What are the recommended prophylaxis and treatment strategies for infection associated with nasal bone fractures?

Infection Prophylaxis and Treatment for Nasal Bone Fractures

Routine antibiotic prophylaxis is not recommended for uncomplicated closed nasal bone fractures, as infection rates are negligible without antibiotics. 1

Closed Nasal Bone Fractures (No Open Wounds)

Evidence Against Routine Prophylaxis

• A retrospective study of 373 patients undergoing closed reduction of nasal bone fractures found zero cases meeting the definition of surgical site infection, regardless of antibiotic use 1
• The 2.1% of infection-related complications (mucosal swelling, synechia, anosmia) occurred exclusively in patients who received antibiotics, suggesting no protective benefit 1
• Nonoperative facial fractures showed no difference in soft tissue infection rates between patients receiving no antibiotics, short-term (1-5 days), or long-term (>5 days) prophylaxis 2

When Antibiotics Are NOT Indicated

• Clean closed reduction procedures performed through the nasal cavity without external incisions 1
• Isolated nasal bone fractures without soft tissue disruption or contamination 2
• Simple fractures regardless of nasal packing use or anesthesia type 1

Open or Contaminated Nasal Bone Fractures

When Prophylaxis IS Indicated

Antibiotics should be administered within 3 hours of injury for open fractures with soft tissue disruption, targeting Staphylococcus aureus, streptococci, and gram-negative organisms. 3

Antibiotic Selection

• First-line: Amoxicillin-clavulanate provides appropriate gram-positive and gram-negative coverage for outpatient management 3
• Penicillin allergy: Clindamycin is the recommended alternative 3
• Farm injuries or gross soil contamination: Add penicillin for anaerobic coverage including Clostridium species 3

Duration of Therapy

• Maximum 48-72 hours for open fractures with contamination 4
• Perioperative dosing should occur within 60 minutes before incision for surgical cases 3
• Extended antibiotic courses beyond 48 hours postoperatively provide no additional benefit in preventing serious infections 5

Frontal Sinus Involvement (High-Risk Scenario)

Critical Timing Considerations

Operative intervention should occur within 48 hours of admission for frontal sinus fractures requiring surgery, as delays beyond this timeframe increase serious infection risk 4-fold. 5

High-Risk Features Requiring Aggressive Management

• Combined posterior table AND nasofrontal outflow tract injury carries a 10.8% cumulative incidence of serious infection (meningitis, brain abscess, frontal sinus abscess, osteomyelitis) 5
• External cerebrospinal fluid drainage catheter use increases infection risk 4.09-fold 5
• Local soft-tissue infection increases risk 5.10-fold 5

Antibiotic Approach for Frontal Sinus Fractures

• Perioperative antibiotics are indicated, but continuation beyond 48 hours postoperatively does not reduce serious infection rates 5
• Surgical debridement and restoration of sinus physiology remain the cornerstone of treatment; antibiotics are adjunctive only 3, 6

Treatment of Established Fracture-Related Infection

Diagnostic Confirmation

• Confirmatory criteria: Sinus tract communicating with bone, wound breakdown exposing bone, purulent drainage, or phenotypically indistinguishable pathogens from ≥2 separate deep tissue specimens 4, 7
• Suggestive criteria: Pain, redness, swelling, fever, elevated inflammatory markers, or radiological signs of implant loosening/bone lysis 4, 7

Management Strategy

• Open the wound and evacuate infected material with continued dressing changes 4
• Obtain appropriate cultures from deep tissue (not superficial swabs) before starting antibiotics 8
• Administer first-line antibiotics: amoxicillin-clavulanate or cephalosporins; for beta-lactam allergies use clindamycin plus gentamicin 4
• Consider imaging studies to assess infection extent 4

Critical Pitfalls to Avoid

• Do not delay operative intervention beyond 48 hours for frontal sinus fractures requiring surgery, as this quadruples infection risk 5
• Do not use superficial wound swabs for culture, as they have low sensitivity and high contamination risk; obtain deep tissue specimens 8
• Do not continue antibiotics beyond 72 hours in the absence of confirmed infection, as this provides no benefit and increases C. difficile risk 2, 5
• Do not rely solely on inflammatory markers for diagnosis, as they may paradoxically increase despite clinical improvement 7