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Preventive antibiotic regimens for patients with open fractures

	Absence of potential soil or water contamination	Presence of potential soil contamination (in absence of water contamination)	Presence of water contamination
Gustilo-Anderson fracture type I or II*
Preferred regimen	Cefazolin 2 g IV every 8 hours^¶^Δ	Cefazolin 2 g IV every 8 hours^¶^Δ PLUS metronidazole 500 mg IV every 8 hours OR Ceftriaxone 2 g IV every 24 hours^◊ PLUS metronidazole 500 mg IV every 8 hours	No modification needed for fracture type I or II
Alternative regimen for patients with beta-lactam hypersensitivity	Vancomycin: Loading dose:^§ 20 to 35 mg/kg Initial maintenance dose and interval determined by nomogram;^¥ typically 15 to 20 mg/kg every 8 to 12 hours for most patients with normal renal function Subsequent dose and interval adjustments based on AUC-guided (preferred) or trough-guided serum concentration monitoring^‡	Clindamycin 900 mg IV every 8 hours	No modification needed for fracture type I or II
Gustilo-Anderson fracture type III^†
Preferred regimen	Cefazolin 2 g IV every 8 hours^¶^Δ PLUS gentamicin 5 mg/kg IV every 24 hours OR Ceftriaxone 2 g IV every 24 hours^◊	Ceftriaxone 2 g IV every 24 hours^◊ PLUS metronidazole 500 mg IV every 8 hours OR Cefazolin 2 g IV every 8 hours^¶^Δ PLUS gentamicin 5 mg/kg IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours	Fresh water contamination: Piperacillin-tazobactam 4.5 g IV every 6 hours^◊,**
			Sea water contamination: Piperacillin-tazobactam (as above)^◊,** PLUS doxycycline 100 mg IV or orally every 12 hours^¶¶
Alternative regimen for patients with beta-lactam hypersensitivity	Clindamycin 900 mg IV every 8 hours	Clindamycin 900 mg IV every 8 hours PLUS gentamicin 5 mg/kg IV every 24 hours	Fresh water contamination: Imipenem 500 mg IV every 6 hours^◊ OR Meropenem 1 g IV every 8 hours^◊
			Sea water contamination: Imipenem or meropenem (as above)^◊ PLUS doxycycline 100 mg IV or orally every 12 hours^¶¶

IV: intravenous; AUC: area under the 24-hour time-concentration curve.
* For type I and II open fractures, prophylactic antibiotics may be discontinued 24 hours after wound closure.
¶ For patients >120 kg, cefazolin dosing consists of 3 g IV every 8 hours.
Δ For patients at risk for methicillin-resistant Staphylococcus aureus (MRSA), gram-positive coverage should consist of vancomycin in place of cefazolin.
◊ For patients at risk for MRSA, vancomycin should be added to the regimen.
§ The vancomycin loading dose is based on actual body weight, rounded to the nearest 250 mg increment and not exceeding 3000 mg. Within this range, we use a higher dose for critically ill patients.
¥ Refer to the UpToDate topic on vancomycin dosing for sample nomogram.
‡ Refer to the UpToDate topic on vancomycin dosing for discussion of AUC-guided and trough-guided vancomycin dosing.
† For Gustilo type III open fractures, prophylactic antibiotics may be discontinued after 72 hours or within a day after soft tissue injuries have been closed.
** For patients on vancomycin, imipenem or meropenem may be used in place of piperacillin-tazobactam, to minimize the likelihood of nephrotoxicity associated with coadministration of vancomycin and piperacillin-tazobactam.
¶¶ A fluoroquinolone (levofloxacin or ciprofloxacin) may be used as an alternative to doxycycline.

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