Antibiotic prophylaxis for open fractures: Difference between revisions

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= Gustilo Classification =
== Gustilo Classification ==
* '''Type I''': open fracture with skin '''wound <1cm''' in length and clean

* 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 II: open fracture with a laceration >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
* Type III: open segmental fracture with >10cm wound with extensive soft tissue injury or a traumatic amputation
⚫
*** All '''farm injuries and gunshots''' are automatically at least IIIA
⚫
** IIIA: adequate soft tissue coverage
⚫
** '''IIIB''': significant soft tissue loss with '''exposed bone''' that requires soft tissue transfer to achieve coverage
⚫
*** All farm injuries and gunshots are automatically at least IIIA
⚫
** '''IIIC''': associated '''vascular injury''' that requires repair for limb preservation
⚫
** 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:
** Special categories:
*** gunshot injuries
*** '''gunshot injuries'''
*** any open fracture caused by a farm injury
*** any open fracture caused by a '''farm injury'''
*** any open fracture with accompanying vascular injury requiring repair
*** any open fracture with accompanying '''vascular injury requiring repair'''

⚫
= Risk of Infection =


⚫
== Risk of Infection ==
* Type I: 0%
* Type I: 0%
* Type II: 2%
* Type II: 2%
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** Type IIIC: 20%
** Type IIIC: 20%


= Management =
== Management ==
⚫
* Don't forget '''tetanus'''!

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


== Further Reading ==
⚫
[[Category:Trauma and surgical infections]]
* Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. ''J Bone Joint Surg Am''. 1976 Jun;58(4):453-8. pmid: [https://www.ncbi.nlm.nih.gov/pubmed/773941 773941]

⚫
[[Category:Trauma and surgical patients]]

Latest revision as of 02:52, 8 February 2022

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

Risk of Infection

  • Type I: 0%
  • Type II: 2%
  • Type III: 6-44%
    • Type IIIA: 2%
    • Type IIIB: 11%
    • Type IIIC: 20%

Management

  • 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

Further Reading

  • Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4):453-8. pmid: 773941
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