Evidence for Systemic Perioperative Antibiotic Prophylaxis for Prevention of Fracture-related Infections Following Open Fractures: Systematic Review and Meta-Analysis of Randomized, Controlled, Clinical Trials

Introduction: Clinical guidelines rely heavily on expert opinions and institution protocols to provide recommendations for administration of systemic antibiotic prophylaxis for open extremity fractures to prevent fracture-related infections. The purpose of this study was to determine evidence-based (1) durations; (2) types; (3) dosing regimens of systemic perioperative antibiotic prophylaxis following Gustilo-Anderson types I, I/II, II, III, and I/II/III, for upper and lower extremity open fractures, isolated upper extremity open fractures, and isolated lower extremity open fractures to prevent fracture-related infections. Methods: Guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analysis, Cochrane, and the GRADE approach were implemented to structure and synthesize this study. Five databases (PubMed, Cochrane Library, Web of Science, Scopus, CINAHL) were systematically and independently searched for randomized controlled trials (RCTs) meeting eligibility criteria. Included patients had open extremity fractures and were treated with prophylactic systemic antibiotics administered perioperatively (preoperative, intraoperative, postoperative). Meta-analyses were done of the data. Results: Twenty-one (n = 21) RCTs met eligibility criteria (Gustilo-Anderson type I = 6, Gustilo-Anderson type II = 4, Gustilo-Anderson type I/II = 12, Gustilo-Anderson type III = 4, Gustilo-Anderson type I/II/III = 21). Summary tables were generated to provide evidence-based durations and types of systemic antibiotic prophylaxis after Gustilo-Anderson types I, I/II, II, III, and I/II/III, for upper and lower extremity open fractures, isolated upper extremity (hand) open fractures, and isolated lower extremity open fractures. Discussion: Although data were derived primarily from older studies, we summarized the strongest available evidence from RCTs for antibiotic prophylaxis following Gustilo-Anderson types I, I/II, II, III, and I/II/III, for upper and lower extremity open fractures, isolated upper extremity open fractures, and isolated lower extremity open fractures.