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


Open fractures have a high risk of infection and benefit from both surgical débridement and early antibiotic prophylaxis. There is a clear benefit to the administration of a cephalosporin for gram-positive coverage within 1 hour of presentation after injury. There is no evidence of benefit for the continued administration of antibiotics beyond 24 hours after definitive coverage or débridement and coverage with a sterile dressing. Many institutions continue to usecaminoglycosides as prophylactic gram-negative coverage in severe open fractures. Prophylactic dosing of aminoglycosides has been shown to be relatively safe in patients without other independent risk factors for kidney injury. There are no current data to support routine prophylaxis with aminoglycosides in all open fractures. Fluoroquinolones should be considered in patients with type III open fractures and pre-existing kidney disease or risk factors for acute kidney injury. Vancomycin is being incorporated into prophylaxis protocols to reduce the incidence of community-acquired and nosocomial MRSA infections. Topical vancomycin powder has evidence for efficacy and avoids the risk of nephrotoxicity with intravenous administration, but should not be used without concomitant systemic antibiotic coverage, and optimal dosing has not yet been defined. Aztreonam can be used for gram-negative aerobic coverage in patients with kidney disease and in patients with a penicillin-allergy to avoid overuse of antibiotics covering MDROs. Although MDROs are becoming more prevalent in the community and in the hospital setting, there is inadequate evidence to suggest prophylactic antibiotic treatment can prevent subsequent MDRO infections.