Surgical Infection Society: Chest Wall Injury Society Recommendations for Antibiotic Use during Surgical Stabilization of Traumatic Rib or Sternal Fractures to Reduce Risk of Implant Infection

Qualitative synthesis

Four studies addressing Clinical Question 1 were identified through the search. Two were retrospective single institution studies, one was a retrospective multi-institution study, and one was a prospective single institution study. In 2019, Beks et al. [22] published a single-center retrospective evaluation of short- and long-term outcomes of 166 adult trauma patients admitted between 2010 and 2016 who underwent surgical rib fixation for either flail chest or multiple rib fractures. All patients received 2 g cefazolin pre-operatively [22]. Short-term outcomes included length of stay (LOS), tracheostomy rate, and in-hospital complications, including SSI and implant infections [22]. Long-term outcomes were evaluated using phone surveys and included quality of life and rate of implant removal because of implant complications [22]. The rate of in-hospital implant-related infections was 3% [22]. Nine patients reported implant removal at least 12 months after surgical fixation; no implant removal occurred secondary to infection [22]. Only 63% of patients responded to post-discharge surveys, which might represent bias in estimating true infection rate.

Beks et al. [23] performed a second study in the same year involving two centers—one that performed SSRF and another that did not—between 2014 and 2017. Inclusion and exclusion criteria were similar to their single-center study [23]. They compared patients who underwent SSRF with those who did not, stratified by indication of SSRF (flail chest or multiple rib fractures). All patients undergoing SSRF received 2 g of cefazolin pre-operatively [23]. Secondary outcomes included in-hospital complications, including rates of pneumonia and SSI [23]. The study included 332 patients, of whom 65 underwent SSRF: 37 patients for flail chest and 28 patients for multiple rib fractures [23]. Propensity matching was used to compare patients between the two hospitals [23]. Three of 65 patients in the operative group had post-operative infection with reported incidence of SSI of 5% with no implant infections reported [23]. This study is also limited by retrospective nature, small sample size that limited study power, and possible selection bias.

In 2020, Xiao et al. [24] published a single-center retrospective analysis of patients who underwent SSRF for either flail chest or multiple rib fractures in comparison to non-operative management. They included patients admitted between 2012 and 2019 24. All patients undergoing SSRF received antimicrobial prophylaxis with 2.25 g intravenous cefuroxime within 30 minutes of incision [24]. Propensity matching was used to control for patient factors, and the analysis was stratified by indication for surgery (flail chest or multiple rib fractures) [24]. Primary outcome was LOS and secondary outcomes included in-hospital complications, including pneumonia and SSI [24]. The study included 1,201 patients; of those, 563 patients underwent SSRF, 430 for multiple rib fractures and 133 for flail chest [24]. There were no differences between the two group after matching [24]. They reported 43 patients (8%) with SSI requiring drainage or debridement [24]. Wound infections occurred between three and seven days post-operatively [24]. They did not mention whether any implant removal was needed or performed [24]. The study has several limitations, including the retrospective and observational design. Additionally, all patients were treated at a single center, limiting generalizability of outcomes.

More recently, Prins et al. [18] assessed the rate of SSI after SSRF using a prospectively maintained SSRF database at a single level 1 trauma center from January 2010 to December 2020. Indications for surgery included presence of one of the following: flail chest, three or more ipsilateral severely displaced rib fractures, decreased respiratory function, respiratory failure caused by chest wall injury, 30% or more volume loss of a hemithorax, or chronic pain or clicking sensation caused by radiographic rib fracture non-union [18]. All patients received 2 g of intravenous cefazolin or vancomycin pre-operatively for antibiotic prophylaxis [18]. The primary outcome was assessed by reviewing medical records for SSI that was documented via clinical examination or radiograph, as well as laboratory markers of infection, and confirmed via microbiology and operative findings [18]. Four of the 228 patients who were reviewed developed SSI (2%) [18]. Occurrence of SSI varied one week to 17 months post-operatively [18]. All patients underwent implant removal along with systemic antibiotic treatment, after which complete clinical recovery occurred [18]. All four patients were current smokers at time of SSRF [18]. Three of the four patients had asthma or chronic obstructive pulmonary disease (COPD) and suffered from alcohol or substance abuse [18]. Notably, three of four patients with SSI had pre-operative tube thoracostomy placement without antibiotic administration [18]. No bivariate analysis was performed to patients who did not develop SSI [18]. Therefore, it is difficult to determine other possible patient or procedural factors that could have resulted in SSI [18].

