Local Antibiotic Therapy for Open Long Bone Fractures: Appropriate Prophylaxis or Unnecessary Exposure for the Orthopedic Trauma Patient?

Introduction: Prophylactic local antibiotic therapy (LAbT) to prevent infection in open long bone fracture (OLBF) patients has been in use for many decades despite lack of definitive evidence confirming a beneficial effect. We aimed to evaluate the effect of LAbT on outcomes of OLBF patients on a nationwide scale. Materials and Methods: In this retrospective analysis of 2017-2018 American College of Surgeons-Trauma Quality Improvement Program database, all adult (≥18 years) patients with isolated OLBF (non–extremity-Abbreviated Injury Scale < 3) were included. We excluded early deaths (<24 h) and those who had burns or non–extremity surgery. Outcomes were infectious complications (superficial surgical site infection, deep superficial surgical site infection, osteomyelitis, or sepsis), unplanned return to operating room, and hospital and intensive care unit length of stay (LOS). Patients were stratified into two groups: those who received LAbT and those who did not receive LAbT (No-LAbT). Propensity score matching (1:3) and chi-square tests were performed. Results: A total of 61,337 isolated OLBF patients were identified, among whom 2,304 patients were matched (LAbT: 576; No-LAbT: 1,728). Both groups were similar in terms of baseline characteristics. Mean age was 43 ± 17 years, 75% were male, 14% had penetrating injuries, and the median extremity-Abbreviated Injury Scale was 1 (1-2). Most common fracture locations were tibia (66%), fibula (49%), femur (24%), and ulna (11%). About 52% of patients underwent external fixation, 79% underwent internal fixation, and 86% underwent surgical debridement. The median time to LAbT was 17 (5-72) h, and the median time to debridement was 7 (3-15) h (85% within 24 h). The LAbT group had similar rates of infectious complications (3.5% vs. 2.5%, P = 0.24) and unplanned return to the operating room (2.3% vs. 2.0%, P = 0.74) compared to the No-LAbT group. Patients who received LAbT had longer hospital LOS (16 [10-29] vs. 14 [9-24] days, P < 0.001) but similar intensive care unit LOS (4 [3-9] vs. 4 [2-7] days, P = 0.19). Conclusions: Our findings indicate that prophylactic LAbT for OLBF may not be beneficial over well-established standards of care such as early surgical debridement and systemic antibiotics. Prospective studies evaluating the efficacy, risks, costs, and indications of adjuvant LAbT for OLBF are warranted.