Antibiotic Prophylaxis

As discussed in other chapters, antibiotic prophylaxis is effective when a wound has more than baseline bacterial contamination, antibiotics effective against expected pathogens are chosen, and such antibiotics are given as soon as possible to achieve antimicrobial blood levels before repair. However, as commonly practiced, antibiotic prophylaxis from the ED is suspect for the following reasons: (1) the use of antibiotics for simple, uncomplicated lacerations fails to satisfy the first requirement; (2) the use of cephalexin for cat bites fails to meet the second requirement; and (3) handing the patient a prescription on discharge fails the third. 6 Antibiotic prophylaxis should be initiated in the ED, before significant wound manipulation, and with agents that rapidly achieve antibacterial blood levels.

The following types of wounds have shown evidence to support the use of continued antibiotic prophylaxis upon discharge from the ED:

1. Intraoral lacerations: penicillin

2. Complicated human bites: amoxicillin/clavulanate or penicillin plus a first-generation cephalosporin

3. Complicated dog bites: amoxicillin/clavulanate or penicillin plus a first-generation cephalosporin

4. Cat bites: penicillin or amoxicillin/clavulanate

5. Plantar puncture wounds, particularly through athletic shoes: ciprofloxacin

Although antibiotic prophylaxis is commonly employed for patients with comorbid conditions predisposing to wound infection (diabetes, cirrhosis, advanced age, and immunosuppression), there is little supporting evidence for this practice in all circumstances except for the types of wounds described above.

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