A Simple Initiative to Decrease Time to Antibiotic Prophylaxis for Open Fractures Is Durable After 2 Years

Avi D. Goodman, MD; Jacob M. Modest, MD; Joey P. Johnson, MD; Roman A. Hayda, MD


J Am Acad Orthop Surg. 2021;29(18):e932-e939. 

In This Article

Abstract and Introduction


Introduction: A simple antibiotic prophylaxis initiative can effectively decrease the time to antibiotic administration for patients with open fractures. We aim to determine whether adherence to the protocol decreased over time without active input from the orthopaedic trauma team.

Patients and Methods: This retrospective cohort study included adult patients with open fractures (excluding hand) presenting directly to the emergency department at one Level I trauma center. Three separate 50-patient groups were included: a preimplementation cohort, immediately postimplementation cohort, and a retention cohort 2 years later. The primary outcome was time from emergency department presentation to antibiotic administration, and secondary outcomes were the percentage of patients receiving antibiotics within 60 minutes and incidence of infection requiring revision surgery within 90 days. The χ 2 and Student t-tests evaluated between-group differences, and multivariable linear or logistic regression evaluated risk factors.

Results: After implementation, the time from presentation to antibiotic administration decreased markedly from 123.1 to 35.7 minutes and remained durable (50.0 minutes) at retention. The proportion of patients receiving antibiotics within 60 minutes increased markedly from 46% preimplementation to 82% postintervention and remained similar at retention (80%). The postintervention and retention groups were markedly more likely to receive antibiotics within 60 minutes than the preintervention group (odds ratio [OR], 8.4 and 4.7, respectively), as were patients with a higher Gustilo-Anderson type (OR, 2.4/unit increase), lower extremity injury (OR, 2.8), and male sex (OR, 3.1); mechanism, age, and Injury Severity Score were not associated. No difference was observed in infection.

Conclusions: Our educational initiative showed durable results in reducing the time from presentation to antibiotic administration after 2 years.

Level of Evidence: Therapeutic Level III


Although prompt antibiotic administration is one of a few interventions that reliably decreases the risk of infection after an open fracture, systemic barriers often stand in the way. Providers in the emergency department (ED) providing initial care to patients with open fractures have variable knowledge about the importance, timing, dose, and choice of antibiotic for prophylaxis when an open fracture is identified.

Recent literature has shown that the administration of antibiotics within 60 or 65 minutes of injury has a notable benefit of reducing infection.[1] Other factors that may be associated with an increased risk of infection include Gustilo-Anderson type and time to coverage of more than 5 days.[1–4] Although the time to surgical débridement was initially believed to be a predictor of infection, systematic reviews and prospective cohort studies in the past two decades have not shown the two to be associated.[1–3,5–7]

Our institution established an interdepartmental working group, whose recommendations were used effectively to decrease the time to antibiotic prophylaxis after open fractures.[8] These interventions were straightforward (see Protocol section below) but, initially, time-intensive for the orthopaedic surgery department and had potential to markedly degrade without continued reeducation from the orthopaedic surgery department. Other recent articles have shown improved time to antibiotic administration with quality improvement projects, but no previous work has looked at the sustainability of these interventions, particularly without continued orthopaedic surgeon didactic or training modules for ED and trauma personnel.[9–12] Our hypothesis was that, over the intervening 2 years, the time to administration of antibiotics for patients with open fractures, including the individual time intervals of patient ED presentation to antibiotic order and order to antibiotic administration, would revert to preintervention levels.