OPEN FRACTURE

ANTIBIOTIC
RECOMMENDATION
• Antibiotic prophylaxis should be administered as soon as possible following the injury and certainly within 3 h.
• With regards to duration of antibiotic prophylaxis, Gustilo grade I open fractures should not be treated beyond 24
h and certainly not beyond 48 h.
• Gustilo grade II and III fractures, prophylaxis should be continued until definitive soft tissue closure or for a
maximum of 72 h, whichever is shorter. This may have to be modified with regards to timing of debridement.
• It is more difficult to recommend specific antibiotics on the basis of the published evidence. The best evidence
that emerges from this review supports the use of first- generation cephalosporins, of which only cephradine is
still available intravenously in the UK at the time of writing.
• British practice, however, has tended to favour cefuroxime,
• The use of the second-generation cephalosporin cefuroxime is so well entrenched that it
might be difficult to persuade prescribers to use a first-generation cephalosporin such as
cephalothin or cefazolin.
• At present in the UK, however, there is considerable pressure to avoid using cephalos-
porins because of the apparent association with Clostridium difficile-related diarrhoea,
and recommendations promoting the use of cephalosporins may meet with resistance.
• the following protocol is proposed: :

• Co-amoxiclav 1.2 g 8-hourly IV or a cephalosporin such as cefuroxime 1.5 g 8-hourly IV as soon after the injury as possible
and continued until debridement.

• Co-amoxiclav/cephalosporin and gentamicin 1.5 mg/kg at the time of debridement and co-amoxiclav/cephalosporin continued
until definitive soft tissue closure, or for a maximum of 72 h, whichever is sooner.

• Gentamicin 1.5 mg/kg and either vancomycin 1 g or teicoplanin 800 mg on in-duction of anaesthesia at the time of skeletal
stabilization and definitive soft tissue closure. These should not be continued post operatively. The vancomycin infusion
should be started at least 90 min prior to surgery.

• Patients with anaphylaxis to penicillin should receive clindamycin (600 mg IV preop/ qds) in place of
augmentin/cephalosporin. For those with lesser allergic reactions, cefuroxime is considered to be safe and is the agent of
choice.
INTRODUCTION

• Open Fracture are contaminated wounds, and positive cultures are obtained from the
initial wound and surgery culture of 46% to 70% of patient with open fracture
• 1st gen Cephalosporin >> lower infection rate
• Antibiotic resistant organism >> associated with a higher rate of infection
• Positive culture after irrigation and debridement >> associated with a higher rate of
infection
ANTIBIOTIC TIMING

• Patzakis et al --- infection rate of 4.7% (17 in 364 pasien) with open fracture in whom
antibiotic were initiated within 3 hours of injury and 7,4% in whom antibiotic more
than 3 hours injury
• Lack et al --- infection rate of zero in patients with an open fracture in whom
antibiotic were initiated within 66 minutes of injury, and 17% in whome more than 66
minutes.
• Antibiotic should initiated ASAP after injury >> kills and prevent bacteria from
replicating and incresing biologic burden on the wound >> increased risk for infection
CULTURE AND ANTIBIOTIC SELECTION

• Culture are helpful in the selection of antibiotic >> based on initial contamining
organism
• Secondary and Nosocomial contamination result in infection caused by gram-negative
organism >> recommend against gram negative antibiotic coverage.
• AAOS 2018 -- All open fracture are contaminated with gram positive organism only,
assume that all gram negative infection are caused by secondary and nosocomial
contamination.
CONT...

• For gram positive coverage, most studies recommend a first generation Cephalosporin
such as Cefazolin, or Clindamicyn if Betalactam alergy.
• For gram negative coverage, gentamicin, tobramicin and 3rd-5th generation
cephalosporin such as cefepime and ceftriaxon are recommended.
DURATION OF ANTIBIOTIC

• Hoff et al --- antibiotic be discontinued 24 hours after successful wound closure in patient
with type I and type II open fracture.
• for open fracture type III, antibiotic be continued 72 hours post injury or no more than 24
hours after successful soft tissue coverage wound.
General Consensus :
• In type I and II: antibiotic is 24 to 48 hours post injury or 24 hours post wound closure
• type III: antibiotic is 48-72 hours post injury or 24 hours post wound closure
Suggested
treatment
algorithm
Melvin JS, Open Tibial
Shaft Fractures: I and
II, JAAOS, Jan-Feb
2010
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