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

Current Treatment Recommendations

Antibiotic Prophylaxis

The Eastern Association for the Surgery of Trauma (EAST) recommends coverage for gram-positive bacteria with systemic antibiotics at the time of presentation for patients with an open fracture.[25] Gram-negative coverage should be added for type III open fractures, and high-dose penicillin should be added for barnyard injuries (ie, those likely to be contaminated with soil or feces).[26] The 2000 EAST guidelines suggest developing specific antibiotic coverage protocols for higher risk injuries such as type IIIB tibia fractures, but specific recommendations are not given.[25] The use of first-generation cephalosporins as soon as possible was also supported in 2011 by the Surgical Infection Society.[10] However, based on the available literature, they were unable to recommend for gram-negative or clostridial coverage.

Intraoperative Wound Cultures

Staphylococcus aureus is the most common cause of surgical site infection after open fracture fixation, while Enterobacter cloacae was the most commonly observed infectious species in baseline wound swabs.[27] Although baseline culture swabs taken intraoperatively from a series of 426 open fractures showed S. aureus was only seen in 3 patients' baseline swabs, it caused 30% of infections.[27] Patients with positive cultures for any organism during initial wound débridement were more likely to develop an infection, with an odds ratio of 1.92. Only 26.9% of those infections were caused by an organism seen on the initial cultures.[27] Although the clinical significance of these data is unclear, routine cultures at the time of injury are still not recommended.