There were four published society guidelines, systematic reviews, or meta-analyses applicable to Clinical Question 1 that did not meet search criteria. The U.S. Centers for Disease Control and Prevention (CDC), SIS, Infectious Disease Society of America (IDSA), and the World Health Organization (WHO) have all released guidelines on the use of antibiotic therapy in the peri-operative period. In a joint statement by the SIS and the IDSA that was published in 2013 it was recommended that antibiotic agents are administered within 30 minutes prior to surgical incision and that antibiotic agents should not be continued beyond 24 hours after the procedure [25]. For thoracic procedures, coverage of gram-positive bacteria was recommended: cefazolin or ampicillin-sulbactam for patients without a penicillin allergy and vancomycin or clindamycin for patients with a penicillin allergy [25]. Similar prophylactic antibiotic recommendations were issued by WHO [26]. In guidelines published in 2017 the CDC similarly recommend against prolonged antibiotics usage beyond the operating room in clean and clean contaminated procedures, stating that no additional prophylactic antimicrobial agents should be dosed after the surgical incision is closed, even in the presence of a drain [27]. The CDC does not recommend application of topical antimicrobial agents prophylactically, nor is there any evidence suggesting that soaking prosthetic devices in antimicrobial solutions reduces the risk of SSI [27]. Finally, in 2013 Parvizi et al. [28] published a summary of the International Consensus Meeting on Surgical Site and Periprosthetic Joint Infection. The authors recommend that antibiotic-impregnated polymethlmethacrylate (PMMA) cement reduces the risk of periprosthetic joint infection but that it was only indicated for patients at high risk of infection, not routine clean cases [28].

Recommendation

We considered the available evidence describing peri-operative antibiotic protocols for patients undergoing SSRF/SSSF. There is insufficient evidence to suggest that among these patients there is reason to suspect existing prophylactic perioperative guidelines or recommendations are inadequate, barring presence of other infectious processes (Grade 2C).

Qualitative synthesis

Three studies addressing Clinical Question 2 were identified through the search. Two were retrospective single-institution studies and one was a case study. In 2018, Junker et al. [29] completed a single-institution retrospective review examining the effect of antibiotic bead placement on bony union after SSRF in adults. There were three cohorts of patients described [29]. The cohort of patients applicable to Clinical Question 2 included patients undergoing SSRF with antibiotic bead placement to prevent infection among patients with high-risk features [29]. A second cohort of patients with known implant infection treated with beads was also described [29]. High-risk features included: pre-operative chest tube placement that traversed fracture lines, pre-operative diagnosis of pneumonia, soft tissue injuries that were in proximity to the fractures, or those patients requiring a thoracotomy after SSRF [29]. This cohort was compared with patients who underwent SSRF without bead placement [29]. Patients in the bead placement cohort were followed for at least a three-month period to ensure absence of further infection as well as assessment of bony union prior to removal of antibiotic beads and SSRF implants [29]. The primary outcome of the study was the bony union of fractures at the time of implant removal [29].

There were eight patients in the prophylactic bead placement arm. Although SSRF implant infection occurred in 10 patients (3.5% of all patients), none occurred in the high-risk prophylaxis arm [29]. The only risk factors associated with SSRF implant infection were increased body mass index and patients who presented with hemorrhagic shock [29]. Although the rate of pneumonia was higher in patients with implant infection this difference was not significant (40% vs. 16%; p = 0.06) [29]. Bony union was seen in 100% of patients undergoing bead implantation, with the authors suggesting bead implantation can salvage implants until bony union occurs [29]. Median bead or implant removal for high-risk patients was 167 days (range, 110–213 days) [29]. There were no associated systemic side effects related to bead implantation noted by the authors [29]. As none of the high-risk characteristics were associated with subsequent infection, the authors noted they have moved away from routine prophylactic bead implantation [29]. This study is limited by a small sample size, single institution participation, variations in wound care management, and low overall incidence of implant infection. Additionally, it is important to note that none of the patients in the no bead implantation cohort had long-term follow-up [29].

