Open Fractures and Antibiotics

Gustilo Classification for Open Fractures

Type I: Open fracture with skin wound < 1 cm and clean

Type II: Open fracture skin laceration > 1 cm without extensive soft tissue damage, flaps, or avulsion

Type III: Open fracture with extensive soft tissue injury or traumatic amputation (includes gun shot wounds and farm injuries)

• IIIA: Adequate tissue coverage
• IIIB: Significant soft tissue loss with exposed bone that will require skin graft
• IIIC: Associated vascular injury requiring repair for limb preservation

Level I Recommendations

• Start systemic antibiotics ASAP and target gram-positive organisms (eg. first generation cephalosporins)
• Add antibiotics for gram-negative fractures for Type III open fractures
• Add high-dose penicillin, if fecal or potential clostridial contamination (e.g. farm-related injuries)
• Fluoroquinolones provide no added benefit compared to the cephalosporin + aminoglycoside combination. Fluoroquinolones may impair fracture healing and result in higher infection rates in type III open fractures.

Level II Recommendations

• Type III fractures: Continue antibiotics for 72 hours post-injury, or not >24 hours after soft tissue coverage achieved
• Once-daily aminoglycoside dosing is safe and effective for type II and III fractures

References

• Hoff WS, Bonadies JA, Cachecho R, Dorlac WC. EAST Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma. 2011 Mar;70(3):751-4. [PubMed]