Do you prescribe antibiotics in cases of open fractures?

Antibiotic Management in Open Fractures

Yes, antibiotics should be administered promptly in all cases of open fractures to reduce infection risk and improve outcomes related to morbidity and mortality. 1

Antibiotic Selection Based on Fracture Type

Type I and II Open Fractures

• First-line: First-generation cephalosporin (cefazolin 1g IV every 8 hours) 1, 2
• Duration: 3 days 1, 3
• Start time: As soon as possible after injury (delay >3 hours increases infection risk) 1

Type III Open Fractures

• First-line: First-generation cephalosporin PLUS aminoglycoside (gentamicin 5mg/kg IV daily) 1, 4
• Add penicillin for anaerobic coverage in cases with soil contamination or severe tissue damage 1, 4
• Duration: 5 days 1, 3
• Start time: Immediate administration upon presentation 1, 5

Alternative Regimens for Penicillin-Allergic Patients

• Fluoroquinolone (ciprofloxacin 400mg IV every 12 hours or levofloxacin 750mg IV daily) + metronidazole (500mg IV every 8 hours) 4
• OR: Clindamycin (600-900mg IV every 8 hours) for gram-positive and anaerobic coverage 4

Timing of Administration

• Antibiotics should be started as soon as possible after injury 1, 5
• Target administration within 60 minutes of emergency department arrival 5
• Delays beyond 3 hours significantly increase infection risk 1

Additional Considerations

Local Antibiotic Therapy

• Consider antibiotic-impregnated polymethylmethacrylate beads as adjunctive local therapy, especially for type III fractures 1, 4
• Particularly beneficial in fractures with bone loss 3

Special Situations

• For secondary procedures (bone grafting, ORIF, soft tissue transfers), add 72 hours of additional antibiotic therapy 6
• For gunshot wounds: Low-velocity wounds have controversial antibiotic requirements, but high-velocity wounds require 48-72 hours of antibiotic therapy 1

Common Pitfalls to Avoid

1. Delayed administration - Ensure antibiotics are given within 60 minutes of arrival 5
2. Inadequate spectrum - Type III fractures require broader coverage than Type I/II 1
3. Excessive duration - Extending antibiotics beyond recommended durations (3 days for Type I/II, 5 days for Type III) does not improve outcomes and increases resistance risk 3, 7
4. Neglecting local therapy - Consider antibiotic-impregnated beads as adjunctive treatment 1

Recent Evidence Update

The 2022 Surgical Infection Society guidelines recommend against extended-spectrum antibiotic coverage for Type I/II open fractures compared to gram-positive coverage alone. For Type III fractures, they recommend no more than 24 hours of antibiotic therapy in the absence of clinical signs of active infection 3. However, the more established recommendation of 3 days for Type I/II and 5 days for Type III remains the standard practice based on earlier guidelines 1.

Remember that antibiotics are an adjunct to, not a replacement for, thorough surgical debridement and irrigation, which remain the cornerstones of open fracture management.