Early complications of antibiotic prophylaxis with cefazolin protocols versus piperacillin-tazobactam for open fractures: a retrospective comparative study

Background: We sought to determine the rates of superficial infection and wound healing complications, return to the operating room for deep infection, and acute nephrotoxicity after treatment of Gustilo type II or III open fractures treated with cefazolin, cefazolin plus aminoglycoside, or piperacillin-tazobactam, in addition to operative debridement and fracture fixation. Methods: A retrospective review of a level 1 trauma center from January 2012 to December 2017 identified 202 patients with Gustilo type II or III open fractures of the extremities treated with either cefazolin (n=65), cefazolin plus an aminoglycoside (n=47), or piperacillin-tazobactam (n=90), in addition to irrigation and debridement and fracture fixation. Associations between antibiotic regimen and rates of superficial infection, wound healing complications, return to the operating room for deep infection, and acute nephrotoxicity were determined. Results: Compared to piperacillin-tazobactam, both cefazolin-based regimens had higher risks of delayed wound healing or superficial infection [Odds Ratio (OR) 2.49; P=0.047 & OR 3.35; P=0.005]. Compared to piperacillin-tazobactam, use of cefazolin alone had higher independent odds of deep infection requiring return to the operating room (OR 3.65; P=0.009). Compared to piperacillin-tazobactam, there was a trend toward higher odds of nephrotoxicity with use of cefazolin plus an aminoglycoside (OR 3.29; P=0.08). Conclusions: Compared to cefazolin based antibiotic regimens, with or without an aminoglycoside, piperacillin-tazobactam single agent therapy may lower the risk of superficial infection or wound healing complications after operative fixation of type II and III open fractures and may also decrease inpatient risk of nephrotoxicity.