Acute Application of Antibiotic Powder in Open Fracture Wounds

Study Overview
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Brief Summary
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The purpose of this study is to help determine the best treatment for severe injures like open fracture wounds. Some broken bone injuries can be more likely to get an infection. It is mostly due to the way they were injured. Surgical site infection in the orthopedic surgery population is a big public health issue. Wound infections result in both longer length of hospital stay and total cost of care. This study will be using an antibiotic called Vancomycin or Tobramycin in a powder form.

Detailed Description
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The investigators aim to investigate the effectiveness of preoperative intrawound antibiotic powder in preventing infection and reducing bacterial burden after open fracture. The investigators hypothesize that the participants who receive preoperative intrawound antibiotic powder will have fewer superficial and deep surgical site infections compared to participants who do not receive the antibiotic powder. The investigators also anticipate that the application of the antibiotic powder to open fracture wounds preoperatively will decrease the bacterial burden. Sample swabs will be analyzed using the 16S metagenomics sequencing on the Illumina platform. Both RNA and DNA extracts will be utilized to identify and quantify the bacterial load in the wound bed at the time immediately prior to surgical debridement.

Official Title
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Acute Application Of Intrawound Antibiotic Powder In Open Extremity Fracture Wounds

Conditions
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Fractures, Open, Wounds and Injuries--Infections, Anti-Bacterial Agents, Fractures, Bone, Extremity Fracture Lower, Extremity Fractures Upper

Intervention / Treatment
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* Drug: Vancomycin
* Drug: Tobramycin


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Subject or proxy willing and able to provide written informed consent. Age between 18 years and 80 years (inclusive), with an upper or lower extremity Gustilo Type II, IIIA, or IIIB open fractures requiring debridement and internal fixation. Open extremity fractures Time from injury to study intervention 24 hours or less Exclusion Criteria: Individuals under the age of 18 years or over 80 years Type I or IIIC open fractures Over 24 hours from time of injury Subjects who have received acute operative care of the open fracture at an outside facility prior to presenting at the Emergency Department. Open fractures distal to the wrist and midfoot History of chronic infection in the extremity involved. Subjects who are currently pregnant Subjects who are Prisoners Subjects with a known allergy to vancomycin or tobramycin Subjects with a condition or social circumstances that would reduce adherence and follow-up. Subjects Participating in other clinical research involving investigational antimicrobial products within 30 days of randomization.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: The management of open fractures involves an expedited administration of systemic antibiotics and while effective in reducing the rate of infection, complications from infections are still common following open fractures. This trial aims to evaluate the incidence of surgical site infections using topical vancomycin antibiotic powder or topical tobramycin antibiotic powder in combination with standard of care treatment and to evaluate the effectiveness of both topical antibiotic powders in reducing surgical site infection.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Control<br>Subjects randomized to the Control Arm will receive standard of care open fracture wound care (no powder) by the clinical team. | |
| Experimental: Vancomycin<br>Subjects randomized to the Intervention arm will receive standard of care plus 1 gram of vancomycin powder applied topically to the wound bed before the dressing is applied. Intervention will occur in the emergency room prior to surgical intervention. | Drug: Vancomycin<br>* 1 vial of Vancomycin 1g powder applied topically to the open fracture wound injury.<br>|
| Experimental: Tobramycin<br>Subjects randomized to the Intervention arm will receive standard of care plus 1.2 grams of tobramycin powder applied topically to the wound bed before the dressing is applied. Intervention will occur in the emergency room prior to surgical intervention. | Drug: Tobramycin<br>* 1 vial of Tobramycin 1.2g powder applied topically to the open fracture wound injury.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Incidence of surgical site infection during the post-operative follow-up period | The percentage of participants who develop an infection at the surgical site following debridement and fixation at the follow up period. | Within 6 months of injury date | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Shannon's index measure of bacterial diversity based on wound cultures | Characterize species and determine whether changes in biodiversity differ across study arms. | Within 1 year of injury date | 
| Simpson index measure of bacterial diversity based on the wound cultures | Consider the number of bacterial species present, alongside the relative abundance of each specie across study arms. | Within 1 year of injury date | 
| Presence of bacterial species commonly attributed to surgical site infections based on would cultures including: Staph, enterococcus, acinetobacter, enterobacter, e. coli, klebsiella, and pseudomonas | Understand the changes that occur in the presence of bacterial species associated with surgical site infection after antibiotic powder treatment . | Within 1 year of injury date | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Open fractures, 16S, Antibiotic powder, Vancomycin, Tobramycin, Infection, Gustilo