Use Of Antibiotics
With the exception of an open fracture, antimicrobial treatment for penetrating extremity wounds is often a source of controversy. Generally accepted indications for empiric antibiotic therapy are associated fractures, shotgun injuries, or wounds with large associated soft-tissue involvement. Studies by Ordog and Dickey demonstrated that patients with low-velocity missile injuries can be successfully treated as outpatients, without antibiotics.127,133 When antibiotics are deemed necessary, Knapp et al found no difference in outcomes when comparing oral and IV antibiotics.134 Risk factors for infection include delays in wound care, inadequate wound care, wounds > 2 cm in length, gross contamination, poor patient compliance, diabetes, and vascular injury.127,133 Patients with grossly contaminated injuries, high-velocity weapon injuries, and shotgun injuries should be admitted for surgical debridement.
When fractures are present, antibiotics are indicated. In a study of 1104 open fracture wounds, Patzakis and Wilkins found the key to reducing infections was early antibiotic administration.135 Fackler stated that one should strive to achieve adequate circulating blood levels of a penicillin-spectrum antibiotic in all gunshot wound patients as soon as possible.136 Surgical debridement for open fractures is typically done within 6 hours, but recent studies have shown that extending this window up to 24 hours has shown no change in the rate of osteomyelitis as long as antibiotics have been started in the ED.137