In 2018, Ju et al. [30] reported successful surgical stabilization of rib fractures despite Enterobacter and Pseudeomonas pneumonia and colonization of the mediastinum by Candida albicans. A 37-year-old male required sternotomy for repair of a right atrial laceration, superior vena cava injury, and right lower lobe pulmonary resection. He had right-sided rib fractures 1–9 with flail segments [30]. He required extracorporeal membrane oxygenation (ECMO) for four days for cardiogenic shock from blunt cardiac injury [30]. After sternotomy closure, the patient developed recurrent shock [30]. Cultures from the right pleural and mediastinal chest tubes isolated Candida albicans [30]. Additionally, Enterobacter and Pseudomonas were isolated from bronchoalveolar lavage specimens, and the patient was diagnosed with pneumonia [30]. He was resuscitated and was treated for his infections with 10 days of antibiotic and antifungal therapy [30]. His chest wall remained unstable, and on hospital day 25 he underwent surgical stabilization of five ribs using a bicortical titanium plating system [30]. He was able to be weaned from mechanical ventilation within three days of his operation and was discharged to a long-term care facility to complete 28 days of antifungal therapy [30]. He did not have any complications related to his wound or implant [30].

In 2020, Uchida et al. [31] performed a long-term retrospective review of 20 adults undergoing SSRF for flail chest and multiple rib fractures between 2014 and 2019. Exclusion criteria included patients above the age of 85, Abbreviated Injury Scale (AIS) >5 and patients with severe brain injury [31]. There were no comparative groups [31]. Twenty-two patients were managed with surgical stabilization of the chest wall. There were two mortalities reported in the immediate post-operative period [31]. Follow-up duration for the remaining 20 patients was 47.5 (interquartile range [IQR], 22–58) months [31]. Three patients undergoing SSRF with concomitant pneumonia at time of surgery needed antibiotic agents during hospitalization [31]. However, none of these patients developed plate infection or required implant removal for infection [31]. The study is limited by its retrospective, single-site design and the small number of patients.

There were three published society guidelines, systematic reviews, meta-analyses or landmark trials applicable to Clinical Question 2 that did not meet search criteria. In 2011 Liu et al. [32] published IDSA guideline based on expert committee review of the relevant literature on methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and pneumonia, among other pathologies. The expert panel reviewed data published since 1961 [32]. Although MRSA sepsis with implants was not directly addressed, IDSA recommended intravenous vancomycin or daptomycin 6 mg/kg per dose daily for six weeks with surveillance blood cultures to prove clearance and transesophageal echocardiography for patients with complicated MRSA bacteremia [32]. Similarly, the IDSA working group recommended treatment with intravenous vancomycin, linezolid 600 mg oral/intravenous twice per day, or clindamycin 600 mg oral/intravenous three times per day for a seven to 21-day course for patients with MRSA pneumonia [32].

In 2016 Kalil et al. [33] developed clinical practice guidelines, endorsed by the IDSA, based on systematic literature review for treatment of hospital acquired (HAP) or ventilator acquired pneumonia (VAP). Regarding treatment for HAP/VAP, they recommend that selection of antibiotic agents be guided by regularly locally generated antibiograms targeted against Staphylococcus aureus, Pseudomonas aeruginosa, and other gram-negative bacilli [33]. Suggested empiric antibiotic regimens included piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem [33]. If MSSA was isolated, oxacillin, nafcillin, or cefazolin was recommended [33]. Should a unit have higher than 10%–20% MRSA infection rate, or if a patient has received prior intravenous antibiotic use in the last 90 days, empiric treatment with vancomycin or linezolid was recommended to be added for MRSA coverage [33]. For Pseudomonas, monotherapy was suggested unless units are known to have >10% resistance to monotherapy or a patient has septic shock, in which case double coverage was recommended [33]. Aminoglycosides were recommended to be avoided if alternatives are available [33]. Duration of antibiotic therapy for HAP and VAP was recommended to conclude in seven days or less, depending on rates of clinical, radiographic improvement [33].

In 2018, Yahav et al. [34] performed a randomized open-label non-inferiority multicenter trial of patients with gram-negative bacteremia who were afebrile and hemodynamically stable comparing seven days of antibiotic (intervention) versus 14 days of antibiotic (control) for patients with uncomplicated gram-negative bacteremia. Patients with urinary tract, intra-abdominal, respiratory tract, central venous catheter, or skin and soft tissue infection or an unknown source of bacteremia were eligible for inclusion [34]. Patients with other sources of infection, uncontrolled focus of infection, polymicrobial growth, specific pathogens (Brucella, Salmonella), or immunosuppression (neutropenia at time of randomization, human immunodeficiency virus, recent allogeneic stem cell transplantation) were excluded [34]. Outcomes were followed for 90 days post-randomization [34]. Outcomes followed include composite of all-cause mortality, clinical failure (relapse of bacteremia, local suppurative complications or distant complications, re-admission, or extended hospital stay [>14 days]) [34].

