Doctors treating open fractures in patients infected with HIV do not need to be more cautious about opportunistic infections compared with HIV-negative patients. The finding, presented by James Aird of Ngwelezane Hospital at the Fourth South African AIDS conference in Durban this month, follows research conducted in KwaZulu-Natal, South Africa.
Many surgeons who treat open fractures (those which result in skin breakages) are concerned that HIV-infected patients may be at higher risk of developing opportunistic infections. Furthermore, this risk of infection may depend on whether the fracture is fixed internally (by mending the fracture with artificial pins and plates) or externally (by repairing the fracture with external splints, pins or supporting structures).
There are few published articles that describe the effects of HIV on fracture healing; those that do often involve small numbers of patients and are frequently statistically insignificant. However, management of bone fractures in HIV-positive individuals is a significant clinical concern in settings where between one in five and one in three adults is infected with HIV.
A previous study suggested that a four-fold increase in infection rate arises when HIV-patients have internally fixed fractures. The researchers in this study attempted to reproduce and extend this finding by comparing fractures repaired with internal and external fixation in both HIV-positive and HIV-negative patients.
The study involved co-operation from 93 patients with open fractures, who were examined in a dedicated clinic with a follow-up period of between one and five months. The socio-economic backgrounds of the individuals were recorded in order to determine possible external risk factors of infection and each patient was offered an HIV test.
Of the fracture patients, 25 were treated with external fixation and 68 with internal fixation. Twenty-four per cent of the patients tested were found to be HIV-positive, while 15% refused to be tested. Within the HIV-positive group, CD4 counts ranged between 131 and 862 (with a mean of 366). Eleven per cent of the wounds suffered a superficial infection, with a relative risk for HIV of 0.66 (0.15 to 2.9). For external fixators, 44% of the pin sites developed superficial infection that required antibiotics with a relative risk for HIV-positive patients of 1.21 (0.5 to 2.98).
These findings suggest that the risk of serious infection in HIV patients with open fractures (fixed with either internal or external fixation) may not be as high as some previous studies have suggested and, by extension, imply that HIV status does not necessarily need to affect the management of fracture patients, particularly those with higher CD4 counts.
The researchers suggest that a larger and more statistically representative study be conducted.
Aird J et al. Study into wound infection rates in open fractures treated with internal fixation, in relation to HIV co-infection Fourth South African Conference on AIDS, Durban, South Africa, abstract 473, April 2009