What medications are used to manage open wounds?

Medications for Managing Open Wounds

For open wounds, systemic antibiotics are the primary medication intervention, with selection based on wound classification and contamination level, while topical antimicrobials like silver sulfadiazine are reserved for burn wounds specifically.

Systemic Antibiotic Therapy by Wound Classification

Open Fractures (Gustilo-Anderson Classification)

Grade I and II Open Fractures:

• First-line: Cefazolin (first- or second-generation cephalosporin) targeting Staphylococcus aureus, streptococci, and aerobic gram-negative bacilli 1, 2, 3
• Alternative: Ciprofloxacin for broad-spectrum coverage with good oral bioavailability 1
• Duration: 3 days from injury 1
• Critical timing: Must start within 3 hours of injury—delays beyond this significantly increase infection risk 1, 2

Grade III Open Fractures:

• First-line: Piperacillin-tazobactam as single agent (preferred by current guidelines) 2
• Traditional alternative: Cefazolin PLUS aminoglycoside (gentamicin) for enhanced gram-negative coverage 1
• Alternatives to aminoglycosides: Third-generation cephalosporins or aztreonam 1
• Duration: 5 days from injury or up to 48-72 hours post-injury but no more than 24 hours after wound closure 1, 3
• Add penicillin for soil contamination/farm injuries to cover anaerobes (especially Clostridium species) 1, 3

Contaminated/Dirty Wounds (Non-Fracture)

Superficial Infections (Impetigo, Erysipelas, Cellulitis):

• Oral therapy for 7 days with agents active against S. aureus: 1
  • Methicillin-susceptible: Dicloxacillin or cephalexin 1
  • MRSA suspected/confirmed: Doxycycline, clindamycin, or trimethoprim-sulfamethoxazole 1

Simple Abscesses/Boils:

• Incision and drainage is primary treatment—antibiotics NOT recommended for simple abscesses 1
• Add antibiotics only if systemic signs present (fever, tachycardia, abnormal WBC) or immunocompromised 1

Necrotizing Infections:

• Urgent surgical debridement is mandatory—antibiotics are adjunctive only 1
• Broad-spectrum empiric therapy: Vancomycin PLUS piperacillin-tazobactam, ampicillin-sulbactam, or carbapenem 1
• For confirmed clostridial myonecrosis: Penicillin PLUS clindamycin 1

Gunshot Wounds

Low-velocity:

• Antibiotics controversial—no difference in infection rates (3-4%) with or without antibiotics 1
• If used: First-generation cephalosporin for 24-48 hours 1

High-velocity:

• Antibiotics recommended for 48-72 hours 1
• First-generation cephalosporin ± aminoglycoside 1
• Add penicillin if gross contamination present 1

Local/Topical Antibiotic Delivery

Antibiotic-Impregnated Systems (for severe open fractures)

• Indicated for Grade III fractures with bone loss as adjunct to systemic therapy 2, 3
• Options: Antibiotic-impregnated PMMA beads, vancomycin powder, tobramycin-impregnated beads, gentamicin-coated implants 1, 2

Topical Antimicrobials (for burn wounds specifically)

• Silver sulfadiazine cream 1%: Apply once to twice daily to thickness of 1/16 inch, continue until satisfactory healing or ready for grafting 4
• Reapply after hydrotherapy and to areas removed by patient activity 4

Critical Timing and Duration Principles

Administration Timing:

• Open fractures: Start within 3 hours of injury 1, 2, 3
• Surgical prophylaxis: Within 60 minutes before incision 1, 3, 5
• Re-dosing: Cefazolin every 4 hours if surgery prolonged 5

Duration Limits:

• Prophylaxis for closed fractures: Maximum 24 hours perioperatively 1, 3
• Grade I/II open fractures: 3 days 1, 3
• Grade III open fractures: 5 days or 48-72 hours post-injury but stop within 24 hours of wound closure 1, 3

Special Populations

Penicillin Allergy:

• Clindamycin 900 mg IV (first-line alternative) 5
• Vancomycin 30 mg/kg IV over 120 minutes (for severe allergy or MRSA risk) 5
• Note: 90% of patients with reported penicillin allergy can safely receive second/third-generation cephalosporins (true cross-reactivity only 2-5%) 5

Bite Wounds:

• Amoxicillin-clavulanate for coverage of aerobic and anaerobic bacteria 1
• Preemptive therapy for 3-5 days if immunocompromised, asplenic, advanced liver disease, or injuries to hand/face 1

Common Pitfalls to Avoid

• Never delay antibiotics beyond 3 hours for open fractures—infection risk increases significantly 1, 2, 3
• Do not extend prophylactic antibiotics beyond 24 hours without evidence of infection—increases resistance risk 1, 3, 5
• Antibiotics are adjuncts to surgical debridement, not replacements—relying solely on antibiotics without adequate debridement is a major error 3
• Do not use initial wound cultures to guide prophylactic antibiotic choice—infecting pathogens do not correlate with initially cultured organisms 6
• Do not automatically avoid all cephalosporins in penicillin allergy—most patients can safely receive them 5
• Do not add antibiotics to simple abscesses—incision and drainage alone is sufficient 1