Early Antibiotic Use in Open Fractures
Benefits in NNT
1 in 16 were helped (avoided early fracture site infection)
93.5% saw no benefit
6.5% were helped by avoiding an early infection of the fracture site
Harms in NNT
An unknown number were harmed (medication side effects/adverse reaction)
An unknown % were harmed by medication side effects/adverse reaction
SourceGosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev.
Efficacy EndpointsEarly Wound Infections
Harm EndpointsNone noted
NarrativeThe use of early antibiotics in the treatment of open limb fractures has long been considered standard in the United States and most other developed nations. Open fractures are, by definition, considered contaminated. Use of systemic antibiotics as part of the initial treatment of these fractures is aimed at preventing this contamination from developing into more serious complications such as osteomyelitis or abscess. This review found that early antibiotic use helped prevent early infections in open limb fractures (ARR 6.5%, NNT = 16).
CaveatsThe interpretation of the data presented by this review is severely limited. The primary outcome of “early infection” was poorly defined and heterogeneous across the 8 studies included (in one study early infection was defined as any infection within 6 weeks of injury, in others it was defined only as “early wound infection”). The studies were underpowered and unable to evaluate significant patient oriented outcomes such as mortality, amputation, development of osteomyelitis (chronic or acute), delayed bone union or bone non-union and length of hospital stay. The use of antibiotics for the treatment of open finger fractures was equivocal, and the little existing data appear to show no benefit (3 trials with N = 367 and 95% CI 0.26 to 1.23). None of the studies reported any data on antibiotic side effects, nor did they examine the potentially significant issue of developing antibiotic resistance. Additionally, only one study was performed within the last 20 years.
While the authors of this Cochrane Review conclude that no further study is needed on the subject of whether early antibiotic use should be standard practice in open limb fractures, they only found statistical significance in one poorly defined primary endpoint. There is a glaring lack of available evidence for a large number of patient-oriented outcomes. There is also no evidence advocating the use of early antibiotics in open finger fractures. Furthermore, the issues of antibiotic side effects and of developing antimicrobial resistance in this patient population have not been examined. In summary, while this evidence does not represent a robust or valid enough dataset to suggest a ‘standard of care’ it is reasonable to utilize antibiotic treatment for open fractures until additional data better elucidate both the benefits and harms associated with this approach.