Ryder Practice Guidelines for Open Fracture

Cefazolin 2g IV Q8H for 24 hours
For patients greater than 120 kg give cefazolin 3g

Clindamycin 600mg IV Q8H for 24 hours

Ceftriaxone 2g IV Q24H for up to 72 hours, no more than 24 hours after wound closure

Clindamycin 600mg IV Q8H plus Levofloxacin 750mg IV Q24H for up to 72 hours, no more than 24 hours after wound closure

Piperacillin-tazobactam 3.375g IV Q8H, for up to 72 hours no more than 24 hours after wound closure

Levofloxacin 750mg IV Q24H plus Metronidazole 500mg IV Q8H for up to 72 hours, no more than 24 hours after wound closure

Ceftriaxone 2g IV Q24H plus Doxycycline 100mg IV Q12H

Levofloxacin 750mg IV Q24H

Retrospective review using the trauma registry of adult patients with open femur fractures, open tibia and/or fibula fractures after implementation of a new antibiotic prophylaxis protocol

Duration of treatment: 48 hours

Pre protocol: (n=101)
Type III open fractures- Cefazolin 1g IV Q8H plus gentamicin 1 to 2mg IV Q8H

Protocol change: (n=73)
Type III open fractures- Ceftriaxone

• The skin and soft tissue infection rate per fracture event was 20.8% before and 24.7% after protocol implementation (p = 0.58)
• Most common pathogens were gram positive bacteria
• Most common gram negative pathogens were Pseudomonas and Enterobacter
• No difference in gram negative infections whether or not gentamicin was administered

Retrospective case-control study to assess the clinical variables associated with infections in open fractures over a 10 year period (n=1292), all types of open fractures were included

The Orthopedic and Traumatology Service at Geneva University Hospitals, Geneva, Switzerland, is a level 1 trauma center serving a population of approximately 800,000

• The median duration of prophylaxis was three days
• Cefuroxime was the most frequently prescribed antibiotic regimen, followed by augmentin
• Compared with one day of antibiotic treatment, two to three days, four to five days or > five days did not show any significant differences in the infection risk
• Infection in open fractures is related to the extent of tissue damage but not to the duration of prophylactic antibiotic therapy. Even for grade III fractures, a one-day course of prophylactic antibiotics might be as effective as prolonged prophylaxis.

Retrospective single center review of grade III fractures (Urban Level 1 Trauma Center) over a 5 year period

Cephalosporin (52%, n=65) alone versus cephalosporin plus aminoglycoside (48%, n=61)

• Clinical parameters demonstrated no difference in the incidence of SSI, infectious-related hardware removal, HLOS, or ultimate disposition
• No difference between baseline serum creatinine
• Patients in cephalosporin group had a 4% incidence of AKI, while the incidence was 10% of patients in cephalosporin plus aminoglycoside group (p<0.05)

Retrospective comparative cohort study comparing patients with open fractures treated between January 2013-September 2015 (group 1) and April 2016-June 2017). Interventions included a standardized protocol and education prior to the group 2 review. (University of Nebraska Medical Center)

Group 1: Pre intervention group (n=79)
Group 2: Post intervention group (n=80)

• Pre intervention group average antibiotic administration time 97 minutes after arrival versus 46 minutes in the post intervention group (p < 0.0001)
• Average time from evaluation to antibiotic order entry improved from 77 to 26 minutes (p < 0.0001)
• Surgical site infection rates remained similar (16% versus 13%, p=0.6) however operative irrigation and debridement time increased during this period from 320 to 630 minutes

• Cefazolin monotherapy for 24 to 72 hours may be both safe and effective for routine use in open fractures of all types based on the available evidence
• It remains unclear if 24 hours of prophylaxis is as effective as 72 hours for type-III open fractures
• There does not appear to be strong enough evidence at the current time to support prophylaxis with an aminoglycoside or a broader-spectrum cephalosporin. Extended-spectrum prophylaxis with aminoglycosides specifically does not seem to reduce the infection rates, even in Gustilo-Anderson type-III open fractures and may carry the risk of renal toxicity and contribute to antimicrobial resistance.
• Prospective, randomized studies comparing cefazolin and non-aminoglycoside-based regimens (e.g., a third-generation cephalosporin and piperacillin-tazobactam) are needed to further identify the optimal prophylactic strategy in type-III open fractures.
• Results should be interpreted in the context of the risks of bacterial antibiotic resistance. Finally, establishment of formal guidelines and recommendations by professional orthopedic societies for the management of open fractures, including antibiotic prophylaxis, deserves consideration to optimize treatment outcomes.

Level I

• Systemic antibiotic coverage directed at gram-positive organisms should be initiated as soon as possible after injury.
• Additional gram-negative coverage should be added for type III fractures.
• High-dose penicillin should be added in the presence of fecal or potential clostridial contamination (e.g., farm related injuries).
• Fluoroquinolones offer no advantage compared with cephalosporin/aminoglycoside regimens. Moreover, these agents may have a detrimental effect on fracture healing and may result in higher infection rates in type III open fractures.

Level II

• In type III fractures, antibiotics should be continued for 72 hours after injury or not >24 hours after soft tissue coverage have been achieved.
• Once-daily aminoglycoside dosing is safe and effective for types II and III fractures.

Level I

• There are sufficient Class I and II data to conclude that no prophylactic antibiotics are required for open fractures resulting from low-velocity civilian gunshot wounds that do not require open reduction and internal fixation
• There are sufficient Class I and II data to conclude that administration of a first-generation cephalosporin (or similar agent active against gram-positive bacteria) for 24–48 h perioperatively is a safe and effective prophylactic choice in patients with Grade I open fractures

Level II

• There are sufficient Class I and II data to conclude that administration of a first-generation cephalosporin (or similar agent active against gram-positive bacteria) for 48 h perioperatively is a safe and effective prophylactic choice in patients with Grade II and III open extremity fractures

Level III

• There are sufficient Class I, II, and III data to conclude that a single broad-spectrum agent given pre-operatively and extended for 48 hours post-operatively is a safe and effective prophylactic option for patients with Grade II and III open fractures

Other recommendations

• There are insufficient data to conclude that routine empiric prolongation of prophylactic antibiotic use past the initial perioperative period is beneficial in any open fracture