Efficacy of Cefazolin versus Ceftriaxone for Extremity Open Fracture Management at a Level 1 Trauma Center

Abstract

Background:

Antibiotic agents have been shown to improve outcomes in open extremity fractures. The first-generation cephalosporins, which are used most often, are often under-dosed based on weight and recommended frequency. Ceftriaxone offers a broader coverage and a decreased frequency of administration. Our institution began utilizing ceftriaxone for open fracture management in 2017 to address those concerns.

Objective:

To examine the efficacy of cefazolin versus ceftriaxone for open fracture management of extremity trauma.

Patients and Methods:

Retrospective study from 2015–2019 of patients who sustained open extremity fractures. Patients were stratified by antibiotic administered and Gustilo-Anderson grade. Outcomes included non-union/malunion, superficial surgical site infection (SSI), deep SSI, osteomyelitis, re-operation after index hospital visit, re-admission due to prior injury, limb loss, and death. Subgroup analysis stratified each antibiotic group by Gustilo-Anderson grade 1 or 2 and grade 3.

Results:

Data was collected from 2015 to 2019. Of the 1,149 patients, 619 patients met inclusion criteria. Three hundred fifty-five patients received cefazolin and 264 patients received ceftriaxone. There were no statistically significant differences between groups on specified outcomes. No statistically significant differences existed during subgroup analysis for the specified outcomes. Multivariable analysis demonstrated increased Gustilo-Anderson grade increased risk of infectious outcome.

Conclusions:

Ceftriaxone is a safe and effective alternative for open fracture extremity management that offers the advantage of 24-hour dosing and single antibiotic coverage for grade 3 open fractures. It does not increase infectious complications and offers benefits of resource efficiency.

Open fractures are defined as having a skin defect that communicates with the underlying deep tissue injury and fracture [1]. The most common grading system of open fractures is the Gustilo-Anderson, which grades fractures based on size and degree of energy impacted on the injury. The Gustilo-Anderson classification spans from grade 1 to grade 3c and helps to determine prognosis, likelihood of infection, and antibiotic coverage needed [2]. Different degrees of infection, including osteomyelitis, are feared complications. Infection rates for grade 1 and 2 open fractures occur anywhere from 1%–4% [3, 4]. Grade 3 fractures have an infection rate anywhere between 5.7%–50% [3,5]. Inter-observer reliability is an issue with any grading system, and studies have shown a moderate agreement with the Gustilo-Anderson classification [6,7].

One of the most important interventions to decrease infectious sequela is timely administration of antibiotic agents in addition to complete debridement. Many antibiotic regimens exist for open fracture management, and issues with dosing and timing of antibiotic agents are still problematic [8,9]. Current management recommends antibiotic agents initiated within three hours of the injury and continued until primary closure or 72 hours [10]. American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) best practice guidelines recommend giving antibiotic agents no later than 60 minutes upon presentation to the hospital [11]. The type of antibiotic is not standardized; cephalosporins and aminoglycosides for higher-grade fractures are the most widely used medications. Cefazolin is a first-generation cephalosporin whose pharmacokinetics mandate weight-based dosing and administration every eight hours. The weight-based dosing has often led to under-dosing [12]. Patzakis et al. [13] studied antibiotic regimens in 1974 for open fractures by comparing no antibiotic, penicillin with streptomycin, and cephalothin. Cephalothin had the lowest infection rate; thus, he concluded that adding streptomycin would be the ideal regimen [13]. Aminoglycosides are still recommended for grade 3 open fractures [1]. Ceftriaxone is a third-generation cephalosporin that offers broader microbial coverage as well as 24 hours of coverage. Ceftriaxone also has adequate bone and soft tissue penetration during its duration of action to treat open fractures [14 –17].

