.9% (95% confidence interval (CI) 65.3 – 92.52) of patients and beyond 6 h in 60.5% (95% CI 44.2 – 76.8). A median of 164 min (Q1 = 115, Q3 = 222) was spent out of hospital with emergency medical care practitioners (EMCPs) being in attendance for a median of 56 min (Q1 = 37, Q3 = 64). The longest delay occurred after arrival at the hospital with a median of 363 min (Q1 = 171, Q3 = 505) until antibiotic administration. 26.3% of patients were transported directly from scene of injury to the hospital, while the remainder first presented to a clinic. Conclusions: There is much room for improvement within the study hospital and its drainage clinics in preventing delay in antibiotic administration. However, although much of the delay occurred due to clinic and in-hospital delays, there is also a hypothetical window available to pre-hospital healthcare providers where antibiotics may be administered which would dramatically decrease the time interval and bypass many of the difficulties encountered in-hospital. It would be safer to consider introducing IV antibiotics to the advanced scope of EMCP practise only; due to need to manage complications of antibiotics. Before considering introducing antibiotics to EMCP spectrum of care, efficacy, safety and cost-effectiveness studies would need to be undertaken. Randomised controlled trials are also recommended to determine the effect on reducing delay, infection and occurrence of adverse events.