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American Association for Hand Surgery

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Antibiotic Prophylaxis and Infectious Complications in Isolated Upper Extremity Gunshot Wounds
Danielle Jere Brown, BS, MS, MD1, Rachael Marie Payne, MD1, Amelia C Van Handel, M.D.2, Kevin G Shim, MD, PhD1, David Chi, MD, PhD3, Damini Tandon, MD1, Adam G Evans, M.D.4 and Mitchell A Pet, M.D.5, (1)Washington University in St. Louis, Saint Louis, MO, (2)Washington University, St. Louis, MO, (3)Washington University Medical Center, Division of Plastic and Reconstructive Surgery, St. Louis, MO, (4)Vanderbilt University Medical Center, Nashville, TN, (5)Washington University School of Medicine, Saint Louis, MO

Introduction: Prophylactic antibiotics are variably prescribed after isolated upper extremity gunshot wounds (GSWs). While prescribing patterns may be influenced by several clinical factors, the risk of infection is poorly understood, and little evidence is available to guide practice.

Materials & Methods: All adult patients discharged from our level 1 trauma center and emergency department over a ten year period were included in this retrospective study. Patients were excluded if they were hospitalized for more than 48 hours. The medical record was reviewed for demographic and injury variables, surgical treatments, antibiotic administration, infectious complications, and follow-up duration. Bivariate and multivariable linear regression were used to identify patient and injury related factors predictive of prophylactic antibiotic prescription and risk factors associated with infection at the site of the GSW.

Results: 281 patients were eligible for inclusion (Table 1). Included patients were predominantly young, non-white, male, and without comorbidity. Injury level was bimodal with most injuries occurring at the shoulder or hand level; ballistic fractures were common (51%). Prophylactic antibiotics were prescribed at discharge for 111 patients (40%). Multivariable analysis revealed that patients with more distal injuries and ballistic fractures were significantly more likely to receive prophylactic antibiotics. Among the 125 patients with at least 30-day post-injury follow-up, 8 (6%) developed infections at the GSW site. Among the explanatory variables examined (demographics, comorbidity, injury level, ballistic fracture, operative treatment, and prophylactic antibiotic administration) none was found to have a significant relationship with the outcome of infectious complication.

Conclusion: We treated 281 patients with isolated upper extremity GSW and prescribed prophylactic antibiotics to 40% of this group with a bias towards patients with more distal injuries and ballistic fractures. Among the 125 patients with available follow-up, 6% developed infection. Neither antibiotic prescription nor any other clinical variable examined was predictive of infection risk. We conclude that infections are relatively uncommon after isolated upper extremity GSW. Our prophylactic antibiotic prescribing practices have been relatively inconsistent, and it is not clear that prophylactic antibiotics reduce the risk of infection in this population. A large, randomized study of prescribing or foregoing antibiotic prescription in this common clinical situation would be useful to promote good antibiotic stewardship and reduce unnecessary prescribing.

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