The most important factor to preventing infection in open fractures is time to antibiotics, less than 1 hour from time of injury is ideal.
Summary Chart:
Injury Type | Penicillin Allergic | |
Type 1 and 2 | Ancef | Clinda or Vanc |
Type 3 | Ancef or Ceftriaxone + Gent or Cipro Some institutions: Cefepime + Vanc | Aztreonam + Vanc |
Barnyard Type 3 (Feces or Soil Gross Contamination) | Pip-Tazo or Ceftriaxone + Metro | Levo + Metronidazole* or Clinda + Levo
|
Fresh Water | Fluoroquinolone (Cipro) or 3rd/4th gen cephalosporin | Levo + Metronidazole* or Clinda + Levo |
Saltwater | Doxycycline + Ceftazidime or Fluoroquinolone (Cipro) |
*Can’t use metronidazole with intoxicated folks
Levo 500mg IV q24h
Metro 500mg IV q8h
Ceftriaxone 2gIV q 24h
Vanc 15mg/kg IV q12h
Clinda 900mg IV q8h
Zosyn 4.5g IV q8h
Ancef 2g IV q8 (3g if >120kg)
Gustillo-Anderson Classification for Open Fractures:
Type 1: Laceration <1cm in diameter
Type 2: Laceration >1cm <10cm without signs of high energy (Extensive soft tissue injury despite intact skin)
Type 3: >10cm soft injury (All High Energy open fracture or those with gross contamination regardless of the size of the wound)
Type 3 A: Adequate soft tissue for coverage of fracture
Type 3 B: Inadequate soft tissue coverage, Flap required
Type 3 C: Associated arterial injury requiring repair
Open Fractures
Always Start with Cefazolin (Ancef)
2-grams IV immediately and then every 8 hours
Infection rate after Ancef prophylaxis is markedly lower than compared with other antibiotics
If allergic to Ancef, give Clindamycin or Vancomycin (if high prevalence of MRSA)
Gram-negative coverage for type 3 open fractures
Aminoglycosides
Once daily dose Gentamicin 5mg/kg/d is preferred to decrease risk of acute kidney injury and ototoxicity
Fluoroquinolone if concern for kidney problems
Avoid if on warfarin (can decrease warfarin liver metabolism
Inhibits endochondral ossification (Don’t use in pediatric open fractures)
May inhibit fracture healing in rats (not well defined in adults)
Barnyard Type Injuries (Soil or Feces = Clostridium Species)
High Dose Penicillins for anaerobic coverage
Piperacillin-Tazobactam (Zosyn)
Noninferiority to use as monotherapy instead of Ancef and Gentamicin in type 3 open fractures
Avoids adverse reactions to aminoglycosides (kidney injury and ototoxicity)
Penicillin allergy
Author example of other antibiotic options
Type 1 and 2
Ancef 2g IV immediately then Q8 hours
Penicillin allergic
Clindamycin 900mg IV immediately and q8 hours
Type 3 injuries
Ceftriaxone 2g IV immediately for 1 dose
Vancomycin 1g IV immediately and q12 hours
Penicillin allergy
Aztreonam 2g IV immediately and q8 hours
Vancomycin 1g IV immediately and q12 hours
Duration of Therapy
Type 1 and 2 open fractures
Discontinue antibiotics 24 hours after wound closure in type 1 and type 2 injuries regardless of duration of therapy between presentation and surgery
Type 3 open fractures
Antibiotics for 72 hours after injury or 24 hours after soft-tissue coverage
References:
https://www.ncbi.nlm.nih.gov/pubmed/31851021
https://www.orthobullets.com/trauma/1004/open-fractures-management
https://www.nebraskamed.com/sites/default/files/documents/for-providers/asp/Antibiotic-Prophylaxis-in-Open-Fractures-Guideline.pdf