What antibiotics are recommended for an open wrist fracture?

From the Guidelines

For an open wrist fracture, immediate antibiotic therapy with a first- or second-generation cephalosporin is crucial to prevent infection, with the recommended duration of therapy being 3 days for Gustilo-Anderson grade I and II open fractures and up to 5 days for grade III wounds. The choice of antibiotic depends on the likely organisms contaminating the wound, with Staphylococcus aureus, streptococci, and aerobic gram-negative bacilli being the most common infecting organisms for grade I and II open fractures 1.

• Key considerations for antibiotic selection include:
  • First- or second-generation cephalosporins for grade I and II open fractures
  • Addition of an aminoglycoside for more severe injuries to provide better coverage for gram-negative organisms
  • Use of a quinolone, such as ciprofloxacin, as a reasonable alternative due to its broad-spectrum coverage and good adverse-effect profile
  • Addition of penicillin for severe injuries with soil contamination and tissue damage to provide coverage against anaerobes
• The severity of the fracture, as classified by the Gustilo-Anderson system, plays a significant role in determining the duration of antibiotic therapy, with more severe injuries potentially requiring longer courses 1.
• It is essential to note that antibiotics should be started as soon as possible, ideally within 3 hours of injury, and continued for the recommended duration to ensure optimal outcomes.
• Open fractures require urgent surgical debridement along with antibiotic therapy to remove all foreign material and devitalized tissue, as antibiotics alone cannot prevent infection in the presence of foreign material or dead tissue.

From the FDA Drug Label

To prevent postoperative infection in contaminated or potentially contaminated surgery, recommended doses are: 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery. The FDA-approved antibiotic for open wrist fracture is cefazolin (IV), with a recommended dose of 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery 2.

• The dose may be repeated during surgery and for 24 hours postoperatively.
• It is essential to administer the preoperative dose just before the start of surgery to ensure adequate antibiotic levels in the serum and tissues at the time of initial surgical incision.

From the Research

Antibiotic Use for Open Wrist Fractures

• The use of antibiotics for open wrist fractures is a common practice to prevent infection and promote healing 3, 4, 5, 6, 7.
• The choice of antibiotic depends on the grade of the open fracture, with first-generation cephalosporins (e.g., cefazolin) recommended for Grade I and II open fractures, and additional coverage with an aminoglycoside for Grade III open fractures 3, 4.
• The optimal timing and duration of antibiotic administration also vary depending on the grade of the open fracture, with antibiotics typically administered within 3 hours of initial injury and continued for 24-72 hours after initial injury 3, 4.

Specific Antibiotic Recommendations

• Cefazolin is a commonly recommended antibiotic for open wrist fractures, particularly for Grade I and II open fractures 3, 6.
• Ceftriaxone is also a viable option, offering broader coverage and a decreased frequency of administration, and can be used as an alternative to cefazolin for open fracture management 5.
• Vancomycin may be added to the antibiotic regimen for Grade 3 open fractures to provide coverage against methicillin-resistant Staphylococcus aureus (MRSA) 7.

Prehospital Antibiotic Administration

• Prehospital antibiotic administration is recommended for suspected open fractures, with cefazolin being a suitable option for prehospital use due to its ease of administration and low cost 6.
• The administration of prehospital antibiotics should not delay transport to the hospital, and should be performed after the management of life-threatening injuries 6.

Comparison of Antibiotic Regimens

• A retrospective comparison of ceftriaxone plus vancomycin versus cefazolin plus gentamicin for Grade 3 open fractures found no significant difference in treatment failure rates between the two groups, although the trend suggested a lower treatment failure rate in the ceftriaxone plus vancomycin group 7.