There is a groundswell of interest in use of topical antibiotic powders (TAP) for prophylaxis in wounds with contaminated fractures. Recent large animal studies comparing TAP and antibiotic PMMA beads in wounds treated with NPWT show that TAP achieves higher sustained wound concentrations and is more effective at curbing bacterial growth.18 Analysis of the collected NPWT drainage indicates about half of the antibiotic is removed with suction, indicating that the amount of powder can be increased when used in conjunction with NPWT. A recent prospective randomized multicenter trial of 980 patients with tibial plateau or pilon fractures at high risk of infection showed a 33% relative risk reduction in deep surgical site infection (SSI) using 1gm of topical vancomycin powder immediately before wound closure. Analysis of the infecting organisms showed that the difference in overall infection rate was directly attributable to gram positive sensitivity to vancomycin, with a 50% relative risk reduction in gram positive deep SSI and no effect on gram negative deep SSI. Fractures without soft tissue coverage or with combined vascular injuries were excluded from enrollment.19 There is insufficient data at this time to advocate widespread antibiotic powder use during serial debridement of war wounds with concomitant fracture.