Overall, there were no differences in baseline demographics between groups [34]. Seven days of antibiotic agents to treat uncomplicated gram-negative bacteremia was non-inferior to 14 days of antibiotic agents for the following outcomes: 90-day all-cause mortality, re-admission, extended hospitalization beyond 14 days, distant complications, relapse of bacteremia, suppurative complication [34]. There was a faster return to baseline in patients who were treated with seven days of antibiotic agents compared with 14 days of antibiotic agents, with a median two weeks (IQR, 0–8.3 weeks) to three weeks (IQR, 1–12 weeks), respectively [34]. Limitation to this study included a preponderance of Enterobacter as the offending agent and failure to identify if patients with implants were included.

Recommendation

We considered the limited available evidence regarding patients with pre-existing pneumonia or sepsis undergoing SSRF/SSSF. There is insufficient data to characterize the rate of subsequent implant infection among those with pneumonia or sepsis at the time of SSRF or SSSF. Because there were no direct comparisons of antibiotic regimens within the identified literature, the optimal duration and route of antibiotic therapy to minimize the risk of implant infection among patients with pneumonia or sepsis undergoing SSRF or SSSF remains unknown. Antibiotic route and duration may be directed according to existing recommendations for management of patients with sepsis or pneumonia, although this literature did not directly address patients with chest wall injury (Grade 2C).

Qualitative synthesis

Three studies addressing Clinical Question 3 were identified through the search. Two were case reports and one was a case series. In the previously discussed report from 2018, Ju et al [30], successful surgical stabilization of rib fractures was reported despite colonization of the mediastinum by Candida albicans. Although not a bacterial empyema, cultures from the right pleural and mediastinal chest tubes isolated Candida albicans [30]. After receiving 10 days of antibiotic and antifungal therapy for a concomitant pneumonia, the patient underwent surgical stabilization of five ribs using a bicortical titanium plating system on hospital day 25 [30]. He was able to be weaned from mechanical ventilation within three days of his operation and was discharged to a long-term care facility to complete 28 days of antifungal therapy [30]. He did not have any complications related to his wound or implants [30].

In 2019, Allen et al. [35] reported a successful SSRF in a patient with polymicrobial empyema. A 48-year female was a pedestrian who was struck by a motor vehicle and suffered left diaphragmatic rupture with herniation of the stomach and spleen into the chest, Grade 3 splenic laceration, gastric perforation, and left anterior 3–7 and posterior 5–12 rib fractures [35]. She underwent primary gastric repair, left chest lavage via the diaphragmatic injury, and splenectomy with repair of the diaphragm [35]. Post-operatively, she developed biventricular heart failure due to sepsis and required ECMO [35]. A left empyema was diagnosed on computed tomography (CT), and she underwent video-assisted thoracoscopic surgery with decortication on hospital day seven [35]. Intra-operative culture grew Enterococcus faecium, Enterococcus faecalis, Enterobacter cloacae, and Candida krusei [35]. The patient was continued on broad-spectrum antibiotic and antifungal agents [35]. The patient continued to be in respiratory failure despite maximal non-operative therapy [35]. She underwent SSRF of ribs 5–10 on hospital day 19 using a bicortical plating system. The patient was extubated nine days after SSRF and discharged to home on hospital day 42 [35]. She was prescribed ciprofloxacin and voriconazole to complete a two-month antibiotic course [35]. She did not develop SSI or require implant removal one year after injury [35].

In 2020, Hwee et al. [36] reported a case series of 21 patients who underwent rib fixation using a bicortical titanium plating system after blunt trauma. Most injuries (62%; n = 13) were due to road traffic crashes and 38% (n = 8) of patients had fallen from a height [36]. In five patients (24%) the indication for operation was decortication for empyema, although there was no information provided verifying presence of active infection [36]. There were no cases of wound infection, re-operation or peri-operative mortality with a mean follow-up of 2.7 (range, 2.5–5.8) years [36]. No mention was made of peri-operative, intra-operative, or post-operative antibiotic strategies.

