Start antibiotic treatment as soon as possible.

Providing open fracture patients with antibiotics can reduce their risk of infection. The infection rate is 3% with antibiotics compared to 14% without.¹ Infections can lead to the need for further surgeries, the removal of osteosynthesis materials, and prolonged hospital stays.

• Start antibiotic prophylaxis as soon as possible, preferably within one hour of the accident.
• Start cefazolin in combination with an aminoglycoside or third-generation cephalosporin.
• Treat for at least 24 hours, extending treatment longer than this has not been scientifically proven.

Read the research on the optimal antibiotic treatment for prevention of infection of an open fracture

Who needs antibiotics?

Eventually, everyone gets antibiotics. But it is important to consider that the category of the fracture affects the risk of infection: the higher the Gustillo-Anderson grade, the higher the risk of infection. Take this into account in preparation for surgery and when using other preventative measures to make sure no infection occurs.

In one study, the risk of infection was 7%, 21% and 29% for Gustillo-Anderson grades I, II and III respectively.⁴ Another study reported infection rates of 1.4% 3.6% and 22.7% for grade I, II and III respectively.¹ That study also found a difference in the anatomical location, with a 10% infection rate for open tibial fractures compared to 5.3% for all other anatomical locations combined. 

When should you give antibiotics?

As soon as possible. General recommendations are to aim for within the first hour of the accident, although in remote settings this will not always be feasible.

One study showed that infection rates were lower when antibiotics were given within three hours, with an infection rate of 4.7% compared to 7.4% when therapy was delayed.³

Which antibiotics should you choose?

The antibiotics you choose will mainly cover common skin flora. It is useful to start a second antibiotic to cover hospital-acquired gram-negative infections.

The choice of antibiotics was originally based on Gustillo-Anderson classifications: patients with grade I and II open fractures should receive first grade cephalosporin, and an aminoglycoside should be added for grade III. Other guidelines mention that when there is a risk of contamination with fecal matter or soil, a penicillin should be added.² However, they also say that over time, the bacteria causing infections are changing. 

A fixed protocol helps to minimize variation in care and can help research and communication, so use your local protocol for treatment.