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

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 species, 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