In 2017, our institution switched from a cefazolin-based regimen, which included an aminoglycoside for Gustilo-Anderson 3 fractures, to ceftriaxone for all grades of open fracture coverage to address such issues as dosing, less frequent administration, and extended antimicrobial coverage. We have completely removed aminoglycosides from open fracture management and use ceftriaxone as the sole antibiotic for open fractures removing the interobserver reliability for the Gustilo-Anderson grading.

The goal of this study is to analyze outcomes of open fractures receiving a cefazolin regimen versus ceftriaxone. We hypothesize that there will be no difference in outcomes between patients with open fractures that received a cefazolin regimen versus ceftriaxone.

Patients and Methods

This was a single-center retrospective study from 2015–2019 looking at patients who sustained open fractures of the extremities. Axial skeleton, foot, and hand fractures were excluded. We identified patients who sustained open extremity fractures using International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, Tenth Revision (ICD-10) codes. Inclusion criteria were 14 years of age and older, radiograpg-proven long bone fracture with associated open wound. Demographic information was gathered for each patient including gender, age, body mass index (BMI), smoking status, and diabetes mellitus status. Hospital length of stay (HLOS) and intensive care unit length of stay (ILOS) were recorded for each index presentation. Exclusion criteria included severe penicillin or cephalosporin allergy that required other classes of antibiotic agents to be administered, both cephalosporins given, no antibiotic agents given, or antibiotic agents given by a consulted subspecialty.

Patients were stratified based on whether they received cefazolin or ceftriaxone for open fracture management. Antibiotic agents were typically given in the first hour of presentation to the hospital. Antibiotic compliance was tracked for Trauma Quality Improvement Program (TQIP) standards starting in 2016. Annual compliance rates for our tertiary referral hospital were 66%, 75%, 84%, and 87% from 2016–2019, respectively. Prior to 2017, cefazolin was primarily used for open fracture management. Gustilo-Anderson 3 treated with cefazolin received additional antibiotic coverage, which predominantly consisted of tobramycin or gentamicin. Starting in 2017, ceftriaxone was the sole antibiotic utilized for open fractures. Patients sustaining open fractures because firearms were not included in the study because patients only received cefazolin for this mechanism. Open fracture grading was determined by the orthopedic surgeon who performed the initial operation utilizing their operative report. The two subgroups included Gustilo-Anderson 1 and 2 and Gustilo-Anderson 3 for each antibiotic group.

Patient outcomes were tracked for the year after their open fracture utilizing chart review. Outcomes were nonunion/malunion, superficial surgical site infection (SSI), deep SSI, osteomyelitis, re-operation after index hospital visit for prior injury, re-admission due to prior injury, limb loss, and death. Additional complications within 30 days of initial antibiotic administration were gathered for this cohort. Complications included pneumonia, acute kidney injury (AKI), urinary tract infection (UTI), Clostridium difficile infection), multi-drug–resistant (MDR) infection, catheter-associated urinary tract infection (CAUTI), and ventilator-associated pneumonia (VAP). Total costs were obtained for each visit that pertained to the open fracture.

Statistical analysis

Demographic and outcome variables were compared across the two antibiotic groups, ceftriaxone and cefazolin. To assess homogeneity of demographic variables in the two antibiotic groups, χ² analyses were performed for categorical variables whereas a parametric independent samples t-test and a non-parametric independent samples Mann-Whitney U test were performed for continuous variables. χ² analyses were conducted to compare the antibiotic groups on categorical outcomes. Frequencies and percentages for all categorical between-subjects comparisons were reported and interpreted. Most continuous variables violated assumptions of normality or homogeneity of variance, so nonparametric independent samples Mann-Whitney U analyses were performed to compare the antibiotic groups on these continuous outcomes. Medians and interquartile ranges for all continuous between-subjects comparisons were reported and interpreted. An independent samples t-test was performed to compare the antibiotic groups on a continuous variable that met assumptions of normality and homogeneity of variance. Averages and standard deviations were reported and interpreted for this between-subjects comparison. All statistical analyses were performed using SPSS, version 27 (IBM Corp, Armonk, NY) and a statistically significant difference was assumed at a two-sided α value of 0.05.

