Antibiotic prophylaxis for open fractures

Gustilo Classification

Type I: open fracture with skin wound <1cm in length and clean
Type II: open fracture with a wound >1cm in length without extensive soft tissue damage, flaps, or avulsions
Type III: open segmental fracture with a wound >10cm in length with extensive soft tissue injury or a traumatic amputation
- IIIA: adequate soft tissue coverage
  - All farm injuries and gunshots are automatically at least IIIA
- IIIB: significant soft tissue loss with exposed bone that requires soft tissue transfer to achieve coverage
- IIIC: associated vascular injury that requires repair for limb preservation
- Special categories:
  - gunshot injuries
  - any open fracture caused by a farm injury
  - any open fracture with accompanying vascular injury requiring repair

Don't forget tetanus!
Antibiotic choice
- Cover Gram-positives as soon as possible after injury, e.g. with cefazolin
- Add Gram-negative coverage for type III fractures, e.g. with tobramycin
- Consider adding anaerobic coverage
- For example, one Ontario trauma center uses cefazolin, tobramycin, and metronidazole
- Add high-dose penicillin to cover Clostridium, in the presence of fecal contamination or farm-related injuries
- Fluoroquinolones should be avoided, if possible, due to slowing bone healing
Duration
- Continue for 24 hours after wound closure
- If type III, continue for at least 72 hours post-injury if Type III