Is IV ceftriaxone a good option for a patient with post-operative open reduction internal fixation (ORIF) of a distal tibia-fibula fracture with periwound cellulitis, who was treated 1 month ago with IV Ancef (cefazolin) for the same condition?

From the Guidelines

IV ceftriaxone is not an optimal first-line choice for a patient with post-operative ORIF periwound cellulitis who previously received IV cefazolin for the same condition one month ago. Instead, consider using an anti-staphylococcal agent with broader coverage such as vancomycin (15-20 mg/kg IV every 12 hours) or daptomycin (6-8 mg/kg IV daily), possibly combined with gram-negative coverage depending on clinical assessment, as recommended by the Infectious Diseases Society of America 1. The recurrence of infection after previous treatment with cefazolin suggests either treatment failure, antimicrobial resistance, or inadequate source control. Orthopedic hardware infections often involve biofilm-forming organisms or resistant pathogens that may not respond to ceftriaxone. Additionally, the previous exposure to a first-generation cephalosporin increases the risk of selecting for resistant organisms. Before initiating antibiotics, obtain wound cultures to guide targeted therapy, as cultures from abscesses and other purulent SSTIs are recommended in patients treated with antibiotic therapy 1. Consult infectious disease and orthopedic specialists to evaluate whether the hardware needs removal or revision, as antibiotics alone may be insufficient if the implant is colonized. Treatment duration typically ranges from 2-6 weeks depending on clinical response, pathogen identified, and whether the hardware remains in place. Some key points to consider in the management of this patient include:

• The importance of obtaining wound cultures to guide targeted therapy 1
• The need for broad-spectrum antimicrobial coverage, including consideration of vancomycin or daptomycin for MRSA coverage 1
• The potential for biofilm-forming organisms or resistant pathogens in orthopedic hardware infections
• The importance of consulting infectious disease and orthopedic specialists to evaluate the need for hardware removal or revision. It is also important to note that the patient's previous treatment with IV cefazolin one month ago may have selected for resistant organisms, making it less likely that IV ceftriaxone will be effective in this case. Therefore, a more broad-spectrum antimicrobial agent such as vancomycin or daptomycin should be considered, as recommended by the Infectious Diseases Society of America 1.

From the FDA Drug Label

SKIN AND SKIN STRUCTURE INFECTIONS Caused by Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes, Viridans group streptococci, Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, Morganella morganii,1Pseudomonas aeruginosa, Serratia marcescens, Acinetobacter calcoaceticus, Bacteroides fragilis1or Peptostreptococcus species

IV ceftriaxone is a viable option for the patient with post-operative open reduction internal fixation (ORIF) of a distal tibia-fibula fracture with periwound cellulitis, as it is indicated for the treatment of skin and skin structure infections caused by susceptible organisms, including those commonly found in periwound cellulitis.

• The patient's previous treatment with IV Ancef (cefazolin) 1 month ago does not necessarily preclude the use of ceftriaxone, as the two antibiotics have different spectra of activity and ceftriaxone may still be effective against the causative organisms.
• However, it is essential to consider the potential for antibiotic resistance and to select an antibiotic based on culture and susceptibility results, if available 2.

From the Research

IV Ceftriaxone for Post-ORIF Distal Tibia-Fibula Fracture with Periwound Cellulitis

• IV ceftriaxone is a viable option for treating skin and soft tissue infections, including those caused by staphylococci and streptococci 3.
• The patient's previous treatment with IV Ancef (cefazolin) 1 month ago may not be directly relevant to the current infection, as the causative organisms may have changed or developed resistance.
• A study comparing IV cefazolin plus oral probenecid to IV ceftriaxone plus oral placebo for moderate-to-severe cellulitis found that both regimens were effective, with clinical cure rates of 86% and 96%, respectively 4.
• Ceftriaxone has a broad spectrum of activity against Gram-positive and Gram-negative aerobic and anaerobic bacteria, making it a suitable option for treating periwound cellulitis 5.

Considerations for Treatment

• The patient's current infection may be caused by different organisms than the previous infection, and IV ceftriaxone may be effective against these organisms.
• The use of IV ceftriaxone may be convenient due to its long half-life, allowing for once-daily administration 3, 5.
• However, it is essential to consider the potential for antibiotic resistance and the need for susceptibility testing to ensure the chosen antibiotic is effective against the causative organisms.

Additional Factors to Consider

• A study on deep surgical site infections after ankle fractures treated by ORIF found that age, current smoking status, chronic heart disease, and lower preoperative albumin level were independently associated with infection occurrence 6.
• Another study found that IV cefazolin achieves sustained high interstitial concentrations in open lower extremity fractures, suggesting that cefazolin may be effective in preventing infections in these cases 7.