Preoperative Antibiotics
Utilization of preoperative antibiotics is suggested to prevent SSI in operative treatment of open fractures.
Prevention of Surgical Site Infection After Major Extremity Trauma (2022)
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: ASES, POSNA, AOFAS, IDSA, OTA

Rationale

This recommendation was upgraded from Limited to Moderate. 

Prophylactic antibiotics prior to fracture surgery has become the standard of care for several decades. Surprisingly the data supporting prophylactic antibiotic use in such procedures is at best scarce. In 1970s and 1980s a handful of studies provided support for preoperative antibiotic use in both closed and open fractures (Boyd 1973, Patzakis 1974, Burnett 1980, Gatell 1984, Braun 1987, Buckley 1990).

Notably there are only two studies in open fracture patients (Patzakis 1974, Braun 1987). The study by Braun (1987) is a moderate quality study that compared administration of cloxacillin for 10 days versus placebo for 10 days in only 100 patients with open fractures. This study demonstrated a decrease in combined group of both superficial and deep infections in the cloxacillin arm (p <0.05). If each subgroup deep and superficial infections) is individually compared, the decrease was not significant.

The additional studies available support the use of prophylactic antibiotics and provide additional evidence for upgrading the level of recommendation, on the other hand, they largely fall outside of the scope of this CPG.

Benefits & Harms
Prevention of SSIs is extremely important in open fractures. Use of initial antibiotics can decrease the bioburden of organisms in the wound. On the other hand, indiscriminate use of antibiotics can lead to significant cost, adverse events and emergence of resistant bacteria.

Outcome Importance
Inappropriate use of antibiotics can lead to an increase in antibiotic related adverse events, emergence of resistance and increased morbidity and mortality. However, post-traumatic bone infections can cause suffering and disability in the patient and result in higher medical costs. Therefore, prevention of such infections is crucial.

Cost Effectiveness/Resource Utilization
Antibiotic use must consider cost of the drug, pharmacy time for drug preparation, and nursing time for administration of the drug. Additionally, if there are adverse events or emergence of resistance related to antibiotics, it can lead to prolongation of hospital stay and worse clinical outcomes.

Acceptability
Antibiotics are indicated for prevention of fracture related infections (FRI) and are currently the standard of care.

Feasibility
Intervention has been extensively used and is feasible.

Future Research
Initial antibiotic therapy for prevention of infections in open fractures is the current standard of care. This data has been derived from small scale studies which have shown marginal benefit. A large-scale research study is needed to address the efficacy of antibiotics for prevention of infection in open fractures and the impact of this therapy on emergence of resistance and antibiotic related adverse events.

Additional References Cited in Rationale

  1. Boyd, Robert J.; Burke, John F.; Colton, Theodore A Double-Blind Clinical Trial of Prophylactic Antibiotics in Hip Fractures, The Journal of Bone & Joint Surgery: September 1973 - Volume 55 - Issue 6 - p 1251- 1255
  2. Burnett JW, Gustilo RB, Williams DN, Kind AC. Prophylactic antibiotics in hip fractures. A double-blind, prospective study. The Journal of Bone and Joint surgery. American Volume. 1980 Apr;62(3):457-462.  PMID: 7364818.
  3. Gatell JM, Riba J, Lozano ML, et al. Prophylactic cefamandole in orthopaedic surgery. The Journal of Bone and Joint surgery. American Volume. 1984 Oct;66(8):1219-1222. PMID: 6386819.
  4. Buckley R, Hughes GN, Snodgrass T, Huchcroft SA. Perioperative cefazolin prophylaxis in hip fracture surgery. Canadian Journal of surgery. Journal Canadien de Chirurgie. 1990 Apr;33(2):122-127. PMID: 2268811
  5. Patzakis, Michael J.; Harvey, J. Paul JR.; Ivler, Daniel The Role of Antibiotics in the Management of Open Fractures, The Journal of Bone & Joint Surgery: April 1974 - Volume 56 - Issue 3 - p 532-541