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Incidence and Predictors of Infections Following Open Fracture Treatment in Northern Tanzania

Article Information

Casto Elilindia Mlay 1,2 *, Rogers Joackim Temu1,2 , Tumaini Fredrick Minja1,2

 1Kilimanjaro Christian Medical University College, P. O. Box 2240 Moshi, United Republic of Tanzania

2Kilimanjaro Christian Medical Centre. P. O. Box 3010   Moshi, United Republic of Tanzania

*Corresponding Author: Dr. Casto Elilindia Mlay, Kilimanjaro Christian Medical University College, P. O. Box 2240 Moshi, United Republic of Tanzania; Kilimanjaro Christian Medical Centre. P. O. Box 3010   Moshi, United Republic of Tanzania

Received: 16 November 2020; Accepted: 23 November 2020; Published: 28 April 2021

Citation: Casto Elilindia Mlay, Rogers Joackim Temu, Tumaini Fredrick Minja. Incidence and Predictors of Infections Following Open Fracture Treatment in Northern Tanzania. Journal of Orthopaedics and Sports Medicine 3 (2021): 039-046.

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Abstract

Background: The burden of open fractures and their subsequent complications is escalating in low and middle-income countries (LMIC’s) due to an increase in motorized transport and underdeveloped trauma care in these countries this result into infections, long term disability. Thus, pose a financial, physiological, social impact and burden to the health care system as well. This study aims to determine the incidence and predictors of infection following open fracture treatment at our center.

 Method: This was a longitudinal cross-sectional hospital-based study conducted at KCMC from October 2018 to April 2019 involving a total of 124 patients with open fractures who were followed for two months after treatment and evaluated for infection by using ASEPISS score and data was analyzed.

Results: This study included a total of 124 study participants. The mean age of the participants was 33 years. The majority 66.1% were living in rural areas, 88.7%, were males and 82.3% of the open fractures were due to road traffic crashes while 59.7% had Gustilo and Anderson grade IIIA, external fixators were the main mode of fracture stabilization 50%. The incidence of infection, after open fracture treatment, was 25.8%. The predictors for infection were Gustilo and Anderson grades, mode of fracture stabilization, fracture pattern, and fracture etiology.

Conclusion: This incidence of infection after open fracture treatment was 25.8%, while predictors of infection in open fractures were fracture patterns, fracture grade, fracture etiology and mode of fracture stabilization should be considered while dealing with an open fracture to reduce the incidence of infection after an open fracture treatment.

Keywords

Open fractures; Infection; Debridement; Tanzania

Open fractures articles; Infection articles; Debridement articles; Tanzania articles

Article Details

1. Introduction

In low and middle income (LMIC’s) like Tanzania open fracture is rapidly escalating due to increased motorized transport with underdeveloped trauma care in these countries hence result in significant morbidity and mortality [4-6]. Open fractures treatment is intending to attain bone union, prevent infection, non-union, and complete functional recovery. Thus, contains early initiation of intravenous antibiotics and early wound debridement with copious irrigation using normal saline, bone stabilization, early soft tissue coverage to overcome complications [7]. This study aims to determine the incidence and predictors of infection after open fracture treatment in our Centre (Kilimanjaro Christian Medical Centre, Tanzania) highlights the magnitude of open fracture related infection and their predictors at our Centre.

2. Method

We conducted a hospital based longitudinal cross-sectional study involved a total of 124 participants conducted at Kilimanjaro Christian Medical Centre (KCMC), Northern Tanzania, from October 2018 and April 2019. KCMC is a zonal referral hospital, catering for around 15 million people. The orthopedic and trauma department is located on the second floor at KCMC is one of the departments within the hospital with 55 bed capacity. All patients admitted with open fractures were enrolled and recruited after obtaining informed consent to participate in the study. Fracture etiology, time of initiation of intravenous antibiotic, open fracture grade, fracture stabilization mode was obtained from the patient’s file.

5th day and 2nd 4th 8th weeks post-operative all patients were assessed for infection using ASEPSIS score, a score of 0-10 was regarded normal wound healing, 10-20 score disturbed wound healing, 21-30 as mild infection, 31-40 score as moderate infection and score of >40 was regarded as severe infection and pus swab culture was taken for isolation of the organism. Data were analyzed using the SPSS version 25 package. Percentages, proportions, mean and tables were used to summarize the study findings. Fisher’s exact tests was used to determine predictors of infection after open fracture treatment and a p-value of ≤0.05 was considered statistically significant.

3. Results

3.1 Characteristics of the study participants

This study included a total of 124 study participants. The mean age of the study participants was 33 (11.9) years.

Characteristics

n (%)

Age (years) (mean (SD))

33 (11.9)

Age (years)

 

< 25

30 (24.2)

25 - 34

46 (37.1)

35 - 44

26 (20.9)

45 - 54

12 (9.7)

≥ 55

10 (8.1)

Residence

 

Rural

82 (66.1)

Urban

42 (33.9)

Sex

 

Male

110 (88.7)

Female

14 (11.3)

Mechanism of injury

 

Road traffic crash

102 (82.3)

Fall from height

8 (6.5)

Assault

6 (4.8)

Industrial / mining accidents

6 (4.8)

Gunshot

2 (1.6)

Table 1:  Social demographic characteristics of the study participants (n=124).

