The literature on antibiotic prophylaxis for traumatic wounds is usually poor and tends to be left to EM physician gestalt or subspecialty preference. In the case of someone without access to subspecialist consultation in a young, healthy patient, understanding the literature may help us decrease our antibiotic prescribing and become better antibiotic stewards. Here, we review some common clinical conditions in which the ED physician may feel comfortable giving or not giving antibiotics using an evidence-based approach.
Should I give prophylactic antibiotics for lacerations?
A meta-analysis of randomized control trials of 1701 patients randomized to prophylactic antibiotics for non-bite lacerations in healthy patients did not find a benefit for prophylactic antibiotics (1). Rosen’s Emergency Medicine chapter on wound management does describe high-risk wounds that merit antibiotics. These include heavily contaminated wounds, crush injuries, or patients with immunocompromising factors (2). From the surgery literature characterizing wound infections, they note diabetes, obesity, malnutrition, chronic renal failure, advanced age, and chronic steroid use are factors that increase the risk of wound infection. Antibiotic selection should cover skin flora (e.g., cefazolin or cephalexin). No specific length of treatment has been recommended, but it typically ranges from 3 to 5 days (3).
Answer: Routine antibiotic prophylaxis should not be done for laceration repairs but should be considered in elderly patients, those with comorbid conditions, contaminated wounds, or those with crush injuries. 3-5 days of narrow-spectrum cephalosporins are sufficient for non-bite wounds.
Should I give prophylactic antibiotics to a patient requiring a tube thoracostomy for a traumatic thoracic injury?
Tube thoracostomy for traumatic hemothorax or pneumothorax may result in post-procedural infections, namely empyema. The Eastern Association for the Surgery of Trauma recently updated their recommendations on antibiotic prophylaxis for patients receiving tube thoracostomy for a traumatic hemothorax or pneumothorax to recommend prophylactic antibiotics (4). These 2022 recommendations state there is a likely benefit to prophylaxis, but a specific guideline has not been provided. At the minimum, a one-time dose of antibiotics, such as ceftriaxone, should be given. These are supported by a recent systematic review and meta-analysis published in the Annals of Emergency Medicine that found a 60% decreased odds of developing a post-procedural infection, with an odds of 0.40 (95% CI 0.22 to 0.75) (5).
Answer: A one-time dose of antibiotics should be given to patients receiving tube thoracostomy for a traumatic thoracic complication, with the decision to continue antibiotic treatment length to a managing subspecialist.
Should I give prophylactic antibiotics for a traumatic, open facial fracture?
Rule one for open fractures is to give IV antibiotics and give them fast. What has always confused me is open facial fractures, such as a nasal fracture with a laceration, are rarely managed with prophylactic antibiotics by our subspecialists. The Surgical Infection Society in 2021 published guidelines for antibiotic prophylaxis for facial fractures and recommended no prophylactic antibiotics be given for upper, midface, or mandibular fractures (6). Notably, these recommendations are Grade C (e.g., evidence is exclusively from case series or low-quality cohort studies).
Answer: Although current evidence does not suggest a need for prophylactic antibiotics, the quality of evidence is so poor that selective antibiotic prescribing in high-risk wounds or individuals can be considered, but routine prescribing would likely have greater risks than benefits.
Authored by Jose Reyes, MD
References:
Cummings, P., & Del Beccaro, M. A. (1995). Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. The American journal of emergency medicine, 13(4), 396–400. https://doi.org/10.1016/0735-6757(95)90122-1
Rosen's emergency medicine : concepts and clinical practice. (2002). St. Louis :Mosby,
Ghafouri, H. B., Bagheri-Behzad, B., Yasinzadeh, M. R., Modirian, E., Divsalar, D., & Farahmand, S. (2012). Prophylactic Antibiotic Therapy in Contaminated Traumatic Wounds: Two Days versus Five Days Treatment. BioImpacts : BI, 2(1), 33–37. https://doi.org/10.5681/bi.2012.004
Freeman JJ, Asfaw SH, Vatsaas CJ, et al. Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open. 2022;7(1):e000886. Published 2022 Oct 25. doi:10.1136/tsaco-2022-000886
MacDonald AG, Long B. What Is the Utility of Antibiotic Prophylaxis in Adult Trauma Patients With Hemothorax or Pneumothorax Who Undergo Tube Thoracostomy?. Ann Emerg Med. 2023;82(5):624-626. doi:10.1016/j.annemergmed.2023.03.012
Forrester JD, Wolff CJ, Choi J, Colling KP, Huston JM. Surgical Infection Society Guidelines for Antibiotic Use in Patients with Traumatic Facial Fractures. Surg Infect (Larchmt). 2021;22(3):274-282. doi:10.1089/sur.2020.107