Do isolated traumatic orbital blow‑out fractures require prophylactic antibiotics when managed non‑operatively, and what peri‑operative antibiotic regimen is recommended if surgical repair or an open contaminated fracture is present?

Antibiotic Management for Traumatic Orbital Blowout Fractures

Prophylactic antibiotics are not indicated for isolated, closed, nonoperative orbital blowout fractures, as multiple studies demonstrate zero infectious complications without antibiotic use.

Nonoperative Management of Isolated Orbital Fractures

No Antibiotics Required for Clean, Closed Fractures

• The largest cohort study (154 patients) showed zero infectious orbital complications in patients managed without prophylactic antibiotics for nonoperative orbital fractures 1
• A prospective study of 268 patients with closed, nonoperative orbital and zygomatic fractures identified no infectious sequelae when antibiotics were excluded 2
• An additional cohort of 172 patients with orbital fractures documented no orbital infections, regardless of antibiotic use 3
• The majority of oculoplastic surgeons (ASOPRS members) do not routinely prescribe prophylactic antibiotics for nonoperative orbital fractures 4

When Antibiotics May Be Considered

• If a concurrent periorbital laceration is present, this represents a contaminated wound requiring therapeutic antibiotics, not prophylaxis 1
• Patients with lacerations were significantly more likely to receive antibiotics (58.8% vs 28.5%) in the largest cohort study 1

Patient Education Instead of Antibiotics

• Educate patients on return precautions for signs of infection (increasing pain, swelling, fever, vision changes) 1
• Offer close follow-up monitoring for the rare but potentially severe infectious complications 1

Perioperative Antibiotics for Surgical Repair

Prophylactic Regimen for Clean Surgical Cases

• Begin antibiotic infusion within 60 minutes before incision and complete before tourniquet inflation 5
• Use a first-generation cephalosporin (e.g., cefazolin) for coverage of Staphylococcus aureus and streptococci 5
• Limit prophylactic antibiotics to no more than 24 hours perioperatively 5
• Single-dose prophylaxis significantly reduces surgical wound infection rates (relative risk 0.4) 5

Therapeutic Antibiotics for Contaminated/Open Fractures

• Open or contaminated orbital fractures require therapeutic antibiotics, not prophylaxis 5
• Start antibiotics as soon as possible, as delay beyond 3 hours increases infection risk 5
• For contaminated wounds, use a first-generation cephalosporin plus an aminoglycoside for gram-negative coverage 5
• Add penicillin if there is soil contamination or tissue damage with ischemia for anaerobic coverage (particularly Clostridium species) 5
• Continue antibiotics for 3 days for less severe contamination or up to 5 days for severe contamination 5

Common Pitfalls to Avoid

• Do not prescribe prophylactic antibiotics for isolated, closed, nonoperative orbital fractures - this exposes patients to unnecessary antibiotic risks without benefit 1, 2
• Among patients who developed orbital cellulitis after orbital fractures, more than 25% had received prophylactic antibiotics, suggesting antibiotics do not prevent this rare complication 4
• Avoid broad-spectrum agents and prolonged courses when antibiotics are indicated; shorter 5-7 day courses are as effective as 10-14 day courses 3
• Do not confuse prophylaxis (for clean wounds) with therapeutic antibiotics (for contaminated wounds) - contaminated wounds require higher doses and longer duration 5
• Antibiotics are not a substitute for proper wound care and debridement in contaminated cases 5