There were two published society guidelines, systematic reviews, or meta-analyses applicable to Clinical Question 3 that did not meet search criteria. In 2017, Shen et al. [37] published the American Association for Thoracic Surgery (AATS) consensus guidelines for the management of empyema. The AATS recommended tissue flaps consisting of pedicled muscle flaps or omentum to fill empyema cavities in which there is space created by incomplete lung expansion or close a bronchopleural fistula [37]. Additionally, thoracoplasty with resection of ribs may be considered in select cases to obliterate the infected pleural space where previous measures (muscle flaps, open window) have failed [37]. For community-acquired empyema a parenteral second- or third-generation cephalosporin (i.e., ceftriaxone) with metronidazole or parenteral aminopenicillin with β-lactamase inhibitor is recommended (i.e., ampicillin-sulbactam) [37]. For hospital-acquired or post-procedural empyema the AATS recommended antibiotic agents active against MRSA and Pseudomonas aeruginosa (i.e., vancomycin, cefepime, and metronidazole or vancomycin and piperacillin-tazobactam [dosed for activity against Pseudomonas aeruginosa]) [37]. Aminoglycosides were not recommended in the management of empyema and the AATS reported there is no role for intrapleural administration of antibiotics agents [37]. The authors recommended choosing antibiotic therapy based on culture results but in the case of anaerobes, continuing anaerobic coverage empirically when the anaerobic cultures are negative [37]. The AATS stated the duration of antibiotic therapy for acute bacterial empyema should be influenced by the organism, adequacy of source control, and clinical response [37]. However, the authors noted a range of two to six weeks of antibacterial therapy for acute empyema reported in the literature, and recommended a minimum of two weeks from the time of drainage and defervescence [37]. Finally, the authors stated that tube thoracostomy should be combined with close CT follow-up to confirm adequacy of drainage [37]. Persistence of any undrained fluid should prompt additional drains or more aggressive management [37].

In 2020, Metsemakers et al. [38] published recommendations on behalf of the Fracture Related Infection (FRI) consensus group of the AO Foundation based on a literature review of local antimicrobial strategies and dead space management in fracture related infection after orthopedic trauma. Although not designed to address empyema specifically, these FRI group recommendations provide guidance on the dual management of orthopedic implants in an infected field when dead space may be present [38]. This group stated that the use of “naked” antibiotic agents (i.e., vancomycin powder) has not been well documented in treatment of fracture-related infection and further research is required prior to recommendation [38]. The authors report that although antimicrobial incorporation of antimicrobial agents in bone grafts is well studied, the optimal carrier, optimal antibiotic, and preferred dose remains poorly defined [38]. The FRI group found that PMMA is the best studied carrier for antibiotic agents but provided guidance that the surgeon must select the correct antimicrobial(s), the state (i.e., liquid or powder), and dosage; the cement type, the use of a porogen, and the mixing method, in combination with the final form and function of the PMMA [38]. Additionally, the FRI group stated that biodegradable ceramics may offer advantages over PMMA because of no need for additional surgery for implant removal and an improved antimicrobial release profile [38]. The FRI-group authors do not provide specific guidance on antimicrobial strategies but note that gentamicin, tobramycin, vancomycin, and clindamycin are commonly used, and stated selection of therapy should be tailored to anticipated organisms and patient comorbidities [38].

Recommendation

We considered the limited available evidence regarding patients with pre-existing empyema undergoing SSRF/SSSF. There are insufficient data to characterize the true rate of subsequent implant infection among those with empyema at the time of SSRF or SSSF. Because there were no direct comparisons of antibiotic regimens within the identified literature, the optimal duration and route of antibiotic therapy to minimize the risk of implant infection among patients with empyema undergoing SSRF or SSSF remains unknown. Antibiotic route and duration may be directed according to existing recommendations for management of patients with an empyema and orthopedic operations in infected fields, although this literature base did not directly address patients with chest wall injury (Grade 2C).

Qualitative synthesis

Three studies addressing Clinical Question 4 were identified through the search. One was a case series, and two were retrospective single-institution studies. In 1978, Thomas et al. [39] published a single-center case series examining four adult patients who underwent operative stabilization of rib fractures for flail chest resulting from blunt trauma, of whom two patients (50%) had open pneumothorax at the time of presentation. The two patients with open chest wounds had a 3 cm² and 10 × 14cm² chest defects, respectively [39]. Patients in this series received stabilization using Jergesen steel plates secured to the fractured rib with 18-gauge wire and chromic suture used to secure adjacent ribs to the plated rib [39]. Intra-operatively, the surgical site was irrigated with an antibiotic solution containing bacitracin and kanamycin [39]. For both patients with open pneumothorax, the interval from injury to surgery was less than one day [39]. Patients with open pneumothoraces survived at least 18 months and six years, respectively [39]. Neither of the two patients with open chest wounds were reported to have developed an implant-related infection [39].

