Laceration — Considerations for All Wounds: Antibiotic Prophylaxis — Clinical Pathway: Emergency

Laceration Clinical Pathway — Emergency Department

Antibiotic: General Principles

  • Most injuries do not require pre-emptive antibiotics unless they meet the criteria below or there is evidence of active infection
  • If indicated, antibiotic therapy is directed at the most common organisms based on the site and source of the injury

Target Pathogens

Injury Target Pathogens
Intraoral Injury/
Human Bite
  • Streptococcus spp.
  • Staphylococcus aureus
  • Eikenella corrodens
  • Fusobacterium spp.
  • Peptostreptococcus spp.
  • Prevotella spp.
  • Porphyromonas spp.
Puncture Wound
  • Staphylococcus aureus
  • Group A Streptococcus
Open Fracture Staphylococcus aureus
Cat or Dog Bite
  • Pasteurella spp.
  • Staphylococcus aureus
  • Streptococcus spp.
  • Anaerobes
  • Capnocytophaga spp.
  • Moraxella spp.
  • Corynebacterium spp.
  • Neisseria spp.

Indications and Choice of Antibiotics Following Bites and Wounds

  • Pre-emptive antibiotics should be given for 3-5 days; consider re-evaluation within 48 hrs to assess for signs of infection
  • Treat infected wounds for at least 5-10 days; duration determined by severity
Injury Comments First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative
Intraoral Injury
  • Antibiotics should be considered in the following scenarios:
    • Wounds contaminated by debris or foreign body
    • Through and through lip lacerations
    • Full thickness, extensive mucosal lacerations
  • Amoxicillin/clavulanate, PO
    • 45 mg/kg/day of amoxicillin component divided
      twice daily
    • Max: 1,750 mg amoxicillin/day
    • Use only 7:1 formulation
      (e.g., amoxicillin/clavulanate 400 mg/57 mg per 5 mL, amoxicillin/clavulanate 875 mg/125 mg tablet)
  • Clindamycin, PO
    • 10 mg/kg/dose three times daily
    • Max: 600 mg/dose
Puncture Wounds
  • Antibiotics should be considered in the following scenarios:
    • Contaminated puncture wound, particularly deep wounds with concern for retained foreign material
    • Immunocompromised
    • Injuries through intact shoe
  • Pseudomonas coverage is not routinely recommended following plantar puncture wounds
  • Cephalexin, PO
    • 50 mg/kg/day in three divided doses
    • Max: 500 mg/dose
  • Clindamycin, PO
    • 10 mg/kg/dose three times daily
    • Max: 600 mg/dose
Bite Wounds
Dog
Cat
Human
  • Pre-emptive therapy should be considered in the following scenarios:
    • Immunocompromised, asplenic, or have advanced liver disease
    • Moderate or severe wounds
    • Wounds with edema or injuries
      that may have penetrated bones
      or joints
    • Puncture wounds following cat bites
    • Bites to the face, hand, or genitals
  • See sections on rabies and
    tetanus prophylaxis
  • Amoxicillin/clavulanate, PO
    • 45 mg/kg/day of amoxicillin component divided
      twice daily
    • Max: 1,750 mg amoxicillin/day
  • Use only 7:1 formulation
    (e.g., amoxicillin/clavulanate 400 mg/57 mg per 5 mL, amoxicillin/clavulanate 875 mg/125 mg tablet)
  • Sulfamethoxazole/
    trimethoprim, PO
    • 5 mg TMP/kg/dose every
      12 hours
    • Max: 160 mg TMP/dose
  • and
  • Clindamycin, PO
    • 10 mg/kg/dose three times daily
    • Max: 600 mg/dose
Open Fracture Open Long Bone Fracture Pathway
Cellulitis or Abscess of Previously Repaired Wound
  • Antibiotic choice is determined by the source, type, and location of the wound
  • Cultures should be obtained when possible to direct definitive antibiotic therapy
  • Recommend ID consult