![]() ![]() Ultimately, no significant increase in infection rate was observed between the two groups (p = 0.58). This single center, prospective/retrospective study enrolled 174 open tibia/fibula fractures and monitored rates of infection in grade III fractures with the standard antibiotic therapy (1st gen cephalosporin + aminoglycoside) vs ceftriaxone monotherapy. Ceftriaxone was chosen due to its broad gram-positive and gram-negative coverage and its long duration of action. In 2014, the University of Michigan published a study proposing ceftriaxone monotherapy (2 grams IV Q24H) for grade III fractures. Unfortunately, many of the alternative regimens studied either carried additional side effects, increased infection rates, or required additional antibiotics to achieve the same infection control. In the last decade, desires for antimicrobial stewardship and concern over the side effects of gentamicin (nephrotoxicity in particular) has prompted clinicians to study alternative antibiotic regimens. Thus, wound cultures are beneficial if a patient develops infection after successfully completing the standard open fracture empiric antibiotic regimen but are of minimal utility in the initial setting. Furthermore, in patients that ultimately develop infections, the isolated microbe(s) is often different than those seen on the initial wound culture. The initial cultures are typically polymicrobial and rarely change the antibiotic regimen. Initial wound cultures are of minimal utility. Longer courses of antibiotics have not shown any additional infection prophylaxis and can lead to the development of drug resistant organisms as well as increase the risk of side effects (drug interactions, organ toxicity, etc). Grade III should receive 72 hrs of IV antibiotics or antibiotics through the first 24 hrs after definitive closure of the wound. Grades I/II receive 24 hours of IV antibiotics. (5) Thus, it is imperative that emergency physicians provide appropriate antibiotics expeditiously to provide the patient the best protection against developing infectious complications.ĭuration of therapy is dependent on the Gustilo-Anderson classification. However, timing of surgery had less impact on preventing infection than administration of antibiotics in the first hour(s) after injury. They found that surgical intervention in the first 24 hours is necessary, preferably in the first 8 hours, provided there were no complicating factors such as vascular injury. (4) Much research has been conducted in the realm of orthopedics to determine the optimal timing of surgery. Due to the patient’s overall stability, need for transport to a referral center, and other factors, it may not be possible for the patient to undergo surgery in the desired 8 hours after their injury. In contrast, 5% of fractures that received antibiotics early in their course developed osteomyelitis. From the literature, approximately 20% of the fractures that receive antibiotics later in their course developed osteomyelitis. Prompt administration of appropriate antibiotics has been shown to drastically reduce the incidence of osteomyelitis. This regimen remained largely unchanged through the rest of the 20th century and into the first decade of the 21st century.Īntibiotics should be given as soon as possible. (3) As a result of these studies, the following antibiotic regimen was proposed: grade I/II fractures receive cefazolin (2 grams IV Q8H) and grade III fractures receive cefazolin (2 grams IV Q8H) + gentamicin (5 mg/kg IV Q24H). In the 1986 study, Gustilo recommended the addition of an aminoglycoside to the treatment regimen for grade III fractures only, preferably gentamicin, extending the gram-negative coverage. Ultimately, first generation cephalosporins were determined to have good antimicrobial coverage for all three injury grades, particularly grades I/II. (2) The resulting antibiotic sensitives informs the antibiotics we use today for empiric treatment. Empiric AntibioticsĪs part of their initial study, Gustilo and Anderson (creators of the Gustilo-Anderson open fracture classification system) obtained wound cultures from each open fracture. Initial management of open fractures is discussed in another post. In this post we will discuss antibiotic recommendations for osteomyelitis prophylaxis for open fractures. (1) Appropriate and timely intervention in the emergency department with proper antibiotic therapy, wound care, and early orthopedic surgery involvement dramatically reduces the risk of developing osteomyelitis. Considered a true orthopedic emergency, these fractures have high morbidity due to osteomyelitis, with infection rates up to 55%. ![]() ![]() In open fractures, the skin barrier has been compromised, exposing sterile bone to the environment. Open fractures are a common pathology seen in emergency departments, especially in trauma centers. ![]()
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