Empirical therapy for open fractures
For patients with superficial soft tissue infection, see Post-traumatic wounds for antibiotic choice and duration of therapy.
For empirical intravenous therapy of suspected bone infection or deep soft tissue infection contiguous with bone, use:
patients without septic shock and not requiring intensive care support: 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g), 6-hourly
patients with septic shock or requiring intensive care support: 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) administered as a loading dose over 30 minutes. After 3 hours, start a continuous infusion of 16+2 g (child 400+50 mg/kg up to 16+2 g), administered over 24 hours12
If the wound has been immersed in water (eg injuries sustained in a natural disaster, marine injuries, sewage-contaminated 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
PLUS
metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly. metronidazole metronidazole metronidazole
If the patient has sepsis or septic shock (for definitions, see Identifying sepsis or septic shock for adults, or Approach to assessing sepsis or septic shock in neonates and children for neonates, infants and children), or is at increased risk of methicillin-resistant Staphylococcus aureus (MRSA) infection (see Risk factors for infection with methicillin-resistant Staphylococcus aureus), add vancomycin to the above regimens. Use:
vancomycin intravenously; see Vancomycin dosing in adults or Intermittent vancomycin dosing for young infants and children for initial dosing. Loading doses are recommended for critically ill adults. vancomycin vancomycin vancomycin
For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use cefepime and metronidazole with or without vancomycin (as above).
For patients who have had a severe immediate3 hypersensitivity reaction to a penicillin, the cefepime containing regimens 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 patients who have had a severe immediate3 hypersensitivity reaction to a penicillin in whom cefepime is not used, or for patients who have had a severe delayed4 hypersensitivity reaction to a penicillin, who do not have sepsis or septic shock and are at low risk for MRSA infection (see Risk factors for infection with methicillin-resistant Staphylococcus aureus); use:
ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 8-hourly5. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment ciprofloxacin ciprofloxacin ciprofloxacin
PLUS
clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly6. clindamycin clindamycin clindamycin
For patients who have had a severe immediate3 hypersensitivity reaction to a penicillin in whom cefepime is not used, or for patients who have had a severe delayed4 hypersensitivity reaction to a penicillin, who have sepsis or septic shock, or are at increased risk of MRSA infection (see Risk factors for infection with methicillin-resistant Staphylococcus aureus); seek expert advice for treatment choice.
Modify therapy according to the results of culture and susceptibility testing, and the extent of deep tissue involvement. For directed therapy of deep soft tissue and bone infection caused by Staphylococcus aureus, see Directed therapy for native bone and joint infection for antibiotic choice and dosage. For other organisms and polymicrobial infection, seek expert advice.
Patients with deep soft tissue infection contiguous with bone or established bone infection require a longer duration of intravenous antibiotic therapy followed by oral continuation therapy (for the suggested duration of therapy, see Duration of therapy for osteomyelitis or, if there is metalwork present, infected fracture fixation devices).