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Antibiotics in Open Fracture Prophylaxis

Jimmy November 20, 2021
DrugMechanism of ActionDoseAdverse EffectsRecommended Fracture Type for AdministrationPearls
CefazolinBactericidal; inhibition of bacterial cell wall synthesisIntravenous, 2g (3g if >120 kg), q8hHypersensitivity reactions, C. difficile-associated diarrhea, central line infections, nosocomial pneumonia, white patches or sores in the mouth or lipsType 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
MetronidazoleBactericidal; inhibition of bacterial cell wall synthesisIntravenous, 500mg, q8hHypersensitivity reactions, irritability, sleep problems, depression, headache, rash, constipation, nausea, mouth soresType 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
ClindamycinBacteriostatic; binds to the 50s ribosomal subunit of bacteriaIntravenous, 900 mg, q8hHypersensitivity reactions, C. difficile-associated diarrhea, nausea, vomiting, stomach pain, mild skin rash, vaginal itching or dischargeType 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
VancomycinBactericidal; Inhibits cell wall synthesis by binding to the D-Ala-D-Ala terminal of the growing peptide chain during cell wall synthesisIntravenous, 15mg/kg, q12hHypersensitivity 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, tinnitusType I and II Open Fracture   Type I, III, III Open Fracture in patients with known MRSA colonizationPreferred initial antibiotic for patients with known MRSA colonization and/or severe PCN allergy
LevofloxacinBactericidal; inhibition of bacterial topoisomerase IV and DNA gyraseIntravenous, 500mg, q24hIncreased pressure in the skill, tinnitus, severe headaches, nausea, dizziness, psychosis, convulsions, tremors, confusion, agitationType 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
CeftriaxoneBactericidal; inhibits the mucopeptide synthesis in the bacterial cell wallIntravenous, 2g, q24hHypersensitivity 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 glandsType 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-TazobactamBacteriostatic; inhibition of bacterial cell wall synthesis by binding to penicillin binding proteinsIntravenous, dosed per policy and is adjusted based on renal functionHypersensitivity 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 heartbeatType 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 ContaminationDuration: 24-72 hours but not more than 24 hours after wound closure   Consider infectious diseases consult