Supplemental on-line material:
Author
Year
Type
n
Duration of
study
Study Findings
Conclusion
Prospective randomized studies
Patzakis et al.
(20)
Patzakis et al.
(13)
Dellinger et al.
(21)
Braun et al. (22)
1974
Prospective
randomized trial
310 patients
with 333
open
fractures,
255 caused
by direct
trauma vs.
gunshot
2000
Prospective,
double-blind
randomized trial
171 patients
with 203
open
fractures
1988
Prospective,
double-blind
randomized trial
248 patients
with open
long bone
fractures
1987
Prospective,
double-blind
randomized trial
100 patients
with open
fractures
12 months
Cephalothin (10 days of
first-generation
cephalosporin) more
effective vs. penicillinstreptomycin and vs.
placebo (2.3% vs. 9.7%
and 13.9%; p<0.05) in
preventing infection of
open fractures. 62% and
20% of pathogenic
organisms resistant to
penicillin-streptomycin
and cephalothin,
respectively.
12 months
No significant difference
in infection rates with
ciprofloxacin vs.
combination cefamandole
+ gentamicin for Types I
& II fractures (5.8% vs.
6%, p=1.000); but
ciprofloxacin alone
associated with higher
rates of infection in Type
III fractures (31% vs.
7.7%, p=0.079).
2 years
No difference in infection
rates with 1 or 5 days of
cefonicid vs. 5 days
cefamandole (13%, 12%,
13%).
n/a
Reduction in infection rate
with 10 days cloxacillin
vs. placebo (4% vs. 24%,
p<0.05).
Cephalothin is an
effective antibiotic
for prophylactic
therapy of open
fractures due to
direct trauma.
Only broadspectrum
antibiotics that can
be expected to be
effective against
coagulase-positive
Staphylococcus
aureus should be
selected and
guided by
susceptibility tests
to detect resistant
organisms.
Single-agent
antibiotic therapy
with ciprofloxacin
is effective in
treatment of Type
I & II open
fracture wounds.
However, cannot
recommend
ciprofloxacin
alone for Type III
wounds. Can
possibly use
fluoroquinolones
in combination
therapy,
specifically as an
alternate to an
aminoglycoside.
A brief course of
antibiotic
administration is
not inferior to a
prolonged course
of antibiotics for
prevention of
postoperative
fracture-site
infections.
In the treatment of
open fractures
with operative
fixation, the use of
a narrow-spectrum
antibiotic active
against
1
Bergman (23)
Saveli et al. (24)
Benson et al.
(25)
Gustilo,
Anderson (8)
1982
2013
1983
1976
Prospective
randomized trial
90 patients
with various
open
fractures (55
Grade I, 35
Grade II-III)
Prospective
randomized trial
130 patients
with open
fractures
Prospective,
double-blind
randomized trial
82 patients
with open
long bone
fractures
Prospective,
non-randomized
(and retrospective)
352 patients
with open
long bone
fractures
(81% Types
I/II and 19%
Type III)
30 months
No significant difference
in superficial infections
between 2 days of
dicloxacillin vs. benzyl
penicillin vs. placebo.
MRSA predominantly
cultured from patients
receiving penicillin and
dicloxacillin. Gram
negative bacteria were
infrequent. No significant
difference in deep
infections between
antibiotic treatment
groups but significant
difference compared to
placebo (p<0.01).
28 months
No significant difference
in SSI rates for cefazolin
vs. vancomycin +
cefazolin given until 24
hrs after surgical
intervention (15% vs.
19%, p=0.62). Nasal
colonization of methicillin
sensitive S. aureus and
MRSA among the sample
were 20% and 3%,
respectively. S. aureus
caused 55% of the deep
incisional/organ space SSI
(18% MRSA). A
significantly higher rate of
MRSA SSI was observed
among MRSA carriers
compared with noncarriers (33% vs.. 1%,
respectively, p=0.003).
n/a
5 days of clindamycin
(2/34) as effective as
cefazolin (3/42) in open
fracture infection rate.