In the previously described study by Junker et al. [29] patients undergoing SSRF deemed high-risk (i.e., those with pre-hospital tube thoracostomy, open wounds adjacent to the site of SSRF, and pre-operative pneumonia) were treated with prophylactic antibiotic-containing beads. Eight patients were deemed high-risk and had antibiotic-containing beads placed prophylactically, although no mention was made of how many of these high-risk patients had open wounds [29]. Outcomes were similarly not stratified by the presence of open chest wound [29]. This study is limited by its single-center retrospective design, the low incidence of infection within the sample population, and selection bias for placement of antibiotic beads.

In the aforementioned study published by Uchida et al. [31] in 2020, retrospective analysis of patients (or the families of patients) who were previously admitted to a trauma center with multiple rib fractures following blunt traumatic injury who underwent SSRF between 2014 and 2019 was performed. One (5%) patient had extensive flail chest with concomitant open pneumothorax. The patient with open pneumothorax had a post-operative course complicated by acute-phase partial-plate detachment and osteomyelitis that was treated successfully with antibiotics and negative pressure wound therapy; no infection-related explantation was required [31]. Although the study has one of the longest follow-up durations in the literature, it is limited by small numbers from a single site, a lack of comparison groups, and retrospective approach.

There were six published society guidelines, systematic reviews, or meta-analyses applicable to Clinical Question 4 that did not meet search criteria, predominately from the literature describing management of open long bone fractures. In 2006, Hauser et al. [40] published SIS guidelines on prophylactic antibiotic use in open fractures. Although the authors acknowledge limitations in data available at the time, they do recommend a short course of first-generation cephalosporin should be initiated as soon as possible after injury in combination with fracture wound management [40]. The authors also recommend against prophylactic coverage of gram-negative organisms [40]. In 2011, Hoff et al. [41] published Eastern Association for the Surgery of Trauma practice management guidelines for prophylactic antibiotic use in open fractures. The authors recommend that systemic antibiotic therapy with gram-positive coverage be initiated as soon as possible for Gustilo-Anderson type III fractures [41]. High-dose penicillin was recommended in the presence of gross contamination with fecal material or for farm-related injuries. Antibiotic therapy was recommended to be stopped 24 hours after soft tissue coverage, or not more than 72 hours after injury, whichever comes first [41]. Finally, the authors stated that once-daily aminoglycoside dosing was both safe and effective for Gustilo-Anderson type II and III fractures [41].

In the previously discussed IDSA guidelines published by Liu et al. [32] in 2011, skin and soft tissue infections with MRSA were addressed. For hospitalized patients with traumatic wound infections or cellulitis, empirical therapy for MRSA should be considered and can include vancomycin, linezolid, daptomycin, telavancin, or clindamycin, in intravenous formulations if possible [32]. In these patients, seven to 14 days of therapy is recommended [32]. In 2017, Messner et al. [42] performed a systematic review and meta-analysis assessing existing literature describing duration of antibiotic therapy for open fractures. The authors concluded that in comparative studies, an antibiotic duration of ≤72 hours was favored as prolonged antibiotic treatment (>72 hours) did not offer any protective effect (odds ratio, 0.85; 95% confidence interval [CI], 0.60–1.21) [42]. Even among subgroup analysis of Gustilo-Anderson III fractures, antibiotic durations >72 hours were not beneficial (17.7% ≤ 72 hours vs. 23.5%>72 hours; p = 0.39) [42]. Also in 2017, the previously discussed AATS guidelines recommended tissue flaps consisting of pedicled muscle flaps or omentum to fill cavities in which there is space created by incomplete lung expansion or close a bronchopleural fistula [37]. In another previously discussed study published by Metsemakers et al. [38], local antimicrobial and dead space management strategies after orthopedic trauma were discussed. Although not designed to address the open chest specifically, these FRI group recommendations provide guidance on the dual management of orthopedic implants in an infected field when dead space may be present [38]. The recommendations listed under Clinical Question 3 for empyema are also applicable for Clinical Question 4 for dead space that may be present with an open chest wound.

Recommendation

In formulating our recommendations, we considered the limited available evidence for patients with open or contaminated chest wounds undergoing SSRF or SSSF. There are insufficient data to characterize the true rate of subsequent implant infection among those with open or contaminated chest wall injury at the time of initial SSRF. Because there were no direct comparisons of antibiotic regimens within the identified literature, the optimal duration and route of antibiotic therapy to minimize the risk of implant infection among patients with open or contaminated chest wall injury remains unknown. Antibiotic route and duration may be directed according to recommendations for open fractures, although this literature base did not directly address patients with chest wall injury (Grade 2C).