This is an international expert consensus (AO Foundation, EBJIS, OTA, PRO-IMPLANT) synthesizing available evidence and expert opinion on systemic antibiotic selection, dosing, duration, and route of administration for fracture-related infection. It addresses three surgical treatment strategies: DAIR, implant removal after fracture healing, and staged exchange. Most recommendations are based on expert opinion, as no randomized controlled trials exist specifically for antibiotic management of FRI.
Orthopedic surgeons managing infected fractures have historically defaulted to 4–6 weeks of IV antibiotics regardless of context — a practice extrapolated from 1970s osteomyelitis data (Waldvogel et al.) with no RCT support specific to FRI.
This consensus reframes the entire decision. Duration and route are not fixed by tradition. They are determined by two variables: what surgery was done, and whether a biofilm-active drug exists for the organism.
When you retain hardware (DAIR), you need 12 weeks of biofilm-active therapy. When you remove consolidated hardware, you need 6 weeks from removal with an early oral switch. The fixed 2-week IV period is gone.
When staph is your organism, rifampicin combination is mandatory. But start it only after the wound seals, never as monotherapy, and never before a new fixation device is in place. When your organism is Gram-negative, a fluoroquinolone is your biofilm-active drug, but only after debridement has cleared the high-burden wound.
One-third of FRI is polymicrobial with resistance rates up to 30%. Go broad empirically, then narrow fast once cultures return.
This is an international expert consensus (AO Foundation, EBJIS, OTA, PRO-IMPLANT) synthesizing available evidence and expert opinion on systemic antibiotic selection, dosing, duration, and route of administration for fracture-related infection. It addresses three surgical treatment strategies: DAIR, implant removal after fracture healing, and staged exchange. Most recommendations are based on expert opinion, as no randomized controlled trials exist specifically for antibiotic management of FRI.
Orthopedic surgeons managing infected fractures have historically defaulted to 4–6 weeks of IV antibiotics regardless of context — a practice extrapolated from 1970s osteomyelitis data (Waldvogel et al.) with no RCT support specific to FRI.
This consensus reframes the entire decision. Duration and route are not fixed by tradition. They are determined by two variables: what surgery was done, and whether a biofilm-active drug exists for the organism.
When you retain hardware (DAIR), you need 12 weeks of biofilm-active therapy. When you remove consolidated hardware, you need 6 weeks from removal with an early oral switch. The fixed 2-week IV period is gone.
When staph is your organism, rifampicin combination is mandatory. But start it only after the wound seals, never as monotherapy, and never before a new fixation device is in place. When your organism is Gram-negative, a fluoroquinolone is your biofilm-active drug, but only after debridement has cleared the high-burden wound.
One-third of FRI is polymicrobial with resistance rates up to 30%. Go broad empirically, then narrow fast once cultures return.