From the Guidelines
For open fracture prophylaxis, antibiotic prophylaxis with systemic cefazolin or clindamycin is recommended, except for Type III open fractures, for which additional gram-negative coverage is preferred. The choice of antibiotic should be based on the severity of the fracture and the potential for contamination. According to the most recent guidelines 1, cefazolin is the preferred antibiotic for most open fractures, but for more severe fractures, such as Gustilo type III, additional gram-negative coverage with an antibiotic such as an aminoglycoside may be necessary.
The duration of antibiotic therapy depends on the severity of the fracture, with more complex injuries potentially requiring longer courses. However, the updated Surgical Infection Society guidelines recommend against extended-spectrum antibiotic coverage compared with gram-positive coverage alone to decrease infections complications, hospital length of stay or mortality in type I or II open extremity fractures 1. For type III open extremity fractures, it is recommended to administer an antibiotic therapy for no more than 24 h after injury, in the absence of clinical signs of active infection, to decrease infectious complications, hospital length of stay or mortality.
Some key points to consider when selecting an antibiotic for open fracture prophylaxis include:
- The severity of the fracture and the potential for contamination
- The patient's allergy history and potential for antibiotic resistance
- The need for additional gram-negative coverage in more severe fractures
- The potential benefits and risks of local antibiotic prophylactic strategies, such as vancomycin powder or gentamicin-impregnated beads 1
It is also important to note that antibiotics should be administered as soon as possible after injury, ideally within 3 hours, as delayed administration is associated with higher infection rates. The use of local antibiotics, such as antibiotic beads, may also be beneficial in managing traumatic fractures 1.
From the FDA Drug Label
To prevent postoperative infection in contaminated or potentially contaminated surgery, recommended doses are: 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery. The prophylactic administration of cefazolin for injection may be continued for 3 to 5 days following the completion of surgery.
Cefazolin is recommended for prophylaxis of open fractures, with a dose of 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery 2.
- The prophylactic administration of cefazolin may be continued for 3 to 5 days following the completion of surgery, especially in cases where the occurrence of infection may be particularly devastating 2.
- It is essential to note that cefazolin should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria 2.
From the Research
Antibiotic Prophylaxis for Open Fractures
- The use of antibiotic prophylaxis in open fracture management is strongly supported by the literature 3.
- Cephalosporins are the drugs of choice in cases of orthopaedic trauma due to their broad spectrum of activity 3.
- The extent of the injury determines the appropriate agent and the length of time it should be given 3.
Recommended Antibiotics
- For Type 1 or Type 2 fractures, cephalothin, cefazolin, cefamandole, or cefuroxime are recommended 3.
- For Type 3 fractures, cefuroxime, cefamandole, and cefotaxime are recommended due to their activity against gram-negative organisms 3.
- Ceftriaxone is a safe and effective alternative for open fracture management, offering the advantage of 24-hour dosing and single antibiotic coverage for grade 3 open fractures 4.
Duration of Antibiotic Prophylaxis
- For Type 1 or Type 2 fractures, brief treatment (one preoperative and two postoperative doses) is recommended 3.
- For Type 3 fractures, antibiotic prophylaxis should continue until 48 hours after adequate soft tissue coverage is achieved 3.
- The Surgical Infection Society recommends antibiotic therapy for no more than 24 hours after injury in Type III open extremity fractures, in the absence of clinical signs of active infection 5.