Characteristics

n (%)

Fracture patterns

 

Transverse

38 (30.6)

Oblique

8 (6.5)

Comminuted

70 (56.5)

Segmental

8 (6.5)

Fracture grade

 

I

2 (1.6)

II

22 (17.7)

IIIA

74 (59.7)

IIIB

22 (17.7)

IIIC

4 (3.2)

Time between injury and first antibiotic dose (hours)

 

< 6

58 (46.8)

6 to 12

46 (37.1)

> 12

20 (16.1)

Time between injury and initial wound debridement (hours)

 

< 6

26 (20.9)

6 to 12

54 (43.5)

13 to 24

42 (33.9)

> 24

2 (1.6)

Fracture stabilization

 

Back slab

20 (16.1)

K-wire

20 (16.1)

External fixator

62 (50.0)

Internal fixation e.g. IMN, plate and screws

22 (17.7)

The incidence of infection after an open fracture treatment at KCMC was 25.8% (32).

Table 2: Clinical characteristics of the study participants (n=124).

 

Wound infection

   
 

No

Yes

   
 

n (%)

n (%)

Total

 

Factors

92 (74.2)

32 (25.8)

n (%)

p-value

Fracture patterns

       

Transverse

34 (89.5)

4 (10.5)

38 (100.0)

 

Oblique

4 (50.0)

4 (50.0)

8 (100.0)

 

Comminuted

50 (71.4)

20 (28.6)

70 (100.0)

 

Segmental

4 (50.0)

4 (50.0)

8 (100.0)

0.012

Fracture grade

       

I

2 (100.0)

0 (0.0)

2 (100.0)

 

II

20 (90.9)

2 (9.1)

22 (100.0)

 

IIIA

56 (75.7)

18 (24.3)

74 (100.0)

 

IIIB

12 (54.6)

10 (45.4)

22 (100.0)

 

IIIC

2 (50.0)

2 (50.0)

4 (100.0)

0.036

Time between injury and first antibiotic dose (hours)

     

< 6

44 (75.9)

14 (24.1)

58 (100.0)

 

6 to 12

32 (69.6)

14 (30.4)

46 (100.0)

 

> 12

16 (80.0)

4 (20.0)

20 (100.0)

0.651

Time between injury and initial wound debridement (hours)

   

< 6

20 (76.9)

6 (23.1)

26 (100.0)

 

6 to 12

44 (81.5)

10 (18.5)

54 (100.0)

 

13 to 24

26 (61.9)

16 (38.1)

42 (100.0)

 

> 24

2 (100.0)

0 (0.0)

2 (100.0)

0.161

Fracture stabilization

       

Back slab

16 (80.0)

4 (20.0)

20 (100.0)

 

K-wire

16 (80.0)

4 (20.0)

20 (100.0)

 

External fixator

42 (67.7)

20 (32.3)

62 (100.0)

 

Internal fixation

18 (81.8)

4 (18.2)

22 (100.0)

0.493

Table 3: The predictors of infection after open fractures treatment (n=124).

In this study predictors of infection after open fracture treatment was fracture grade classified by Gustilo and Anderson (p=0.036) and fracture patterns (p=0.012) were significantly associated with infection in long bone open fracture however other factors were not significant with infection. This is shown in Table 3.

4. Discussion

This study included 124 study participants who met the inclusion criteria. The mean age of the participants was 33 years while male was 88.7% and road traffic crashes account for a vast majority 82.3% and 59.7%% had Gustilo and Anderson grade IIIA.

Our findings were similar to other studies done in Brazil, Rwanda and Nigeria they both found the mean age of 31.76 and 31 years and majority were male 78.14% while the leading cause was road traffic crash 74.18%, 71.5%, and   91.4% and Gustilo and Anderson grade III represent the majority of the open fractures [5-7].

In this study, the incidence of infection in open fracture treated at KCMC was 25.8 % (32) the result observed was similar to the study done in Chadi and California they observed the overall incidence of infection was 28% and 22.6 %   after open fracture treatment respectively [8, 9].

This study found that fracture patterns and Gustilo and Anderson grade were predictors of infection, comminuted fracture and grade IIIA open fracture had a high number of infections 20 (28.6%) and 18(24.3%) respectively and were statistically significant.

 A similar results observed a high rate of infection IIIA fractures and up to 17% for type IIIB fractures. The overall infection rate was 13–15% in open fracture grade III fractures [10].

Time of initial surgical debridement was not a predictor for infection although patients who had surgical debridement after six hours 6-12 hours had more infection, however, the observation was not statistically significant similar study observe time of surgical debridement was not an independent predictor of infection after open fracture treatment [11].

Time of initiation antibiotic initiation was not associated with infection in contrary to study done in Tanzania found patients who had antibiotics in less than six hours post had less infection 4.8% compared to those who had antibiotics after six hours post injury 7.8%.

 These results could be explained a high resistance pattern to the antibiotic used in the hospital a study at KCMC observed resistance to cefazolin 72.9% and ceftriaxone 51.8% [12, 13].

5. Conclusion

This study found that the incidence of infection was 25.8%, after open fracture treatment while predictors of infection in open fractures were fracture patterns, fracture grade, fracture etiology and mode of fracture stabilization should be considered while dealing with an open fracture to reduce the incidence of major complications.

Acknowledgments

We would like to thank the nurses in the Orthopedic and trauma department at Kilimanjaro Christian Medical Centre for their support in data collection. We would also like to thank all colleagues, specialists, and consultants in the Department of Orthopedic and Trauma for their input on this study.

Disclosure

The authors report no conflicts of interest in this work.

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