Antibiotic Prophylaxis in Open Fractures

Evidence, Evolving Issues, and Recommendations

Matthew R. Garner, MD; Saranya A. Sethuraman, MD; Meredith A. Schade, MD; Henry Boateng, MD


J Am Acad Orthop Surg. 2020;28(8):309-315. 

In This Article

Abstract and Introduction


Open fractures are often associated with high-energy trauma and have an increased risk of infection because of surrounding soft-tissue damage and the introduction of environmental contaminants that may communicate with the fracture site. The Gustilo-Anderson classification of open fractures has been used to guide prophylactic antibiotic therapy because different types of open fracture have been shown to have varying rates of surgical site infections with different combinations of pathogens. Prophylactic treatment with various classes of antibiotics, including penicillins and cephalosporins, aminoglycosides, and fluoroquinolones, has evolved over the past half century. More recently, broader spectrum agents including monobactams and glycopeptides have been used for additional coverage. Duration of antibiotic therapy remains variable between institutions, and antibiotic choice is not standardized. Coverage for nosocomial and multidrug-resistant organisms is an ongoing area of clinical research.


An open fracture is any fracture accompanied by a break in skin that communicates with the fracture or its associated hematoma. To date, the Gustilo-Anderson classification (Table 1) is the most widely accepted classification system for open fractures and is often used to dictate antibiotic management.[1,2] Limitations have been described with this system, leading to alternatives such as the Orthopaedic Trauma Association Open Fracture Classification systems (OTA-OFC).[3] Concern for infection motivates the use of prophylactic antibiotics because traumatic injuries are responsible for up to 19% of cases of osteomyelitis.[4] However, pathogens demonstrate seasonal and geographic variation, as well as variation with fracture severity.[5] It is not surprising that confusion exists when discussing appropriate antibiotic management of open fracture patients with regard to both type of antibiotic and duration of use. The current review discusses today's antibiotic prophylaxis regimens and describes current research into more effective prophylaxis algorithm.