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Antibiotic prophylaxis protocol for gunshot wound-related open fractures: A single-center retrospective analysis
Karim Gubara1, Dominique Gordy1, Nicolas Echeverria2
1Department of Orthopaedic Surgery and Sports Medicine, 3509 N Broad St 5th Floor, Philadelphia, PA 19140, USA; Lewis Katz School of Medicine at Temple University, 3500 N Broad St, Philadelphia, PA 19140, USA.
Background:
Gunshot-induced open fractures (ballistic OFs) present significant challenges in trauma management due to high risk of infection and lack of standardized antibiotic prophylaxis protocols. This study evaluates the implementation of an institutional antibiotic prophylaxis protocol for ballistic OFs at a Level I trauma center, assessing its impact on infection rates and protocol adherence.
Methods:
A retrospective analysis of patient records was conducted, including all cases of ballistic OFs treated between June 7, 2021, and March 31, 2024. Patients were stratified into pre-implementation and post-implementation groups, with the latter further divided into adherent and non-adherent subgroups. Infection rates, time to antibiotic administration, and demographic and clinical variables were analyzed using chi-squared tests and logistic regression.
Results:
Among 289 patients included, post-implementation protocol adherence was observed in 36% of cases. Infection rates were 7.1% (12/168, 95% CI 4.1-12.1%) before implementation, and 11.6% (14/121, 95% CI 7.0-18.5%) after with no significant difference (Fisher's exact test, p = 0.276). On multivariable analysis, infection was associated with vancomycin use (adjusted OR 5.24, 95% CI 1.95-13.77, p = 0.001), use of irrigation and debridement (adjusted OR 4.60, 95% CI 1.85-12.24, p = 0.001), and use of flap closure or split-thickness skin graft (adjusted OR 4.70, 95% CI 1.29-16.48, p = 0.020). Protocol non-adherence was predominantly attributable to delayed antibiotic initiation and improper metronidazole dosing in the setting of concomitant bowel injury.
Conclusions:
The findings suggest that while the introduction of an institutional antibiotic protocol did not significantly alter infection rates, challenges in adherence underscore the need for enhanced implementation strategies. Associations between infection and variables such as irrigation and debridement, flap reconstruction, and vancomycin use likely reflect underlying injury severity and wound contamination. Improved adherence, particularly in cases involving concomitant bowel injuries, may further optimize outcomes and support antibiotic stewardship in trauma care.
