General treatment principles for fracture-related infection: recommendations from an international expert group
General treatment principles for fracture-related infection: recommendations from an international expert group
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DOI：
10.1007/s00402-019-03287-4
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发表时间：
2019-10-29
影响因子：
2.3
通讯作者：
Zimmerli, Werner
中科院分区：
文献类型：
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作者：
Metsemakers, Willem-Jan;Morgenstern, Mario;Zimmerli, Werner
骨折相关感染（FRI）仍然是一个具有挑战性的并发症，给骨科创伤患者、其家属、治疗医生以及医疗保健系统造成了沉重的负担。FRI的诊断标准化程度较差，这给研究的开展和比较带来了困难。最近，一个基于FRI诊断标准的共识定义被发表。由于明确的诊断是FRI治疗过程的第一步，这样的定义不仅应该提高已发表报告的质量，而且应该提高日常临床实践的质量。FRI共识小组最近制定了标准化治疗途径和结果测量的指南。这些建议的核心是多学科团队（MDT）方法的实施。如果没有这样的团队，建议将复杂的病例转诊到有MDT的专业中心，那里的医生对FRI的治疗有经验。这应该导致适当使用抗菌素和标准化的手术策略。此外，MDT可以在主机优化中发挥重要作用。总的来说，考虑了两个主要的手术概念，基于骨折固定装置主要针对骨折巩固，愈合后可以移除，与假体周围关节感染相比，植入物是永久性的。第一个概念包括种植体保留，第二个概念包括种植体移除（愈合骨折）或种植体置换（未愈合骨折）。在这两种情况下，深层组织取样进行微生物检查是强制性的。FRI手术处理的关键方面是彻底清创、生理盐水冲洗、骨折稳定性、死腔处理和足够的软组织覆盖。需要强烈考虑使用局部抗菌剂。对于FRI，应在组织取样后开始经验性广谱抗生素治疗。之后，需要尽快根据培养结果进行调整。最后，建议在停止治疗后至少随访12个月。目前还没有纯粹关注FRI的标准化患者结果测量方法，但患者报告的结果测量信息系统（PROMIS）似乎是评估患者短期和长期结果的首选工具。本文根据FRI共识小组的建议总结了目前FRI患者在整个治疗过程中应考虑的一般原则。
Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients' short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group.