5 years
Oxacillin + ampicillin IV
for 3 days after surgery or
secondary wound closure
+/- gentamicin if wound
“severely contaminated”.
70.3% with contaminated
wound by positive culture
either on admission or at
wound closure. Eight
staphylococci can
reduce the
frequency of
infections.
There is not a
clear-cut
superiority for
either of the two
antibiotics used. It
might be stated
that penicillin
seems to be better
than no antibiotic
at all and that the
use of
dicloxacillin is a
further
improvement.
There seems to be
no need for broad
spectrum
antibiotics, which
might cause an
ecological
disturbance.
S. aureus nasal
colonization in
trauma patients
with open
fractures is similar
to that of the
general
community. The
addition of
vancomycin to
standard antibiotic
prophylaxis was
found safe, but its
efficacy should be
evaluated in a
larger multiinstitutional trial.
Infection rates not
different with time
of wound closure,
cefazolin vs.
clindamycin, and
internal fixation.
Cephalosporins
(cephalothin and
cefazolin)
appeared to be the
most effective
antibiotics for
prophylaxis after
open fractures –
effective against
2
(2.4%) became infected.
No antibiotic comparison
performed.
Carsenti-Estesse
et al. (10)
1999
Double-blind,
placebocontrolled,
randomized trial
616 patients
from 43
centers with
grade I/II
open leg
fractures
5 years
No difference in infection
between pefloxacin (IV,
single dose) vs.
combination 2 days IV
cefazolin + 3 days oral
oxacillin for Grade I/II
fractures at 3 months
(6.6% vs. 8%, p=0.51).
Protocol included
anaerobic prophylaxis
with penicillin G (2 days)
or metro/ornidazole.
Gram-positives more
prevalent in infection
isolates from pefloxacin
vs. gram-negatives in
combination group. Most
cases were nosocomial
bacteria.
all gram-positive
organisms
including
Staphylococcus
coagulase positive
and negative, and
the majority of E.
coli, Klebsiella,
and Proteus,
excluding
Pseudomonas. We
did not find that
anaerobes were
particularly
significant,
presumably due to
unsatisfactory
culture technique.
No difference
between
pefloxacin vs.
cefazolin +
oxacillin. Infecting
species were those
escaping the
spectrum of
prescribed
antimicrobrial
prophylaxis, and
most infections
isolates were
nosocomial
bacteria.
Longitudinal cohort, retrospective and in vitro studies
Patzakis,
Wilkins
(14)
1989
Longitudinal cohort
1104 open
fractures
2 years
Cephalothin alone (5.6%)
more effective than
penicillin + streptomycin
(10%), and equally
effective as cefamandole
+ tobramycin (4.5%) in
preventing open fracture
infection.
Recommend
starting broadspectrum
antibiotics as soon
as possible after
injury and
continue for 3
days.
3
Dunkel et
al. (26)
Holtom et
al. (27)
2013
2000
Retrospective casecontrol
In vitro
1492
patients with
open
fractures
14 years
No difference with 1 day
of antibiotics vs. 2-3 days
(odds ratio (OR) 0.6 (95%
CI 0.2 to 2.0)), 4-5 days
(OR 1.2 (95% CI 0.3 to
4.9)), or >5 days (OR 1.4
(95% CI 0.4 to 4.4)) in
infection risk for open
fractures. Similar results
with analysis of Grade III
fractures only.
Fluoroquinolones inhibit
osteoblast activity and
fracture healing in vitro;
yet to be demonstrated in
clinical trials.
Infection in open
fractures is related
to the extent of
tissue damage but
not to the
duration of
prophylactic
antibiotic therapy.
Even for grade III
fractures, a oneday course of
prophylactic
antibiotics might
be as effective as
prolonged
prophylaxis.
In vitro and
animal
(Huddleston)
studies have
shown
fluoroquinolones
may inhibit
fracture healing.
Further in vivo
studies are
advocated to
evaluate the
relevance of the in
vitro cytotoxicity
reported here to
bone healing in
orthopaedic
patients.
4