Antibiotics for preventing infection in open limb fractures

Wound and bone infections are frequently associated with open fractures of the extremities and may add significantly to the resulting morbidity. The administration of antibiotics is routinely used in developed countries as an adjunct to a comprehensive management protocol that also includes irrigation, surgical debridement and stabilisation when indicated, and is thought to reduce the frequency of infections.

To quantify the evidence for the effectiveness of antibiotics in the initial treatment of open fractures of the limbs.

We searched the Cochrane Musculoskeletal Injuries Group specialised register (April 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 1, 2003), MEDLINE (1966 to April 2003), EMBASE (1988 to April 2003), LILACS (1992 to June 2002) and reference lists of articles. Proceedings of meetings of the American Academy of Orthopaedic Surgeons (1980 to 2001), the Orthopaedic Trauma Association (1990 to 2001) and the Société Internationale de Chirurgie Orthopedique et Traumatologique (1980 to 2001) were hand searched. We also contacted published researchers in the field.

Randomised or quasi-randomised controlled trials involving: participants - people of any age with open fractures of the limbs; intervention - antibiotic administered before or at the time of primary treatment of the open fracture compared with placebo or no antibiotic; outcome measures - early wound infection, chronic drainage, acute or chronic osteomyelitis, delayed unions or non-unions, amputations and deaths.

Two reviewers independently screened papers for inclusion, assessed trial quality using an eight item scale, and extracted data. Additional information was sought from three trialists. Pooled data are presented graphically.

Data from 913 participants in seven studies were analysed. The use of antibiotics had a protective effect against early infection compared with no antibiotics or placebo (relative risk 0.41 (95% confidence interval (CI) 0.27 to 0.63); absolute risk reduction 0.08 (95% CI 0.04 to 0.12); NNT 13 (95% CI 8 to 25)). There were insufficient data in the included studies to evaluate other outcomes.

Antibiotics reduce the incidence of early infections in open fractures of the limbs. Further placebo controlled randomised trials are unlikely to be justified in middle and high income countries. Further research is necessary to the determine the avoidable burden of morbidity in countries where antibiotics are not used routinely in the management of open fractures.