Antibiotic Stewardship in Nonoperative Facial Trauma: Necessary or Not?

Closed facial fractures are common and often treated nonoperatively. Routine systemic antibiotic prophylaxis is controversial because infection rates are low and antibiotics can cause harm. We assessed whether prophylactic antibiotics reduce infectious complications in closed, nonoperative facial fractures.

A systematic review was conducted of adults with closed, nonoperative facial fractures (emergency department, inpatient, intensive care unit). PubMed, Scopus, and Google Scholar were searched from inception through September 19, 2025. Studies compared systemic prophylaxis versus none and/or ≤24 hours versus >24 hours.

Seven US studies comprising 3274 patients met the inclusion criteria. Across studies, fracture-related infection rates were low and were not reduced by prophylactic antibiotics. In the largest prospective multicenter cohort, Mian et al reported a 30-day facial fracture-associated infection rate of 1.0%, with no significant benefit for ≤24 hours or >24 hours of prophylaxis compared with none (adjusted odds ratio 1.24-1.32). Orbital and zygomatic cohorts reported no infectious complications regardless of prophylaxis strategy. In sinus-involving and intensive care unit cohorts, fracture-site infection and sinusitis were rare; most infectious events were pneumonia or ventilator-associated pneumonia rather than facial fracture-specific infections. Longer antibiotic exposure was associated with isolated cases of Clostridioides difficile colitis.

Available evidence does not support routine systemic prophylaxis for uncomplicated closed, nonoperative facial fractures. The strongest inference applies to patients without another indication for antibiotics. Current data do not identify fracture-specific subgroups in whom prophylaxis improves outcomes; accordingly, management should emphasize local care, return precautions, and structured follow-up.