Maximizing Adherence and Minimizing Time to Antibiotics: A Multi-Disciplinary Institutional Trauma Bay Protocol for Single Antibiotic Prophylaxis in Open Fractures

Objectives:

To determine if a multi-disciplinary institutional protocol can optimize the time to antibiotic (Abx) administration for open fractures (openFx) and improve compliance with the administration of Abx prophylaxis during trauma activation.

Methods:

Design: Retrospective pre-post study design.

Setting:

Single Level II Trauma Center.

Patient Selection Criteria:

All patients that triggered a trauma activation with suspected openFx and were treated according to the institutional single antibiotic regimen were eligible for inclusion. Patients were excluded if fractures did not involve the appendicular skeleton. Patients treated prior to implementation of a standardized institutional protocol where premixed IV bags of antibiotics were stocked in automated dispensing systems within ED trauma bays (Jan 2021-Oct 2022) were defined as the “pre” group, and those treated following implementation the “post” group.

Outcome Measures and Comparisons: The primary outcome was time from trauma bay arrival to antibiotic aministration, measured in minutes, with comparisons made between pre- and post-protocol implementation. Secondary outcomes for comparison included rates (%) of time to Abx < 60 minutes, allergic reactions, acute kidney injury, ototoxicity, surgical site infection, multi-drug resistant organisms identified in blood or biopsy cultures in cases requiring reoperation, and Clostridium difficile infection in the gastrointestinal system, confirmed by stool test results, within 30 days.

Results:

Twenty-four patients (mean age 39.5±16.3) met the criteria after protocol implementation compared to 72 patients (mean age 34.3±14.8) prior to implementation. Implementation of the institutional protocol resulted in a significant reduction in the time to Abx administration for openFx from 87.9±104.6min to 22.2±12.8min in the post-protocol group (p<0.001). Additionally, only 53% in the pre-protocol group received Abx within 60 minutes compared to 97% in post-protocol group (p<0.001). Post-hoc power analysis revealed that the study was powered at 92% (effect size=0.72) to detect a significant difference between the pre- and post-protocol groups.

Conclusion:

This study provides evidence that a multi-disciplinary institutional protocol for the administration of Abx prophylaxis can be an effective strategy for optimizing the time to Abx administration in cases of suspected openFx. This protocol may be implemented in other trauma centers to optimize time to Abx administration for openFx.

Level of evidence:

III, Retrospective pre-post study.