Antibiotic Options for the Fracture Related Infections Russell

Antibiotic Options for the Fracture Related Infections Russell Norris, MD Vidant Medical Center

Complex Problems/Decisions • Multidisciplinary Approach • • Ortho ID Plastics Pharmacy, Nutrition, Social Work… • Don’t totally abdicate to ID!

Oral ABX Utility • Optimally directed by DEEP/Operative culture • Suppression • 3 mo’s • Until Union • Superficial • Abscess/infection above Fascia/capsule • Osteomyelitis? • Fracture Related Infections?

Bioavailabilty… • Amoxicillin • Amox/Clav • Cephalexin • Doxycycline • Cipro • Clindamycin • TMP-SMZ 74 -92% 60% 90 -100% >90% 65 -85% 90% 70 -90% • Percentage entering circulation, NOT correlated with efficacy

Inertia vs. Evidence? • Osteo/FRI/PJI means IV ABX for 6+ weeks… • NO conclusive Evidence for • 4 -weeks vs 12+ weeks • Oral vs PO

Cochrane Database 2013 • RTCs for Adult Chronic Osteo • Data old, 20+ years • Wide variation in technique, confounders • No clear superiority Oral vs. IV

OVIVA 2019 • RCT, Multi-center in UK • 1054 pts • Equal effectiveness PO vs IV

Other Factors—Biofilm Activity • Beta-lactams and Cephalosporins very little penetration • Gm+ Rifampin! • Gm – Cipro! • Debridement/Mechanical

Other Factors--Social/Payor • Cost of home infusion • IVD history • PICC or Port care • Compliance • Inpatient/SNF/Rehab stay • Burden to family/care-givers

Key Aspects of Antimicrobial Therapy • Empiric IV antimicrobial therapy • Started as soon as tissue samples are taken • Should be broad spectrum * include a glycopeptide & an agent against gram-negative bacilli • Targeted antimicrobial therapy • According to culturing results as soon as possible • Short term (up to 7 days) IV = outcome compared to prolonged • Duration of antimicrobial therapy is controversial and not well investigated. * 6– 12 wks commonly (ID, Pharmacy? )

Bottom Line PO IV • Shorter Stay • Cheaper • Better long term compliance • Fewer complications • Broader Spectrum • More options • Observed Compliance

Take Home • When in doubt: Broad spectrum IV (cover MRSA/Gm Negative) • Get Deep/Surgical Cultures • Early conversion to PO • Consider synergistic/biofilm active orals • Collaborate: ID, Multi-disciplinary team