Table 2

Summary of antibiotic recommendations

InjuryAntibiotic recommendationsAdditional considerations
Face and scalp
Open or contaminated facial fracturesProphylactic antibiotics 24 h or less
  • Cefazolin—coverage against GP bacteria

  • Ceftriaxone—broader GN coverage and CNS penetration

  • Ampicillin/sulbactam—broader GN and anaerobic coverage

  • Clindamycin—for penicillin-allergic patients

  • Frontal sinus fracture that involves the posterior table

  • Contaminated fractures

  • Open mandible fractures

Closed or non-contaminated operative facial fracturesPreoperative antibiotics
  • Cefazolin—coverage against GP bacteria

  • Ceftriaxone—broader GN coverage and CNS penetration

  • Ampicillin/sulbactam—broader GN and anaerobic coverage

  • Clindamycin—for penicillin-allergic patients


No postoperative antibiotics
  • Fractures of the upper one-third of the face

  • Frontal sinus fractures that do not involve the posterior table

  • Fractures of the middle one-third of the face (LeFort, zygomaticomaxillary complex, orbital, maxillary sinus, nasal bone)

  • Fractures of the lower one-third of the face (non-dentate segments of mandible)

Non-operative facial fracturesNo prophylactic antibiotics
  • Orbital fractures

  • Upper face fractures

  • Mid-face fractures

  • Mandibular fractures

Facial and scalp lacerationsProphylactic antibiotics 24 h or less if complex or high-risk patient
  • Amoxicillin-clavulanate

  • Clindamycin—for penicillin-allergic patients

  • Communication to oral cavity

  • High infection risk: significant tissue destruction, large dead space, extensive contamination, underlying medical problems that place a patient at high risk (diabetes, immunosuppression, steroids, extremes of age, obesity, etc)

Nasal packingNo prophylactic antibiotics
Central nervous system
PneumocephalusNo prophylactic antibiotics
  • Associated with open skull fracture and communication to the sinuses

CSF leaksNo prophylactic antibiotics
  • Associated with basilar skull fractures

Penetrating brain injuryShort course of prophylactic antibiotics, <3 days
  • Cefazolin

  • Clindamycin - for penicillin-allergic patients

  • Visible contamination—add metronidazole

Penetrating spine injuryShort course of prophylactic antibiotics, no more than 48 h
  • First and second-generation cephalosporins

  • Ampicillin-sulbactam

  • Piperacillin-tazobactam

  • Clindamycin with second-generation cephalosporin

  • Gastrointestinal involvement, specifically transcolonic

Extremity
Closed extremity fracturesNo prophylactic antibiotics if non-operative management


Preoperative antibiotics within 1 h of incision
  • First-generation cephalosporin

  • Clindamycin—for penicillin-allergic patients

Open extremity fracturesProphylactic antibiotics 24 h or less
  • Types I and II should be treated with GP coverage

    • First-generation cephalosporin

    • Clindamycin - for penicillin allergic patients

  • Type III should be treated with GP and GN coverage

    • First-generation cephalosporin and aminoglycoside

    • Piperacillin/tazobactam

    • Ceftriaxone

  • Antibiotics should be initiated within 1 h of injury and continued for 24 h

  • Washout and debridement should take place within 24 h of injury

Soft tissue injury
Soft tissue Lacerations/stab woundsProphylactic antibiotics 24 h or less if complex or high-risk patient
  • First-generation cephalosporin

  • Clindamycin—for penicillin-allergic patients

High-risk infection
  • Specific wound-related concerns (presence of significant contamination, crush injury, or specific at-risk anatomic sites)

  • Underlying patient factors that would increase the risk or worsen the outcome of infection

GSWProphylactic antibiotics 24 h or less if complex or high-risk patient
  • First-generation cephalosporin

  • Clindamycin—for penicillin-allergic patients

  • Surgical debridement of devitalized tissue if needed

  • Consideration of low-energy vs. high-energy mechanism

Burn injuryNo prophylactic antibiotics
  • Providers should take into account their institutional antibiogram when choosing antibiotics for prophylaxis and/or treatment.

  • CNS, central nervous system; CSF, cerebrospinal fluid; GN, Gram-negative; GP, Gram-positive; GSW, gunshot wound.