Antibiotic Prophylaxis in Open Fractures

Kiri Rolek, PharmD, BCPS; Angela Hewlett, MD; Justin Siebler, MD; Trevor Van Schooneveld, MD

BACKGROUND:
Open fracture are high energy injuries with an increased risk of infection due to potential exposure of
bone and deep tissue to a variety of environmental debris. Infection can lead to serious complications
including nonunion of fractures and osteomyelitis.

DEFINITIONS:
The Gustilo-Anderson classification system is the most commonly used grading system for open
fractures. Fractures are designated as one of three types based on wound size, soft tissue involvement,
contamination, and fracture pattern (Table 1). The category of fracture is determined in the operating
room following debridement.

Table 1: Gustilo-Anderson Classification System

Type I fracture Open fracture with clean wound <1 cm long
Type II fracture Open fracture with laceration >1 cm long without extensive soft-tissue damage
Type III fracture Open segmental fracture, open fracture with extensive soft tissue damage, or
traumatic amputation

RECOMMENDATIONS:
A short course of narrow-spectrum antibiotic prophylaxis is appropriate for type I and II fractures,
whereas broader gram-negative spectrum therapy is warranted for type III fractures depending on the
environment the wound is exposed to.
Typical pathogens causing infections in type I and II fractures are gram positive cocci, including
streptococci and staphylococci.
When there is significant soil or fecal contamination broader spectrum gram negative and
anaerobic coverage is indicated in addition to covering gram positive cocci.
When standing water contaminates the wound pathogens such as Pseudomonas and
Aeromonas are more likely and agents which cover these pathogens are indicated.
Coverage for methicillin-resistant strains of Staphylococcus aureus (MRSA) should be
considered in patients known to be colonized with MRSA.
Antibiotic recommendations based on fracture type are summarized in Table2.

Infectious disease consultation should be seriously considered in type III fractures which are highly
contaminated as prolonged treatment with antimicrobials may be necessary.

Antibiotics should be started as soon as possible after the injury (ideally in the emergency department)
and duration should be based upon the nature of the injury. If severe contamination or infection is
suspected cultures of obviously infected material should be obtained to guide therapy.

Open Fracture Prophylaxis Order Set

An order set entitled Antibiotic Prophylaxis for Open Fracture is available in One Chart and can be
found by typing fracture into the order set search. The purpose of this order set is to guide initial
selection of antibiotics based on fracture type and antibiotic improve adherence to institutional
recommendations.
Table 2: Prophylactic Antibiotic Recommendations
Fracture Prophylactic Antibiotic(s) Duration
Type I and II* Cefazolin 2 g (3 g if patient weight > 120 kg) IV q8h
o Severe -lactam allergy: Clindamycin 900 mg IV q8h
24 hours
o Known MRSA colonization: Add vancomycin 15 mg/kg IV q12h

Type III Ceftriaxone 2g IV q24h

48 hours OR
o Severe -lactam allergy: Levofloxacin 500 mg IV q24h +
No gross 24 hours
clindamycin 900 mg IV q8h
contamination after wound
o Known MRSA colonization: Add vancomycin 15 mg/kg IV q12h
closure
Type III Ceftriaxone 2 g IV q24h + metronidazole 500 mg IV q8h
o Severe -lactam allergy: Levofloxacin 500 mg IV q24h +
Soil or fecal metronidazole 500 mg IV q8h
contamination
o Known MRSA colonization: Add vancomycin 15 mg/kg IV q12h
48 hours
*ID consult recommended
after wound
Type III Piperacillin/tazobactam 4.5 g IV q8h
closure
o Severe -lactam allergy: Levofloxacin 500 mg IV q24h +
Standing water metronidazole 500 mg IV q8h
contamination
o Known MRSA colonization: Add vancomycin 15 mg/kg IV q12h

*ID consult recommended

*Type I or II fractures with contamination should receive therapy as outlined for type III fractures based on the type of
contamination (soil/fecal vs. standing water)

References:
1. Kim PH, Leopold SS. Gustilo-Anderson classification. Clin Orthop Relat Res. 2012;470:3270-4.
2. Rodriguez L, Jung HS, Goulet JA, et al. Evidence-based protocol for prophylactic antibiotics in
open fractures: improved antibiotic stewardship with no increase in infection rates. J Trauma
Acute Care Surg. 2013;77(3):400-8.
3. Hauser CJ, Adams CA Jr, Eachempati SR. Surgical infection society guideline: prophylactic
antibiotic use in open fractures: an evidence-based guideline. Surg Infect (Larchmt).
2006;7(4):379-405.
4. Dunkel N, Pittet D, Tovmirzaeva L, et al. Short duration of antibiotic prophylaxis in open
fractures does not enhance risk of subsequent infection. Bone Joint J. 2013;95-B:831-7.
5. Anderson A, Miller AD, Bookstaver PB. Antimicrobial prophylaxis in open lower extremity
fractures. Open Access Emergency Medicine. 2011:3:7-11.
6. Hoff WS, Bonadies JA, Cachecho R, Dorlac WC. East Practice Management Guidelines Work
Group: update to practice management guidelines for prophylactic antibiotic use in open
fractures. J Trauma. 2011;70(3):751-4

Approved by ASP Subcommittee: March 2016