Antibiotic Prophylaxis for Facial and Nasal Fractures
Amoxicillin is ordered for facial and nasal fractures primarily to prevent infection when the fracture communicates with the nasal cavity or sinuses, creating a pathway for bacterial contamination—though current evidence suggests this practice may not be necessary in most cases.
Evidence-Based Rationale for Antibiotic Use
When Antibiotics May Be Indicated
Open fractures with soft tissue disruption warrant antibiotic coverage targeting Staphylococcus aureus, streptococci, and gram-negative organisms, similar to other open fracture management 1, 2.
Mandibular fractures with oral cavity communication historically showed infection reduction with perioperative antibiotics (42.2% infection rate without antibiotics vs. 8.9% with cefazolin) 3.
Fractures with gross contamination or open wounds should be covered with a clean dressing and may benefit from prophylactic antibiotics to reduce contamination risk 4.
Current Guidelines Against Routine Prophylaxis
The Surgical Infection Society strongly recommends against prophylactic antibiotics for both operative and non-operative facial fractures in adults, including mandibular and non-mandibular fractures 5.
For non-operative nasal bone fractures, a retrospective study of 373 patients found zero cases of surgical site infection regardless of antibiotic use, with infection-related complications (2.1%) occurring only in the antibiotic group 6.
For non-operative facial fractures involving sinuses, no difference in soft tissue infection rates was found between patients receiving no antibiotics, short-term (1-5 days), or long-term (>5 days) prophylaxis, though one case of C. difficile colitis occurred in the long-term group 7.
Appropriate Antibiotic Selection When Indicated
First-Line Agents
Cefazolin (first-generation cephalosporin) is the gold standard when antibiotics are deemed necessary, administered within 1 hour of surgery and continued no longer than 24 hours postoperatively 8, 3.
Amoxicillin or amoxicillin-clavulanate provides similar gram-positive and some gram-negative coverage, making it a reasonable oral alternative for outpatient management 4, 9.
Penicillin-Allergic Patients
Clindamycin is the recommended alternative for patients with penicillin allergy 2, 7.
Doxycycline or respiratory fluoroquinolones (levofloxacin, moxifloxacin) are additional options for severe allergies 4.
Critical Timing Considerations
Antibiotics should be administered within 3 hours of injury if used, as delays beyond this timeframe significantly increase infection risk in open fractures 1, 2, 10.
Perioperative dosing should occur within 60 minutes before incision for surgical cases 1, 2, 10.
Duration should not exceed 24 hours postoperatively for most facial fractures to minimize unnecessary antibiotic exposure and resistance 5, 8.
Common Clinical Pitfalls
Prescribing prolonged postoperative courses (7-10 days) is not supported by evidence and increases risk of antibiotic-related complications including C. difficile colitis 7.
Routine prophylaxis for closed nasal fractures is unnecessary and may cause more harm than benefit 6.
Using broad-spectrum agents without indication (such as adding aminoglycosides or vancomycin) is not recommended for simple facial fractures 5, 8.
Special Considerations
Dosing adjustments are required for patients with renal impairment (GFR <30 mL/min) when using amoxicillin 9.
Farm-related injuries or gross soil contamination may warrant adding penicillin for anaerobic coverage including Clostridium species 1, 2.
Surgical debridement remains the cornerstone of treatment for contaminated wounds; antibiotics are adjunctive, not a replacement for proper wound management 2, 10.
Clinical Decision Algorithm
For closed, non-operative nasal/facial fractures: No antibiotics recommended 5, 6, 7.
For operative facial fractures without oral/sinus communication: Single perioperative dose of cefazolin (or clindamycin if allergic), discontinued within 24 hours 5, 8, 3.
For open fractures with significant soft tissue injury: Cefazolin or amoxicillin-clavulanate for 24-48 hours maximum, with consideration for local wound care and surgical debridement 1, 2, 8.
For mandibular fractures with oral communication: Perioperative cefazolin or amoxicillin-clavulanate, discontinued within 24 hours postoperatively 5, 8, 3.