Antibiotic Prophylaxis in Open Fractures: A quick review
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An open fracture is any fracture accompanied by a break in the skin that communicates with the fracture or its associated hematoma. To date, the Gustilo-Anderson classification is the most widely accepted classification system for open fractures and is often used to dictate antibiotic management. Limitations have been described with this system, leading to alternatives such as the Orthopaedic Trauma Association Open Fracture Classification systems (OTA-OFC).

Concern for infection motivates the use of prophylactic antibiotics because traumatic injuries are responsible for up to 19% of cases of osteomyelitis. However, pathogens demonstrate seasonal and geographic variation, as well as variation with fracture severity. It is not surprising that confusion exists when discussing appropriate antibiotic management of open fracture patients with regard to both types of antibiotics and duration of use.

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 use aminoglycosides 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.