From the Guidelines
For open fractures, a broad-spectrum antibiotic regimen is recommended, typically including cefazolin or clindamycin, with the addition of gram-negative coverage with an aminoglycoside for Gustilo/Anderson Type III (and possibly Type II) open fractures, as supported by the most recent and highest quality study 1. The choice of antibiotic depends on the severity of the fracture and contamination, with cefazolin 2g IV every 8 hours for 24-72 hours being a common recommendation.
- For patients with penicillin allergy, clindamycin 600 mg IV every 8 hours for 24-72 hours is a suitable alternative.
- For high-risk injuries, such as farm injuries or contaminated wounds, the addition of gram-negative coverage with an aminoglycoside, such as gentamicin, is recommended.
- The use of local antibiotic strategies, such as vancomycin powder or tobramycin-impregnated beads, may also be beneficial as an adjunct to systemic antibiotics 1. The duration of antibiotic therapy depends on the severity of the fracture and contamination, but generally continues until definitive wound closure.
- Prompt antibiotic administration is crucial to prevent infection, which can lead to serious complications in open fractures, as emphasized by the recent study 1. The choice and duration of antibiotics may be adjusted based on wound severity, patient factors, and local antibiotic resistance patterns.
- It is essential to note that the use of antibiotics should be balanced with the potential risks, including allergies, the emergence of resistance, and clostridium difficile infections, as highlighted in the recent guideline summary 1.
From the FDA Drug Label
The prophylactic administration of Cefazolin for Injection, USP preoperatively, intraoperatively, and postoperatively may reduce the incidence of certain postoperative infections in patients undergoing surgical procedures which are classified as contaminated or potentially contaminated (e.g., vaginal hysterectomy and cholecystectomy in high-risk patients such as those older than 70 years, with acute cholecystitis, obstructive jaundice, or common duct bile stones). The perioperative use of Cefazolin for Injection, USP also may be effective in surgical patients in whom infection at the operative site would present a serious risk (e.g., during open-heart surgery and prosthetic arthroplasty).
Recommended antibiotics for open fracture:
- Cefazolin (2) may be used for perioperative prophylaxis in surgical procedures classified as contaminated or potentially contaminated, which includes open fractures. However, the FDA label does not directly state the use of cefazolin for open fractures. Other antibiotics such as clindamycin (3) may be considered for the treatment of serious infections caused by susceptible anaerobic bacteria, but the label does not specifically mention open fractures.
The FDA label does not provide a direct answer to the question of recommended antibiotics for open fractures.
From the Research
Recommended Antibiotics for Open Fractures
- Cephalosporin and aminoglycoside antibiotics are currently recommended for infection prophylaxis in high-energy open tibial shaft fractures 4
- For type I or II open extremity fractures, gram-positive coverage alone is recommended, whereas for type III open extremity fractures, antibiotic therapy for no more than 24 hours after injury is recommended 5
- A first-generation cephalosporin (e.g., cefazolin) should be administered within 3 hours of initial injury for Grade I and II open fractures, and continued for 24 hours after initial injury 6
- For Grade III open fractures, coverage with an aminoglycoside in addition to a first-generation cephalosporin is recommended, and antibiotics should be continued for 48-72 hours after initial injury but no more than 24 hours after wound closure 6
Specific Antibiotic Regimens
- Cefazolin (1 g) and gentamicin (5 mg/kg) can be given before operation, and antibiotic therapy can be continued for 48 hours after definitive wound closure 4
- Vancomycin (95.8% sensitivity) has been shown to be effective against gram-positive organisms, while amikacin (98.8% sensitivity), meropenem (96.3% sensitivity), and gentamicin (94.2% sensitivity) have been shown to be effective against gram-negative organisms 7