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Antibiotic Prophylaxis in the Management of Open Fractures

A Systematic Survey of Current Practice and Recommendations

Chang, Yaping, MSc1; Bhandari, Mohit, PhD, MD1; Zhu, Kan Lun, BHSc1; Mirza, Reza Donald, MD1; Ren, Melody, MD2; Kennedy, Sean Alexander, MD2; Negm, Ahmed, MSc, MD1; Bhatnagar, Neera, MLIS1; Naji, Faysal N., BHSc, MPH, MD1; Milovanovic, Lazar, MD3; Fei, Yutong, PhD, MD4; Agarwal, Arnav, BHSc2; Kamran, Rakhshan1; Cho, Sung Min, BHSc2; Schandelmaier, Stefan, MD1,5; Wang, Li, PhD1; Jin, Lin, MPH, MD1; Hu, Shiyun, PhD, MD6; Zhao, Yanping, PhD7; Lopes, Luciane Cruz, PhD8; Wang, Mei, MSc, MD1; Petrisor, Brad, MD1; Ristevski, Bill, MD1; Siemieniuk, Reed A.C., MD1; Guyatt, Gordon H., MD1

doi: 10.2106/JBJS.RVW.17.00197
Evidence-Based Systematic Reviews
Supplementary Content

Background: Evidence with regard to antibiotic prophylaxis for patients with open fractures of the extremities is limited. We therefore conducted a systematic survey addressing current practice and recommendations.

Methods: We included publications from January 2007 to June 2017. We searched Embase, MEDLINE, CINAHL, the Cochrane Central Registry of Controlled Trials (CENTRAL), and the Cochrane Database of Systematic Reviews for clinical studies and surveys of surgeons; WorldCat for textbooks; and web sites for guidelines and institutional protocols.

Results: We identified 223 eligible publications that reported 100 clinical practice patterns and 276 recommendations with regard to systemic antibiotic administration, and 3 recommendations regarding local antibiotic administration alone. Most publications of clinical practice patterns used regimens with both gram-positive and gram-negative coverage and continued the administration for 2 to 3 days. Most publications recommended prophylactic systemic antibiotics. Most recommendations suggested gram-positive coverage for less severe injuries and administration duration of 3 days or less. For more severe injuries, most recommendations suggested broad antimicrobial coverage continued for 2 to 3 days. Most publications reported intravenous administration of antibiotics immediately.

Conclusions: Current practice and recommendations strongly support early systemic antibiotic prophylaxis for patients with open fractures of the extremities. Differences in antibiotic regimens, doses, and durations of administration remain in both practice and recommendations. Consensus with regard to optimal practice will likely require well-designed randomized controlled trials.

Clinical Relevance: The current survey of literature systematically provides surgeons’ practice and the available expert recommendations from 2007 to 2017 on the use of prophylactic antibiotics in the management of open fractures of extremities.

1Department of Health Research Methods, Evidence, and Impact (Y.C., M.B., R.K., S.S., L.J., M.W., R.A.C.S., and G.H.G.), Division of Orthopedic Surgery, Department of Surgery (M.B., B.P., and B.R.), School of Rehabilitation Science (A.N.), Department of Medicine (K.L.Z., R.D.M., and G.H.G.), Health Science Library (N.B.), Division of Vascular Surgery (F.N.N.), Department of Anesthesia (L.W.), and Michael G. DeGroote Institute for Pain Research and Care (L.W.), McMaster University, Hamilton, Ontario, Canada

2Faculty of Medicine (M.R., A.A., and S.M.C.), and Department of Diagnostic Radiology (S.A.K.), University of Toronto, Toronto, Ontario, Canada

3Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada

4Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China

5Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel and University of Basel, Basel, Switzerland

6Cardiovascular and Cerebrovascular Disease Prevention and Control Research Center of Zhejiang Province, Zhejiang Hospital, Hangzhou, Zhejiang, China

7School of Public Health, The University of Hong Kong, Hong Kong, China

8Pharmaceutical Sciences Postgraduate Course, University of Sorocaba (UNISO), Sorocaba, Sao Paulo, Brazil

E-mail address for Y. Chang:

Investigation performed at the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada

Disclosure: There was no source of external funding for this study. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated
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