What are the appropriate antibiotics for emergency department discharge in a patient with an open finger fracture?

From the Guidelines

For open finger fractures in the emergency department, I recommend prophylactic antibiotics to prevent infection, with a first-choice recommendation of amoxicillin-clavulanic acid or cloxacillin, as suggested by the WHO Essential Medicines List 1.

Recommended Antibiotics

• For mild infections, amoxicillin-clavulanic acid (500mg orally three times daily) or cloxacillin (250-500mg orally four times daily) can be prescribed for 3-5 days.
• For patients with a penicillin allergy, cefalexin (500mg orally four times daily) is an appropriate alternative.
• In cases of more severe contamination or suspected methicillin-resistant Staphylococcus aureus (MRSA) infection, vancomycin or linezolid can be considered, as recommended by the Infectious Diseases Society of America guidelines 1.

Important Considerations

• Tetanus prophylaxis should also be updated if needed, as open fractures expose bone and soft tissue to environmental contaminants, significantly increasing infection risk.
• Patients should be instructed to complete the full antibiotic course even if symptoms improve and to seek immediate medical attention if signs of infection develop, such as increasing pain, redness, swelling, drainage, or fever.
• The choice of antibiotic should be guided by the severity of the injury, the presence of any allergies, and the suspected causative organisms, with consideration of local resistance patterns and antibiotic stewardship principles 1.

From the Research

Emergency Department Discharge Antibiotics for Open Finger Fractures

• The use of prophylactic antibiotics in open finger fractures is supported by current evidence to decrease infectious complications 2, 3, 4, 5.
• The administration of antibiotics should be performed as soon as possible, and the choice of antibiotic should be based on the type of fracture and patient-specific factors 3, 4.
• For open finger fractures, the use of a cephalosporin, such as cefazolin, is recommended as a first-line treatment 3, 4.
• The duration of antibiotic therapy should be limited to 24 hours after injury, in the absence of clinical signs of active infection, to decrease infectious complications and hospital length of stay 2.
• The amount of fluid used for washout and the type of oral antibiotic used are significant factors in preventing infection, whereas the level of contamination is not a significant factor 6.
• Current practice and recommendations strongly support early systemic antibiotic prophylaxis for patients with open fractures of the extremities, including open finger fractures 5.

Antibiotic Regimens

• Recommended antibiotic regimens for open finger fractures include first-, second-, and third-generation cephalosporins 4.
• Expanded gram-negative coverage is recommended for more severe fractures, and additional anaerobic coverage is required if the open fracture is contaminated with organic or farm-related material 4.
• The choice of antibiotic regimen should be based on patient-specific factors and hospital protocols 4.

Administration of Antibiotics in the Emergency Department

• Administration of intravenous antibiotics and thorough wound cleansing can be performed on open finger fractures in the emergency department under adequate anesthesia 6.
• Most open fractures in the hand do not need to be treated early in the operating theater, and can be managed in the emergency department with proper antibiotic administration and wound care 6.