Duration of Administration of Antibiotic Agents for Open Fractures: Meta-Analysis of the Existing Evidence

Background: Surgical site infection remains a significant concern in treating patients with open fractures. In prevention of such, current guidelines support the immediate administration of antibiotic agents. The duration of antibiotic treatment is still controversial. A maximum of 72 hours, even in the absence of definitive soft tissue coverage, is recommended in a number of recent guidelines and consensus reports. The aim of this meta-analysis was to review and analyze all published literature evidence with regard to antibiotic duration in open fracture treatment.

Methods: We conducted a comprehensive review of the available literature from the 1970s until the present, including five comparative (1284 open fractures) and 27 observational (5408 open fractures) studies. A subgroup analysis was further performed, based on the Gustilo type of open injury and the anatomic location of the fracture. In addition, we investigated the effect of antibiotic regimes shorter than 72 hours on infection rates.

Results: In the comparative studies, the summarized estimate of infection rate favored less than a 72-hour duration of antibiotic treatment, because prolongation of antibiotic treatment more than 72 hours did not seem to offer any protective effect against septic complications of open fractures (odds ratio: 0.85, 95% confidence interval [CI]: 0.60–1.21). The same trend was also documented in the observational studies, where the overall pooled estimate of infection rate was 10% (95% CI: 6.8%–14%) when antibiotic treatment did not exceed 72 hours and 9.2% (95% CI: 6.6%–12.2%) for more than 72 hours of antibiotic treatment (p = 0.53). In Gustilo I and II open fractures, the calculated pooled estimate of infection rate did not differ significantly when antibiotic treatment exceeded 72 hours (6%, 95% CI: 3.3%–9%) compared with shorter (up to 72 h) antibiotic protocols (4%, 95% CI: 1.8%–7%) (p = 0.52). In Gustilo III open fractures also, the calculated pooled estimate of infection rate (21.3%, 95% CI: 13%–31%) when duration of antibiotic treatment was more than 72 hours did not differ significantly compared with a shorter (less than 72 h) antibiotic treatment (17.7%, 95% CI: 12.5%–23.5%) (p = 0.39). A further subgroup analysis indicated that even shorter antibiotic regimes (24–48 h) were also equivalent to prolonged regimes of more than 72 hours in terms of infection rates.

Conclusions: The results of the present systematic review and meta-analysis could not substantiate any benefit against septic complications of a prolonged duration of antibiotic treatment of open fractures, irrespective of their severity.