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Evidence-based protocol for prophylactic antibiotics in open fractures: Improved antibiotic stewardship with no increase in infection rates

Rodriguez, Lauren MD; Jung, Hee Soo MD; Goulet, James A. MD; Cicalo, Ashley; Machado-Aranda, David A. MD; Napolitano, Lena M. MD

Journal of Trauma and Acute Care Surgery: September 2014 - Volume 77 - Issue 3 - p 400–408
doi: 10.1097/TA.0000000000000398
AAST 2013 Plenary Paper
Editor's Choice

BACKGROUND Evidence-based guidelines for prophylactic antibiotic use in open fractures recommend short-course, narrow-spectrum antibiotics for Gustilo Grade I or II open fractures and broader gram-negative coverage for Grade III open fractures. No studies to date have assessed the impact of these guidelines on infection rates in open fractures. Infection rates before and after the new protocol implementation were examined.

METHODS A new protocol was implemented including antibiotic prophylaxis based on grade of open fracture: Grade I/II fractures, cefazolin (clindamycin if allergy); Grade III fractures, ceftriaxone (clindamycin and aztreonam if allergy) for 48 hours. Aminoglycosides, vancomycin, and penicillin were removed from the protocol. Data for 174 femur and tibia/fibula open fractures (101 preprotocol and 73 postprotocol) were analyzed. Patients who were moribund or managed at another institution for greater than 24 hours were excluded. The National Healthcare Safety Network risk index was used to provide risk adjustment.

RESULTS No significant differences in the study cohorts (preprotocol and postprotocol) were identified for demographics (age, 37.2 [14.8] years vs. 40.0 [17.9] years; male, 71.3% vs. 79.5%) or mechanism of injury (motor vehicle crash, 67.3% vs. 64.4%; other blunt, 28.7% vs. 32.9%; penetrating, 4.0% vs. 2.8%). After protocol implementation, the use of aminoglycoside and glycopeptide antibiotics was significantly reduced (53.5% vs. 16.4%, p = 0.0001). The skin and soft tissue infection rate per fracture event was 20.8% before and 24.7% after protocol implementation (p = 0.58). There was no statistically significant change after stratification for fracture grade, National Healthcare Safety Network risk index, or fracture site. The rate per fracture event of resistant gram-positive and gram-negative organisms (15.8% vs. 17.8%, p = 0.84) and methicillin-resistant Staphylococcus aureus (2.0% vs. 4.1%, p = 0.65) was not different.

CONCLUSION Implementation of an evidence-based protocol for open fracture antibiotic prophylaxis resulted in significantly decreased use of aminoglycoside and glycopeptide antibiotics with no increase in skin and soft tissue infection rates.

LEVEL OF EVIDENCE Therapeutic study, level IV.

Supplemental digital content is available in the article.

From the Departments of Emergency Medicine (L.R.), and Orthopaedic Surgery (J.A.G.), University of Michigan Medical School; University of Michigan (A.C.); and Trauma and Surgical Critical Care (L.M.N.), and Department of Surgery (L.M.N.), University of Michigan Health System (D.A.M.-A.), University Hospital, Ann Arbor, Michigan; Section of Trauma and Acute Care Surgery (H.S.J.), Division of General Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin.

Submitted: November 2, 2013, Revised: June 5, 2014, Accepted: June 6, 2014.

This work was presented at the 72nd annual meeting of the American Association for the Surgery of Trauma, September 18–21, 2013, in San Francisco, California.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: Lena M. Napolitano MD, Trauma and Surgical Critical Care, Department of Surgery, University of Michigan Health System, Room 1C340-UH, University Hospital, 1500 East Medical Dr, SPC 5033, Ann Arbor, MI 48109–5033; email:

© 2014 Lippincott Williams & Wilkins, Inc.