This narrative review synthesizes 50 years of evidence on antibiotic prophylaxis for open fractures. It addresses antibiotic class selection, timing, duration, and coverage of resistant organisms, organized around the Gustilo-Anderson classification. The authors also propose an institutional protocol based on current evidence.
Every open fracture patient who arrives in your ED is on a clock: the 66-minute threshold for first-dose cefazolin is the most evidence-backed intervention in this entire review.
When the patient arrives, push cefazolin immediately — before imaging, before the trauma surgery consult, before anything else that can wait. This threshold outweighs decisions about which antibiotic to choose or how long to continue it.
When deciding duration, the answer is simple regardless of fracture grade: stop at 24 hours after wound closure for type I and II injuries. For type III injuries, the outer limit is 72 hours after injury or 24 hours after soft-tissue coverage.
For type III fractures in patients at renal risk, substitute fluoroquinolones for aminoglycosides. But avoid fluoroquinolones entirely in children and use caution in patients on warfarin. The authors recommend against routine aminoglycoside use in any open fracture given the nephrotoxicity risk and lack of efficacy evidence.
This narrative review synthesizes 50 years of evidence on antibiotic prophylaxis for open fractures. It addresses antibiotic class selection, timing, duration, and coverage of resistant organisms, organized around the Gustilo-Anderson classification. The authors also propose an institutional protocol based on current evidence.
Every open fracture patient who arrives in your ED is on a clock: the 66-minute threshold for first-dose cefazolin is the most evidence-backed intervention in this entire review.
When the patient arrives, push cefazolin immediately — before imaging, before the trauma surgery consult, before anything else that can wait. This threshold outweighs decisions about which antibiotic to choose or how long to continue it.
When deciding duration, the answer is simple regardless of fracture grade: stop at 24 hours after wound closure for type I and II injuries. For type III injuries, the outer limit is 72 hours after injury or 24 hours after soft-tissue coverage.
For type III fractures in patients at renal risk, substitute fluoroquinolones for aminoglycosides. But avoid fluoroquinolones entirely in children and use caution in patients on warfarin. The authors recommend against routine aminoglycoside use in any open fracture given the nephrotoxicity risk and lack of efficacy evidence.