An a priori sample size calculation was performed so that adequate power could be achieved in the study. Using a two-tailed hypothesis, an effect size of 5% and 10% between the independent groups, an α value of 0.05, a β value of 0.2, and an allocation rate of 1.4, a total of n = 3,137 and n = 768 participants would be needed to achieve enough statistical power to perform the analyses in the study to detect a difference of 5% or 10% respectively. The analysis was performed using G*Power, version 3.1.

A multivariable logistic regression controlling for confounding variables was utilized to analyze infectious outcomes for both antibiotic groups. For the model, infection was defined as the occurrence of a superficial or deep skin and soft infection, nonunion or malunion, or osteomyelitis. Age, gender, BMI, history of smoking, diabetes myelitis and antibiotic selection were included in the model. Goodness-of-fit was assessed with both the Pearson and Deviance χ² tests.

Results

A total of 1,149 records were assessed for eligibility for the project. We excluded 530 patient records for duplication of record, not receiving antibiotic of interest, or receiving both antibiotic agents. Of the 619 patients analyzed, 355 patients received cefazolin and 264 patients received ceftriaxone. Table 1 displays demographics of each antibiotic group. The cefazolin group had more males (p = 0.018). The ceftriaxone group was more likely to have diabetes mellitus (p = 0.028) and older with an average age of 49.18 compared with 45.73 in the cefazolin group (p = 0.026). There were no statistically significant differences in BMI (p = 0.064), smoking status (p = 0.767), or frequency of Gustilo-Anderson grade (p = 0.914) between the antibiotic groups.

Table 1.

Patient Demographic Information

	Ceftriaxone (N = 264)	Cefazolin (N = 355)	p (α = 0.05)
Gender^a			0.018
Male	154 (58.3%)	240 (67.6%)
Female	110 (41.7%)	115 (32.4%)
Age^b	49.18 (19.67)	45.73 (18.48)	0.026
BMI^c			0.064
<19	6 (2.3%)	8 (2.3%)
19–24.9	64 (24.6%)	99 (28.3%)
25–29.9	84 (32.3%)	113 (32.3%)
>30	106 (40.8%)	130 (37.1%)
Smoking status^a			0.767
Smoker	96 (36.4%)	125 (35.2%)
Non-smoker	168 (63.6%)	230 (64.8%)
Diabetes mellitus^a			0.028
Yes	37 (14.0%)	30 (8.5%)
No	227 (86.0%)	325 (91.5%)
Gustillo Anderson grade^a			0.914
Grades 1 and 2	187 (71.1%)	251 (70.7%)
Grade 3	76 (28.9%)	104 (29.3%)

Demographic information for ceftriaxone and cefazolin is reported as frequency (valid percentage) for each variable.

Denotes categorical variables measured with χ² statistics.

Denotes continuous variables measured with independent samples t-test statistics.

Denotes nonparametric continuous variables measured with independent samples Mann-Whitney U statistics.

BMI = body mass index.

When controlling for all variables in a multivariable model, only having a Gustilo Anderson grade of 3 was statistically associated with a higher odd of developing an infection (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.0–4.5; p < 0.001). In addition, when controlling for all other variables in the model, the use of ceftriaxone did reduce the odds of developing infection as compared to cefazolin, but this did not reach statistical significance (OR, 0.784; 95% CI, 0.580–1.317; p = 0.52). All other variables in the model, including receipt of ceftriaxone or cefazolin, were not statistically predictive for the prediction of infection. Full model results can be seen in Table 2.

Table 2.

Multivariate Logistic Regression Model Predicting for Development of Infection

Variable	OR	95% CI	p (α = 0.05)
Age	0.993	0.982–1.005	0.238
Male gender	0.982	0.636–1.516	0.935
BMI	1.021	0.991–1.052	0.166
History of smoking	1.299	0.845–1.998	0.233
History of diabetes mellitus	1.459	0.768–2.771	0.249
Receipt of ceftriaxone	0.874	0.580–1.317	0.52
Gustilo Anderson grade 3	2.992	1.990–4.501	< 0.001

Goodness of fit: Pearson, p = 0.381; deviance 0.460.

