Antibiotics in the treatment of low-velocity gunshot-induced fractures: a systematic literature review.

BACKGROUND Low-velocity gunshots are often associated with extremity fractures. There is no consensus, however, on the use of antibiotics for these injuries. QUESTIONS/PURPOSES We performed a literature review to answer the following questions: (1) Are antibiotics needed for the treatment of these fractures? (2) Is gram-negative coverage necessary? (3) How long should antibiotics be administered? And (4) which is the optimal administration route? METHODS We conducted a MEDLINE(®) search and found only two relevant prospective, randomized studies. Further searches identified all case series with information on the use of antibiotics in gunshot fractures. In total, 33 studies provided enough data to answer the study questions. An assessment of the quality of the identified studies was performed. Twenty-three studies met at least ½ of the quality items of the assessment tool. RESULTS Antibiotics did not significantly reduce the infection rate for fractures treated nonoperatively (1.7% with antibiotics versus 5.1% without) with the numbers available. There was no significant difference in infection rates when gram-negative coverage was added, either in nonoperatively treated fractures (1.7% versus 2.8%) or in operatively treated fractures (0% versus 2.5%). Duration of antibiotic administration did not significantly affect the infection rate. No difference was found between intravenous and oral antibiotic administration for nonoperatively treated fractures. CONCLUSIONS This literature review could not demonstrate a significant benefit with the use of antibiotics for low-velocity gunshot fractures treated nonoperatively; however, the statistical power for these comparisons was low in the available literature, which is insufficiently strong to recommend a treatment. Gram-negative coverage did not alter the infection rates in gunshot fractures, nor did longer duration of antibiotic administration. For fractures treated nonoperatively, oral antibiotics are as efficacious as intravenous antibiotics.