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

Authors' Institutional Policy

Based on the available evidence, we have recently revised our institution's policy on antibiotic prophylaxis in the setting of an open fracture. The rational for this change was nonstandardized implementation of a previous policy and concern regarding the use of aminoglycosides in polytrauma patients who are already at elevated risk of acute renal injury due to hypotension and hypovolemia.[16,17] The following policy was developed in conjunction with our General Surgery Trauma division and our Pharmacy department and can be seen in Table 2.

The authors' institutional policy is to treat type I and II fractures with 2-gram IV cefazolin immediately and then every 8 hours (3 total doses). Type III fractures are given 2-gram IV ceftriaxone immediately (1 total dose) and 1 gram of IV vancomycin every 12 hours for 24 hours (2 total doses). If patients are allergic to penicillin, they are given 900-mg IV clindamycin immediately and then every 8 hours for 24 hours (3 total doses) for type I and II fractures; for type III fractures, they are given 2 grams of aztreonam every 8 hours for 24 hours (3 total doses) as well as 1 gram of vancomycin at the time of presentation and again 12 hours later (2 total doses). Penicillins are added at the discretion of the surgeon if there is fecal or farm contamination. Cultures are not routinely obtained. Doses are based on average body mass and can be adjusted based on weight as indicated. After débridement, antibiotics are continued or discontinued at the discretion of the treating surgeon based on intraoperative findings. Soft-tissue coverage occurs within 1 week of definitive fixation, provided the wound bed is clean and the patient is able to tolerate the planned procedure. All antibiotics are discontinued 24 hours after definitive wound closure unless there is a documented infection.