OR = odds ratio; CI = confidence interval; BMI = body mass index.

Table 3 displays outcomes of each antibiotic group one year after index presentation. Overall, no statistically significant differences were obtained between each group for non-union/malunion (p = 0.801), SSI (p = 0.649), deep SSI (p = 0.837), osteomyelitis (p = 0.653), re-operation on extremity (p = 0.746), re-admission after index event (p = 0.857), limb loss (p = 0.266), and mortality (p = 0.787). Hospital LOS (p = 0.125) did not differ between the two groups. There was a significant decrease in ILOS for patients receiving ceftriaxone, but the median values were 0 for each group. Further breakdown information can be seen in Table 3. Table 4 and 5 contain subgroup analysis for Gustilo-Anderson 1 and 2 and Gustilo-Anderson 3, respectively. No statistically significant differences existed during subgroup analysis for the specified outcomes. No differences between UTI, pneumonia, or AKI existed between groups. One instance of Clostridium difficile infection, MDR infection, CAUTI, and VAP occurred during the study period. No instances of ototoxicity occurred during the study period.

Table 3.

Effect of Drug Type on Outcome Variables

Outcome variables	Ceftriaxone	Cefazolin	p (α = 0.05)
Non-union/malunion^a			0.801
Yes	33 (12.5%)	42 (11.8%)
No	231 (87.5%)	313 (88.2%)
SSI superficial^a			0.649
Yes	14 (5.3%)	16 (4.5%)
No	250 (94.7%)	339 (95.5%)
SSI deep^a			0.837
Yes	24 (9.1%)	34 (9.6%)
No	240 (90.9%)	321 (90.4%)
Osteomyelitis^a			0.653
Yes	26 (9.8%)	31 (8.7%)
No	238 (90.2%)	324 (91.3%)
Re-operation or same extremity^a			0.746
Yes	76 (28.8%)	98 (27.6%)
No	188 (71.2%)	257 (72.4%)
Re-admission due to injury^a			0.857
Yes	52 (19.7%)	72 (20.3%)
No	212 (80.3%)	283 (79.7%)
Loss of limb^a			0.266
Yes	11 (4.2%)	22 (6.2%)
No	254 (95.8%)	333 (93.8%)
Death^a			0.787
Yes	10 (3.8%)	12 (3.4%)
No	254 (96.2%)	343 (96.6%)
UTI^a			0.408
Yes	11 (4.2%)	20 (5.6%)
No	253 (95.8%)	335 (94.4%)
Pneumonia^a			0.834
Yes	6 (2.3%)	9 (2.5%)
No	258 (97.7%)	346 (975%)
AKI^a			0.323
Yes	14 (5.3%)	13 (3.7%)
No	250 (94.7%)	342 (96.3%)
Hospital LOS^b	5.0 (3.0–10.0)	6.0 (3.0–11.0)	0.125
ICU LOS^b	0.0 (0.0–2.0)	0.0 (0.0-3.0)	0.033

All variables were measured against an α level of 0.05.

Denotes categorical variables measured with χ² statistics; frequency (percentage).

Denotes nonparametric continuous variables measured with independent samples Mann-Whitney U statistics; median (interquartile range).

SSI = surgical site infection; UTI = urinary tract infection; AKI = acute kidney injury; LOS = length of stay; ICU = intensive care unit.

Table 4.

