Antibiotic prophylaxis in trauma and orthopedic surgery: Current practices across 36 German hospitals and comparison with recently published national guidelines

TL;DR

This study examines antibiotic use in German trauma and orthopedic surgeries, comparing current practices with new national guidelines to identify areas of deviation and potential overuse.

Contribution

The study provides a detailed comparison of antibiotic prophylaxis practices in 36 German hospitals against newly published national guidelines.

Findings

Most hospitals use first- or second-generation cephalosporins for closed fractures with single-shot administration.

Extended antibiotic prophylaxis beyond 72 hours in type III open fractures and frequent use in distal phalanx injuries deviate from guidelines.

Local vancomycin powder is commonly used in spine surgery despite not being recommended in guidelines.

Abstract

Antibiotic prophylaxis is a key component of infection prevention in trauma and orthopedic surgery. Until 2024, no uniform nationwide guidelines existed in Germany regarding the optimal choice, dosage, and duration of perioperative antibiotic use.

A nationwide survey was conducted among 36 German trauma and orthopedic centers to assess current practices of antibiotic prophylaxis in closed and open fractures, primary arthroplasty, and posterior spinal instrumentation. The questionnaire included the choice and duration of systemic antibiotics, empirical strategies, and the use of local antibiotics such as vancomycin powder. The current practice was then compared to the recently published S3-guideline “Perioperative and periinterventional antibiotic prophylaxis” (AWMF 067-009; https://register.awmf.org/de/leitlinien/detail/067-009) in Germany.

For closed fractures, 94.4% of hospitals used first- or second-generation cephalosporins, with single-shot administration. In Gustilo–Anderson (GA) type I open fractures, cefuroxime and ampicillin/sulbactam were each used by 13 hospitals (36.1%), with 63.9% applying a single-shot regimen. In type III open fractures, piperacillin/tazobactam was most common (33.3%), and 72 h prophylaxis was most frequently reported in both type II and III fractures (38.9%). In distal phalanx fractures, 94.4% of hospitals administered systemic antibiotics despite guideline recommendations to omit prophylaxis when no osteosynthesis is required. In arthroplasty, cefuroxime (50.0%) and cefazolin (41.7%) predominated, with single-shot use in 94.4%. In spine surgery, 38.9% additionally used local vancomycin powder.

While guideline adherence is high in routine indications, significant deviations remain in open fractures and distal phalanx fractures of the fingers. Extended prophylaxis beyond 72 h in GA type III fractures and the frequent use of antibiotics in distal phalanx injuries contrast with current recommendations. Stronger implementation of national standards is essential to reduce overtreatment and support antimicrobial stewardship.

The questionnaire used in this study is available in the online version of this article (10.1007/s00113-025-01659-7).

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