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Antibiotics in Open Fracture Prophylaxis
Drug | Mechanism of Action | Dose | Adverse Effects | Recommended Fracture Type for Administration | Pearls |
Cefazolin | Bactericidal; inhibition of bacterial cell wall synthesis | Intravenous, 2g (3g if >120 kg), q8h | Hypersensitivity reactions, C. difficile-associated diarrhea, central line infections, nosocomial pneumonia, white patches or sores in the mouth or lips | Type I and II Open Fracture Type III Open Fracture with No Gross Contamination (+ Gentamicin 5mg/kg IV q24h) | Preferred initial antibiotic for open fractures Duration: 24 hours |
Metronidazole | Bactericidal; inhibition of bacterial cell wall synthesis | Intravenous, 500mg, q8h | Hypersensitivity reactions, irritability, sleep problems, depression, headache, rash, constipation, nausea, mouth sores | Type I and II Open Fracture Type I and II Open Fracture with Soil or Feces Contamination (+ Penicillin G 4 milion units IV, q4h) | Duration: 24 hours |
Clindamycin | Bacteriostatic; binds to the 50s ribosomal subunit of bacteria | Intravenous, 900 mg, q8h | Hypersensitivity reactions, C. difficile-associated diarrhea, nausea, vomiting, stomach pain, mild skin rash, vaginal itching or discharge | Type I and II Open Fracture Type III Open Fractures with No Gross Contamination (+ Levofloxacin 500mg IV, q24h) Type III Open Fractures with Soil or Feces and Standing Water Contamination and patient is acutely intoxicated with severe PCN allergy (+ Levofloxacin 500mg IV, q24h) | Preferred antibiotic for severe beta-lactam allergy |
Vancomycin | Bactericidal; Inhibits cell wall synthesis by binding to the D-Ala-D-Ala terminal of the growing peptide chain during cell wall synthesis | Intravenous, 15mg/kg, q12h | Hypersensitivity reactions, bitter taste to the tongue, red neck or red man syndrome related to infusion rate, low blood pressure, eosinophilia, rash, bloody urine or stool, tinnitus | Type I and II Open Fracture Type I, III, III Open Fracture in patients with known MRSA colonization | Preferred initial antibiotic for patients with known MRSA colonization and/or severe PCN allergy |
Levofloxacin | Bactericidal; inhibition of bacterial topoisomerase IV and DNA gyrase | Intravenous, 500mg, q24h | Increased pressure in the skill, tinnitus, severe headaches, nausea, dizziness, psychosis, convulsions, tremors, confusion, agitation | Type I and II Open Fracture Type III Open Fractures with Soil or Feces and Standing Water Contamination and patient is acutely intoxicated with severe PCN allergy (+ Metronidazole 500mg IV, q8h) | Most bactericidal quinolone |
Ceftriaxone | Bactericidal; inhibits the mucopeptide synthesis in the bacterial cell wall | Intravenous, 2g, q24h | 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 | Type III Open Fracture with No Gross Contamination Type III Open Fracture with Soil or Feces Contamination (+ Metronidazole 500mg IV, q8h, + Pencillin G 4 million units IV, q4h) | Duration: 24-72 hours but not more than 24 hours after wound closure Consider infectious diseases consult |
Piperacillin-Tazobactam | Bacteriostatic; inhibition of bacterial cell wall synthesis by binding to penicillin binding proteins | Intravenous, dosed per policy and is adjusted based on renal function | 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 | Type III Open Fractures with Soil or Feces Contamination and patient is acutely intoxicated (Change to Ceftriaxone + Metronidazole when intoxication is resolved) Type III Open Fracture with Standing Water Contamination | Duration: 24-72 hours but not more than 24 hours after wound closure Consider infectious diseases consult |