Effect of Drug Type on Outcome Variables for Gustillo Anderson Grades 1 and 2 Subgroup

Outcome variables	Ceftriaxone	Cefazolin	p (α = 0.05)
Non-union/malunion^a			0.782
Yes	15 (8.0%)	22 (8.8%)
No	172 (92.0%)	229 (91.2%)
SSI superficial^a			0.592
Yes	5 (2.7%)	9 (3.6%)
No	182 (97.3%)	242 (96.4%)
SSI deep^a			0.355
Yes	10 (5.3%)	19 (7.6%)
No	177 (94.7%)	232 (92.4%)
Osteomyelitis^a			0.882
Yes	12 (6.4%)	17 (6.8%)
No	175 (93.6%)	234 (93.2%)
Re-operation or same extremity^a			0.616
Yes	38 (20.3%)	56 (22.3%)
No	149 (79.7%)	195 (77.7%)
Re-admission due to injury^a			0.364
Yes	24 (12.8%)	40 (15.9%)
No	163 (87.2%)	211 (84.1%)
Loss of limb^a			0.082
Yes	1 (0.5%)	7 (2.8%)
No	186 (99.5%)	244 (97.2%)
Death^a			0.637
Yes	5 (2.7%)	5 (2.0%)
No	182 (97.3%)	246 (98.0%)
UTI^*			0.073
Yes	5 (2.7%)	16 (6.4%)
No	182 (97.3%)	235 (93.6%)
Pneumonia^a			0.851
Yes	5 (2.7%)	6 (2.4%)
No	182 (97.3%)	245 (97.6%)
AKI^a			0.397
Yes	8 (4.3%)	7 (2.8%)
No	179 (95.7%)	244 (97.2%)
Hospital LOS^b	5.0 (3.0–8.0)	5.0 (3.0–10.0)	0.390
ICU LOS^b	0.0 (0.0–2.0)	0.0 (0.0–3.0)	0.033

All variables were measured against an α level of 0.05.

Denotes categorical variables measured with χ² statistics, Frequency (Percentage).

Denotes nonparametric continuous variables measured with independent samples Mann-Whitney U statistics; median (interquartile range).

SSI = surgical site infection; UTI = urinary tract infection; AKI = acute kidney injury; LOS = length of stay; ICU = intensive care unit.

Table 5.

Effect of Drug Type on Outcome Variables for Gustillo Anderson Grade 3 Subgroup

Outcome variables	Ceftriaxone	Cefazolin	p (α = 0.05)
Non-union/malunion^a			0.471
Yes	18 (23.7%)	20 (19.2%)
No	58 (76.3%)	84 (80.8%)
SSI superficial^a			0.364
Yes	8 (10.5%)	7 (6.7%)
No	68 (89.5%)	97 (93.3%)
SSI deep^a			0.472
Yes	14 (18.4%)	15 (14.4%)
No	62 (81.6%)	89 (85.6%)
Osteomyelitis^a			0.366
Yes	14 (18.4%)	14 (13.5%)
No	62 (81.6%)	90 (86.5%)
Re-operation or same extremity^a			0.269
Yes	37 (48.7%)	42 (40.4%)
No	39 (51.3%)	62 (59.6%)
Re-admission due to injury^a			0.503
Yes	27 (35.5%)	32 (30.8%)
No	49 (64.5%)	72 (69.2%)
Loss of limb^a			0.809
Yes	10 (13.2%)	15 (14.4%)
No	66 (86.8%)	89 (85.6%)
Death^a			0.968
Yes	5 (6.6%)	7 (6.7%)
No	71 (93.4%)	97 (93.3%)
UTI^a			0.243
Yes	6 (7.9%)	4 (3.8%)
No	70 (92.1%)	100 (96.2%)
Pneumonia^a			0.482
Yes	1 (1.3%)	3 (2.9%)
No	75 (98.7%)	101 (97.1%)
AKI^a			0.573
Yes	6 (7.9%)	6 (5.8%)
No	70 (92.1%)	98 (94.2%)
Hospital LOS^b	7.0 (4.0–11.0)	9.0 (5.0–16.0)	0.136
ICU LOS^b	0.0 (0.0–4.0)	0.0 (0.0–3.0)	0.519

All variables were measured against an α level of 0.05.

