Antibiotics are indicated in all open wounds, regardless of the mechanism of injury. Proper wound care, including irrigating the wound, should be performed; but even when wounds are properly treated, antibiotics should be initiated.

Highlighting this issue, it should be noted that extremity injuries have been prevalent in recent conflicts and infections have caused significant morbidity. For example, osteomyelitis has been reported in up to 9% of type III tibia fractures, and extremity infections have led to decreased success in limb salvage, an increase in additional surgical procedures and late amputations, as well as a decrease in the likelihood of the casualty being able to return to duty.

As just mentioned, the safety profile of both oral and parenteral antibiotics on the battlefield has been very good, and the only contraindication is a known drug allergy. As with any medication, there is a small risk of an adverse drug reaction that would require management, but to date that has rarely happened, and the benefits of early infection prevention far outweigh the small risk of an adverse reaction.

One of the considerations in choosing the best antibiotic is the need for effectiveness across a broad range of pathogens, as opposed to the process of choosing antibiotics in a normal clinical setting where you use the wound site, potential pathogens known to exist in the environment, and the patient’s health status to determine the best treatment choice. Also, a desire for minimal side effects, environmental stability, simple and infrequent dosage regimens, and comparatively low cost are all important considerations.

Since 2002, fourth-generation fluoroquinolones have been the oral antibiotic of choice. The second-generation cephalosporin cefotetan was initially the parenteral antibiotic of choice, but in 2011 ertapenem (a carbapenem antibiotic) was added as an alternative option, and then in 2017, ertapenem became the antibiotic of choice. Ertapenem and moxifloxacin are not ideal prophylaxis for every type of wound, but they are safe and effective broad-spectrum antibiotics. They are also recommended for prehospital care of penetrating wounds of the chest or abdomen in the current Joint Trauma System Infection Prevention Clinical Practice Guideline.