Antibiotic prophylaxis for open fractures

Administer antibiotic prophylaxis as soon as possible, ideally within 3 hours of injury. Duration of prophylaxis depends on injury severity; the Gustilo–Anderson system of classifying injury severity is widely used and, despite intra-observer variability, correlates with infection rate.

Prophylaxis for nonsevere injuries comparable to Gustilo–Anderson type I or II (open fractures resulting from indirect injury or direct, low-energy injury) can be discontinued at definitive wound closure. Do not continue prophylaxis for more than 24 hours after definitive closure of a severe injury comparable to Gustilo–Anderson type III (including open fractures resulting from high-energy injury or exhibiting high-energy fracture patterns [severe comminution or segmental bone loss] with extensive soft tissue injury, or a traumatic amputation). Regardless of injury severity, the total duration of prophylaxis should be no more than 72 hours, even if soft tissue coverage is not achievable.

Note: The total duration of prophylaxis should be no more than 72 hours.

For prophylaxis, use:

cefazolin 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see cefazolin dosage adjustment. cefazolin cefazolin cefazolin

If the wound has been immersed in water (eg injuries sustained in a natural disaster, marine injuries), use:

cefepime 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see cefepime dosage adjustment. cefepime cefepime cefepime

If there is likely to be a delay in accessing cefepime, give an immediate dose of cefazolin (as above), because the benefit of prophylaxis is greatest when it is given immediately after injury. Switch to cefepime as soon as it is available.

Additional anaerobic activity is recommended for severe injuries that are heavily contaminated with material embedded in bone or deep soft tissues (eg agriculture injuries, injuries involving sewage). For such injuries, add metronidazole to the above regimens. Use:

metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly. metronidazole metronidazole metronidazole

For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, the above regimens are suitable.

For patients who have had a severe immediate¹ hypersensitivity reaction to a penicillin, cefazolin or cefepime (at the dosages above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).

For prophylaxis for patients who have had a severe immediate¹ hypersensitivity reaction to a penicillin in whom cefazolin or cefepime is not used, or for patients who have had a severe delayed² hypersensitivity reaction to a penicillin, use:

clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly³ clindamycin clindamycin clindamycin

PLUS if the wound has been immersed in water

ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 8-hourly⁴. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment. ciprofloxacin ciprofloxacin ciprofloxacin

For patients who have had a severe (immediate or delayed)⁵ hypersensitivity reaction to a penicillin, who have adequate oral absorption and can tolerate oral therapy; use:

clindamycin 450 mg (child: 10 mg/kg up to 450 mg) orally, 8-hourly clindamycin clindamycin clindamycin

PLUS if the wound has been immersed in water

ciprofloxacin 750 mg (child: 20 mg/kg up to 750 mg) orally, 12-hourly⁴ ⁶. For dosage adjustment in adults with kidney impairment, see ciprofloxacin oral dosage adjustment. ciprofloxacin ciprofloxacin ciprofloxacin

¹ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

² Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return

³ There are more clinical and microbiological data to support the use of clindamycin than lincomycin. Intravenous lincomycin can be used at the same dosage if clindamycin is unavailable or if a local protocol recommends its use.Return

⁴ Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Ciprofloxacin can be used in children when it is the drug of choice.Return

⁵ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse. Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return

⁶ An oral liquid formulation of ciprofloxacin is not commercially available; for formulation options for children or people with swallowing difficulties, see the Don’t Rush to Crush Handbook, published by the Society of Hospital Pharmacists of Australia [URL].Return