Denotes categorical variables measured with χ² statistics, frequency (percentage).

Denotes nonparametric continuous variables measured with independent samples Mann-Whitney U statistics; median (interquartile range).

SSI = surgical site infection; UTI = urinary tract infection; AKI = acute kidney injury; LOS = length of stay; ICU = intensive care unit.

Table 6 displays total costs per patient who sustained an open fracture. Antibiotic groups and subgroups are displayed in table. Ceftriaxone yielded lower costs per patient in each of the groups.

Table 6.

Average Total Costs per Patient of Each Antibiotic Group

Outcome variables	Ceftriaxone	Cefazolin
All grades^*	$20,542	$25,490
Grade 1 & 2^a	$16,865	$21,886
Grade 3^a	$29,471	$32,961

Denotes variable measured in American dollars.

Discussion

We saw no differences in outcomes in open extremity fracture patients who received cefazolin versus ceftriaxone. There were no statistically significant differences in infectious complications, readmissions, limb loss, or mortality between the antibiotic groups. Subgroup analysis stratifying by Gustilo-Anderson grade also did not demonstrate statistically significant differences. Multivariable analysis did not demonstrate significant confounders and demonstrated increased risk of infectious complication with increased Gustilo-Anderson grade. These results support our hypothesis that ceftriaxone is as efficacious as cefazolin in the management of open fractures.

Our results are in agreement with previous studies that have analyzed cefazolin and ceftriaxone. Eastern Association for the Surgery of Trauma (EAST) currently recommends gram-positive coverage for patients with low-grade Gustilo-Anderson open fractures at presentation and gram-negative coverage in Gustilo-Anderson grade 3 open fractures, but no specific antibiotic regimen is recommended [18]. Cefazolin has been studied and has been shown to decrease infectious complications in patients with open fractures and is one of the most widely used antibiotic agents for gram-positive coverage [1,19,20]. Studies have compared both antibiotic agents in patients sustaining open fractures caused by firearms and demonstrated no differences in outcomes [21]. No differences in outcomes of ceftriaxone and cefazolin have been demonstrated in studies outside of open fractures, which included pre-operative administration for hysterectomies, open skull fractures, and open-heart surgery [16, 22,23].

One study analyzed our treatment plan for open fractures with ceftriaxone being utilized for their Gustilo-Anderson 3 open fractures. The study demonstrated no significant differences in outcomes after protocol switch [24]. This study helps advocate that ceftriaxone could serve as effective antibiotic prophylaxis for Gustilo-Anderson 3 open fractures and eliminates aminoglycosides. A standardized antibiotic that covers Gustilo-Anderson grade 1 to 3 would also be beneficial as one antibiotic could be used for all Gustilo-Anderson grades for better adherence to appropriate antibiotic prophylaxis. Studies have demonstrated moderate adherence to Gustilo-Anderson grade 1 and 2, but poor adherence to Gustilo-Anderson 3 with a 17.2% adherence with dual cefazolin and aminoglycosides or 6.7% adherence with piperacillin-tazobactam [9]. Another study demonstrated inadequacy in antimicrobial scheme, period of antimicrobial treatment, and antimicrobial treatment for patients with open fractures [8]. Inter-observer reliability is only moderate with Gustilo-Anderson classification, which creates the opportunity for non-adherence when deciding between Gustilo-Anderson 2, and Gustilo-Anderson 3 [6,7]. This creates a dilemma when deciding antibiotic coverage during initial presentation prior to operative debridement where the full extent of the open fracture can be assessed for accurate grading. These two studies demonstrate the need for a simplified and effective scheme of antimicrobial prophylaxis for open fractures to aid providers during the initial presentation. Ceftriaxone could provide a simplified and effective scheme for use in Gustilo-Anderson grade 1 through 3.

