What antibiotics are indicated for gunshot wounds (GSW)?

From the Guidelines

Antibiotics are crucial in the management of gunshot wounds, and a broad-spectrum regimen is recommended to prevent infection, with the specific choice depending on the wound characteristics and patient factors. The use of antibiotics in gunshot wounds is supported by the principles of managing open fractures, as gunshot wounds are classified as a type of open fracture [ 1 ]. For initial treatment, a regimen that includes coverage for Staphylococcus aureus, streptococci, and aerobic gram-negative bacilli is essential.

Key Considerations

• The duration of antibiotic therapy can vary, but for high-velocity gunshot wounds, 48 to 72 hours of antibiotic therapy is recommended [ 1 ].
• The choice of antibiotic should consider the potential for contamination with soil or other materials that may introduce anaerobes, such as Clostridium species, into the wound.
• A first-generation cephalosporin, with or without an aminoglycoside, is often recommended for most patients, but in cases of gross contamination, adding a penicillin to manage anaerobes is advised [ 1 ].
• For patients with penicillin allergies, alternative regimens such as clindamycin with ciprofloxacin can be considered.

Management Approach

• Treatment should begin as soon as possible after injury, ideally within the first hour.
• In addition to antibiotics, proper wound cleaning, debridement of devitalized tissue, and removal of accessible foreign bodies are crucial components of care.
• Once culture results are available, the antibiotic regimen may be narrowed to target specific pathogens, ensuring effective treatment while minimizing unnecessary antibiotic exposure.

From the Research

Antibiotics for Gunshot Wounds

• The use of antibiotics for gunshot wounds (GSW) is a topic of ongoing research, with various studies investigating the efficacy of different antibiotic regimens in preventing infections 2, 3, 4, 5, 6.
• A study published in 2019 found that broad-spectrum antibiotics were often necessary to treat infections in patients with combat-related penetrating craniocerebral gunshot wounds, and recommended the use of initial de-escalation of empiric antibiotic therapy with the broadest-spectrum drugs 2.
• Another study published in 2024 found that prophylactic antibiotics were prescribed in 40% of patients with isolated upper extremity gunshot wounds, but the overall incidence of infection was low (6%) and similar in patients who received antibiotics and those who did not 3.
• A retrospective study published in 2024 found that antibiotic prophylaxis was not associated with a decrease in spinal and paraspinal infections (SPI) after spinal gunshot wounds, but recommended a maximum of 4 days of antibiotics for SPI prophylaxis following GSW 4.
• An observational study published in 2020 found that antimicrobial prophylaxis reduced the risk of in-hospital GSW-related infection by 12-14% in a South African hospital setting 5.
• A review of the literature and current guidelines published in 2024 recommended a 7- to 10-day course of ertapenem or moxifloxacin, with vancomycin if methicillin-resistant Staphylococcus aureus is suspected, for all penetrating trauma in prolonged casualty care, but noted that narrower regimens may be appropriate based on available resources and expertise of treating providers 6.

Specific Antibiotics

• Ertapenem and moxifloxacin are recommended for penetrating trauma in prolonged casualty care 6.
• Vancomycin is recommended if methicillin-resistant Staphylococcus aureus is suspected 6.
• Cefazolin and metronidazole may be appropriate for narrower regimens, with the addition of metronidazole for esophageal or abdominal involvement, or gross contamination of central nervous system trauma 6.
• Levofloxacin is appropriate for ocular trauma 6.