Antibiotic Prophylaxis for Orbital Fractures
Prophylactic antibiotics are not routinely indicated for isolated orbital fractures managed nonoperatively, as high-quality evidence demonstrates no reduction in infectious complications with their use. 1
Evidence Against Routine Antibiotic Use
The strongest and most recent evidence shows that antibiotic prophylaxis provides no benefit for nonoperative orbital fractures:
In a cohort of 154 patients with nonoperative orbital fractures, zero infectious complications occurred in either the antibiotic group (n=17) or the no-antibiotic group (n=137). 1
A separate retrospective study of 172 patients with orbital fractures found no documented orbital infections, regardless of whether patients received antibiotics, with calculated effectiveness boundaries ranging from a Number Needed to Treat of 75 to a Number Needed to Harm of 198. 2
Among 289 patients with nonoperative facial fractures (including orbital fractures), no soft tissue infections occurred in any group—whether receiving no antibiotics, short-term (1-5 days), or long-term (>5 days) prophylaxis. 3
When Antibiotics May Be Considered
If antibiotics are prescribed despite limited evidence of benefit, the following approach is recommended:
For Nonoperative Fractures with Specific Risk Factors:
Concurrent periorbital laceration: Patients with associated soft tissue injury are more likely to receive antibiotics in clinical practice (58.8% vs 28.5%), though infection rates remain zero. 1
Sinus involvement: While commonly prescribed for fractures involving sinus cavities, no evidence supports this practice. 3
Antibiotic Selection (If Used):
First-line agents: Amoxicillin-clavulanate or cephalexin orally are equally effective and most commonly prescribed. 2
Alternative for penicillin allergy: Clindamycin. 3
Duration (If Used):
1-day postoperative course is as effective as 5-day course: In a randomized controlled trial of 60 patients with displaced orbital fractures undergoing surgery, infection rates were identical between 1-day (3.2%) and 5-day (6.8%) antibiotic regimens. 4
Short courses (1-5 days) are preferred over long courses (>5 days) to minimize antibiotic resistance and adverse effects like Clostridium difficile colitis. 2, 3
Critical Caveats and Pitfalls
Patient education is paramount: Rather than prescribing antibiotics, clinicians should educate patients on return precautions (fever, increasing pain, purulent discharge, vision changes) and provide close follow-up for the rare but potentially severe infectious complications. 1
Avoid overmedication: Coordination between trauma teams and specialists is essential to prevent unnecessary antibiotic exposure and resistance. 2
Broad-spectrum agents should be avoided when antibiotics are deemed necessary. 2
Surgical Cases
For orbital fractures requiring surgical repair, the ophthalmology guidelines focus on timing of repair (immediate for muscle entrapment with oculocardiac reflex, within 2 weeks for symptomatic diplopia or large fractures) but do not specifically address antibiotic prophylaxis. 5 Standard perioperative prophylaxis with a first-generation cephalosporin (cefazolin) within 60 minutes of incision would be appropriate based on general surgical principles, with discontinuation within 24 hours postoperatively. 4