From the Guidelines
For open fractures, the recommended antibiotics are cefazolin or clindamycin for all types, with additional gram-negative coverage using an aminoglycoside for Gustilo/Anderson Type III (and possibly Type II) open fractures, as stated in the most recent guideline summary 1. The choice of antibiotic is crucial in preventing infection and promoting healing in open fractures.
- Cefazolin is a first-line treatment option, with a recommended dose of 2g every 8 hours for adults, adjusted for weight in children.
- Clindamycin is an appropriate alternative for patients with penicillin allergy, with a recommended dose of 600-900mg IV every 8 hours.
- For cases of severe contamination, farm injuries, or aquatic exposure, adding gram-negative coverage with an aminoglycoside, such as gentamicin, is recommended 1.
- The use of local antibiotic strategies, such as vancomycin powder, tobramycin-impregnated beads, or gentamicin-covered nails, may also be beneficial as an adjunct to systemic antibiotics 1. The duration of antibiotic therapy should be tailored to the severity of the contamination, with a recommended course of 24-72 hours after wound closure, depending on the contamination severity 1. It is essential to note that timely surgical debridement remains equally important, as antibiotics alone cannot prevent infection in devitalized or heavily contaminated tissue, and the goal is to prevent osteomyelitis and soft tissue infections that could compromise fracture healing and limb function.
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. In surgery where the occurrence of infection may be particularly devastating (e.g., open-heart surgery and prosthetic arthroplasty), the prophylactic administration of cefazolin for injection may be continued for 3 to 5 days following the completion of surgery.
The recommended antibiotic for an open fracture is cefazolin. The dosage is 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery, and may be continued for 3 to 5 days following the completion of surgery 2.
From the Research
Recommended Antibiotics for Open Fractures
- Cephalosporin and aminoglycoside antibiotics are currently recommended for infection prophylaxis in high-energy open tibial shaft fractures 3
- For Grade I and II open fractures, a first-generation cephalosporin (eg, cefazolin) should be administered within 3 hours of initial injury and be continued for 24 hours after initial injury 4
- Grade III open fractures require coverage with an aminoglycoside in addition to a first-generation cephalosporin within 3 hours of initial injury, and antibiotics should be continued for 48-72 hours after initial injury but no more than 24 hours after wound closure 4
- Ceftriaxone is a safe and effective alternative for open fracture extremity management that offers the advantage of 24-hour dosing and single antibiotic coverage for grade 3 open fractures 5
- Cefazolin plus gentamicin, or cefazolin plus ciprofloxacin can be successfully used for prevention of infection in type IIIA open fractures 6
Duration of Antibiotic Therapy
- Antibiotic therapy should be continued for 48 hours after definitive wound closure for types II and III open tibial shaft fractures 3
- For type III open extremity fractures, antibiotic therapy should be administered for no more than 24 hours after injury, in the absence of clinical signs of active infection 7
- Antibiotics should be continued for 48-72 hours after initial injury but no more than 24 hours after wound closure for Grade III open fractures 4
Special Considerations
- If a fracture is at risk of contamination with clostridium species, such as a farm-related injury, penicillin should be added to the antibiotic regimen 4
- Patients' medication allergy history or reconcile allergy records should be considered when using antibiotics for infection prophylaxis in open fractures 4