JOT - 2026-09-23 - Journal Article
Ceftriaxone versus cefazolin plus gentamicin for antibiotic prophylaxis in Gustilo-Anderson type III open lower extremity fractures.
Foster C, Richardson L, Pegg B, Garg V, Kye B, Lu X, Young P
Topics
Key Takeaway
Ceftriaxone monotherapy produced equivalent FRI rates compared to cefazolin plus gentamicin for Gustilo-Anderson Type III open lower extremity fractures (12.8% vs 18.3%, adjusted HR=1.26, p=0.545), while IIIB/C severity (HR=3.05) and time-to-antibiotics >60 minutes (HR=2.56) were the dominant independent predictors of infection.
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Summary
This single-center retrospective cohort compared FRI rates between ceftriaxone monotherapy and cefazolin plus gentamicin in 307 GA Type III open lower extremity fractures from 2013–2024. After Cox proportional hazards modeling adjusting for GA subtype, fracture location, time to debridement, and time to antibiotics, no significant difference in FRI (HR=1.26, 95% CI 0.59–2.68, p=0.545) or AKI (OR=1.51, p=0.349) was detected. GA IIIB/C classification (HR=3.05, p<0.001) and antibiotic administration >60 minutes from injury (HR=2.56, p=0.003) independently predicted FRI regardless of regimen.
Key Limitation
The non-randomized design with unequal cohort sizes (229 vs 78) and differential follow-up duration introduces selection bias and risks underdetection of late infections in the ceftriaxone group, limiting causal inference.
Original Abstract
OBJECTIVES
To compare fracture related infection (FRI) rates and outcomes between ceftriaxone (CTX) and cefazolin plus gentamicin (C+G) for antibiotic prophylaxis in Gustilo-Anderson (GA) type III open lower extremity fractures.
METHODS
Design: Retrospective cohort study.
SETTING
Single, academic level one trauma center.
PATIENT SELECTION CRITERIA
Included were patients age 18-89 years with GA type III open lower extremity fractures (AO/OTA 32,33,41,42,43,4F3, 44) from 2013 to 2024 with at least 6 weeks follow-up.
OUTCOME MEASUREMENTS AND COMPARISONS
The primary outcome was FRI. Secondary outcomes included acute kidney injury (AKI), nonunion, and other complications. Cox proportional hazards models and multivariable logistic regression adjusted for confounding variables.
RESULTS
Of 3,334 lower extremity fractures reviewed, 307 met inclusion criteria: 229 C+G and 78 CTX. Mean age (40.4 [range 18-88] vs 41.2 [range 18-81] years, p=0.7) and sex (75.1% vs 64.1% male, p=0.084) were similar between the C+G and CTX cohorts. Mean follow-up was 23.8 months (C+G) and 14.0 months (CTX) (P=0.002). The C+G cohort had more tibial shaft fractures (34.1% vs 19.2%, P=0.014) and type IIIB injuries (19.7% vs 7.7%, P=0.014). On unadjusted analysis, there was no significant difference in FRI (18.3% vs 12.8%, P=0.343) or AKI (11.4% vs 12.8%, P=0.728) or organisms cultured. After adjusting for GA type, fracture location, time to debridement and time to antibiotics there remained no significant difference in FRI (HR=1.26, 95% CI: 0.59-2.68, P=0.545), AKI (OR=1.51, 95% CI: 0.62-3.49, P=0.349) or other complications between antibiotic regimens. Tibial shaft fractures trended towards higher risk of FRI compared to femur fractures (HR=2.15, P=0.052). GA type IIIB/C fractures (HR=3.05, p<0.001) and time to antibiotics of >60min (HR=2.56, p=0.003) were associated with higher odds of FRI.
CONCLUSIONS
Ceftriaxone monotherapy demonstrated similar rate of FRI and complications compared to cefazolin plus gentamicin for Gustilo-Anderson type III open lower extremity fractures. Severity of the open fracture and time to antibiotics were independently associated with higher infection risk regardless of antibiotic regimen.
LEVEL OF EVIDENCE
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.