Ceftriaxone offers other potential benefits as an antibiotic for open fractures. Ceftriaxone is dosed every 24 hours, which offers prolonged coverage compared to cefazolin. The extended coverage may shorten hospitalization for patients who require a short course of intravenous antibiotic agents [21]. This may lead to decreased costs as long as ceftriaxone does not have an increased infection rate, which was not seen in this study [25]. Our results demonstrate that ceftriaxone yields cheaper costs per patient, which included additional visits and operations. Ceftriaxone offers good tissue and body fluid penetrance [14 –17]. Although cefazolin and ceftriaxone are shown to have anti-inflammatory properties, only ceftriaxone has demonstrated analgesic effects [27,28].

This project did have some limitations. There are inconsistencies early in the data collection period of which antibiotic agents were used. Multiple patients received either both antibiotic agents or neither antibiotic agents. Although some patients fell out of the antibiotic protocol, most patients excluded had a cephalosporin allergy. Patients who received both antibiotic agents usually received cefazolin as surgical prophylaxis after receiving ceftriaxone in the trauma bay. This identified an area of multidisciplinary performance improvement. This project did not track the adherence to cefazolin dosage and administration, so some patients in the study may have been under dosed due to weight or were not administered again after eight hours. This study was underpowered and could only detect a difference of 11% due to limitations in number of open fractures following the protocol change. Trends were noted for increased complications in the cefazolin group for lower grade fractures and increased complications in the ceftriaxone group for higher-grade fractures. Multivariable analysis also yielded a non-significant trend of decreased risk of complications for patients utilizing ceftriaxone. None of these findings were significant demonstrating a need for increased power to accurately assess whether a true difference is present.

A future study will be a prospective study of both antibiotic agents. This could delineate which antibiotic is more efficacious, specifically in patients presenting with Gustilo-Anderson 3. Due to the limitations in power, this would likely need to be multi-institutional. A prospective study would also allow analysis of rates of MDR infections that possibly could arise with increased utilization of broader antimicrobial coverage.

This study demonstrates that ceftriaxone is as efficacious as cefazolin in open fractures. Ceftriaxone may be advantageous due to the dosing profile and increased half-life. Ceftriaxone is a suitable antibiotic for traumatic open long bone fracture management with useful properties that could contribute to easier administration, improved antibiotic adherence, and prolonged coverage. Ceftriaxone can be used as a single-agent antibiotic prophylaxis for all grades of open fracture to increase adherence for higher Gustilo-Anderson grade fracture for which true extent of bone devitalization may be unknown until intraoperative inspection.

Footnotes

Acknowledgments

We would like to acknowledge the Department of Othopedics for assisting with this project in terms of background knowledge on the topic and utilizing our mutual patient population. As corresponding author, I would like to acknowledge the efforts by the four students who put in many hours harvesting this data from the electronic health records. It would not have been possible without their efforts.

This project was presented at the annual meeting of Tennessee American College of Surgeons, August 5–8, 2021, Memphis, Tennessee.

Authors' Contributions

All authors have contributed to this manuscript. Detailed contributions are as follows.

Methodology (lead): Salomon. Validation (lead): Salomon. Writing–original draft (lead): Salomon. Writing–review and editing (lead): Salomon. Writing–original draft: Patel, Wideman, Mcgee, Price, Heidel. Writing–review and editing: McKnight.Writing–draft with revisions: Rowe. Project administration (lead): Salomon. Visualization (lead): Salomon. Conceptualization (lead): Griffard.

Data curation (equal): Patel, Wideman, Mcgee, Corbitt. Formal analysis (equal): Price, Heidel. Multivariable analysis: Rowe. Supervision (lead): McKnight. Project administration: McKnight.

Funding Information

No external funding was received for this project.

Author Disclosure Statement

None of the authors have any disclosures.

Our study was reviewed by UT Knoxville Institutional Review Board (IRB) and given exempt status under IRB number 4662 due to retrospective nature. All data was protected and deidentified. No patient contact was needed for this project and consent was not obtained.

All of the data was from the electronic health records at University of Tennessee in Knoxville without the use of external sources.

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