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Lesson 10 of13
In Progress

Type 3 Open Fracture Antibiotics

Jimmy November 20, 2021

Antibiotic Recommendations for Grade 3 Open Fractures


Type III Open Fractures with No Gross Contamination

Ceftriaxone

  • Mechanism of Action: Bactericidal; inhibits the mucopeptide synthesis in the bacterial cell wall
  • Dose: Intravenous, 2g, q24h
  • Pharmacokinetics: Elimination half-life of ceftriaxone is 5.8-8.7 hours
  • Contraindications: Hemolytic anemia, liver problems, diseases of the gal bladder, severe renal impairment
  • Adverse Effects: Hypersensitivity reactions, black or tarry stools caused by C. difficile-associated diarrhea, chest pain, shortness of breath, unusual tiredness or weakness, sores or white spots on the lips or mouth, swollen glands
  • Pearls: Duration: 24-72 hours but not more than 24 hours after wound closure
  • Spectrum of Activity:
    • Staphylococcus aureus (methicillin susceptible), Coagulase negative Staphylococci, Streptococcus pneumoniae (penicillin susceptible), Streptococcus spp., Haemophilus influenzae, Moraxella catarrhalis, Neisseria meningitides, Neisseria gonorrhoeae, Enterobacteriaceae, E.coli

Or

Administer Cefazolin 2g IV, q8h + Gentamicin 5mg/kg IV q24h

  • For Severe PCN allergy, administer:

Clindamycin 900mg IV q8h + Levofloxacin 500mg IV q24h


Type III Open Fractures with Soil or Feces Contamination


  • Administer Ceftriaxone 2g IV, q24h + Metronidazole 500mg IV, q8h +/- Penicillin G 4 million units IV, q4h;
    • Duration: 24-72 hours but not more than 24 hours after wound closure
    • Consider infectious diseases consult
  • For patients with Severe PCN allergy, administer:

Levofloxacin 500mg IV q24h + Metronidazole 500mg IV, q8h

  • For Acutely intoxicated patients, administer:

Piperacillin/Tazobactam 4.5g IV q8h (Change to Ceftriaxone + Metronidazole when intoxication is resolved)

  • For Acutely intoxicated patients with Severe PCN allergy, administer:

Clindamycin 900mg IV, q8h + Levofloxacin 500mg IV, q24h

  • For patients with known MRSA colonization in injury, administer:

+ Vancomycin 15mg/kg IV, q12h


Type III Open Fractures with Standing Water Contamination

Piperacillin-Tazobactam

  • Mechanism of Action: Bacteriostatic; inhibition of bacterial cell wall synthesis by binding to penicillin binding proteins
  • Dose: Intravenous, dosed per policy and is adjusted based on renal function
  • Pharmacokinetics: Half-lives are 1.14 hours for Piperacillin and 0.92 hours for Tazobactam
  • Contraindications: Low blood potassium, low seizure threshold, low neutrophil count
  • Adverse Effects: Hypersensitivity reactions, diarrhea – most common, bladder pain, burning upper abdominal or stomach pain, changes in urination, fever or sweating, blurred vision, pain or burning sensation on extremities, nausea, inconsistent heartbeat
  • Pearls: Duration: 24-72 hours but not more than 24 hours after wound closure; Consider infectious diseases consult
  • Spectrum of Activity
    • Staphylococcus aureus (methicillin susceptible), Coagulase negative Staphylococci, Streptococcus pneumoniae (penicillin susceptible), Streptococcus spp., Haemophilus influenzae, Moraxella catarrhalis, Neisseria meningitides, Neisseria gonorrhoeae, Enterobacteriaceae, E. coli, Pseudomonas aeruginosa, Clostridium sp, Prevotella bivia(Bacteroides), fusobacterium necrophorum, Prevotella intermedius.

  • For Severe PCN allergy, administer:

Levofloxacin 500mg IV q24h + Metronidazole 500mg IV, q8h

  • For Acutely intoxicated patients with Severe PCN allergy, administer:

Clindamycin 900mg IV, q8h + Levofloxacin 500mg IV, q24h

  • For patients with known MRSA colonization in injury, administer:

+ Vancomycin 15mg/kg IV, q12h