---
title: "Topical antibiotic powder reduces fracture-related infections in pelvic and lower-limb fractures"
id: "pubmed-42560574"
canonical_url: "https://medichelpline.com/clinical-feed/pubmed-42560574"
content_type: "clinical_feed_article"
specialty: "Pharmacology"
source_name: "PubMed / NCBI"
source_url: "https://pubmed.ncbi.nlm.nih.gov/42560574/"
doi: "10.1007/s00590-026-04882-z"
published_at: "2026-08-06T00:00:00.000Z"
evidence_level: "Journal Article"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Topical antibiotic powder reduces fracture-related infections in pelvic and lower-limb fractures
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/pubmed-42560574
- **Specialty:** [Pharmacology](https://medichelpline.com/clinical-feed/pharmacology.md)
- **Primary Source:** PubMed / NCBI
- **Source URL:** [Original Journal Publication](https://pubmed.ncbi.nlm.nih.gov/42560574/)
- **DOI:** [10.1007/s00590-026-04882-z](https://doi.org/10.1007%2Fs00590-026-04882-z)
- **Published At:** 2026-08-06T00:00:00.000Z
- **Evidence Rating:** Journal Article
## Executive GIST (TL;DR)
- Fracture-related infection (FRI) remains a major public health concern after operative treatment of pelvic and lower-limb fractures. The review evaluated intrawound **topical antibiotic powder** (vancomycin and/or tobramycin) versus standard systemic prophylaxis. - A systematic search identified 14 studies (three randomized controlled trials and 11 observational studies) including 4,906 patients; 1,779 received topical antibiotic powder. - Pooled analysis found topical powder reduced the odds of **FRI** (OR 0.63; 95% CI 0.45–0.87), corresponding to a 37% relative reduction in odds overall. - The largest relative benefits were seen in high-risk and open fractures (OR 0.54 and OR 0.49, respectively). - No significant impact was observed on **superficial surgical site infection** (OR 0.79; 95% CI 0.51–1.21) or **nonunion** (OR 1.03; 95% CI 0.64–1.66). - A shift in microbiology was reported: **Gram-negative organisms** were more frequent with topical powder (OR 2.52; 95% CI 1.24–5.14), while Gram-positive trends favored the intervention (OR 0.42; 95% CI 0.16–1.08). - No significant difference was found for **acute kidney injury** (AKI) (OR 0.94; 95% CI 0.44–2.02) or hospital length of stay (MD -1.72 days; 95% CI -4.05 to 0.61). - Certainty of evidence was rated moderate overall but derived predominantly from observational studies; safety outcomes were based on few studies with low to very low certainty and warrant cautious interpretation. - Authors conclude intrawound antibiotic powder is associated with reduced FRI without increased nonunion or AKI, but the observed microbiologic shift and limited safety data require further investigation.
## Clinical Analysis & Structured Key Points
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Affiliations Expand ### Affiliations * 1 Afya Centro Universitário Itaperuna, Itaperuna, Brazil. * 2 Hospital São Vicente de Paulo, Rio de Janeiro, Brazil. * 3 Hospital Ortopédico do Estado da Bahia, Salvador, Brazil. * 4 Universidad de Las Américas, Quito, Ecuador. * 5 Prefeitura da Cidade do Rio de Janeiro, Rio de Janeiro, Brazil. * 6 Spitalzentrum Oberwallis, Glis, Switzerland. * 7 Prefeitura da Cidade do Rio de Janeiro, Rio de Janeiro, Brazil. v_giordano@me.com. * PMID: **42560574** * DOI: [ 10.1007/s00590-026-04882-z ](https://doi.org/10.1007/s00590-026-04882-z) Item in Clipboard Review # Topical antibiotic powder reduces fracture-related infections in pelvic and lower limb fractures: a systematic review and meta-analysis João Pedro Campos Lima et al. Eur J Orthop Surg Traumatol. 2026. Show details Display options Display options Format Abstract PubMed PMID Eur J Orthop Surg Traumatol Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Eur+J+Orthop+Surg+Traumatol%22%5Bjour%5D&sort=date&sort_order=desc) * [ Search in NLM Catalog ](https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Eur+J+Orthop+Surg+Traumatol%22%5BTitle+Abbreviation%5D) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) . 2026 Aug 6;36(1):324. doi: 10.1007/s00590-026-04882-z. ### Authors [João Pedro Campos Lima](https://pubmed.ncbi.nlm.nih.gov/?term=Lima+JPC&cauthor_id=42560574)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42560574/#short-view-affiliation-1 "Afya Centro Universitário Itaperuna, Itaperuna, Brazil.")[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42560574/#short-view-affiliation-2 "Hospital São Vicente de Paulo, Rio de Janeiro, Brazil."), [Ilana Moreira Araujo](https://pubmed.ncbi.nlm.nih.gov/?term=Moreira+Araujo+I&cauthor_id=42560574)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42560574/#short-view-affiliation-3 "Hospital Ortopédico do Estado da Bahia, Salvador, Brazil."), [Steven Patricio Valarezo-Brazales](https://pubmed.ncbi.nlm.nih.gov/?term=Valarezo-Brazales+SP&cauthor_id=42560574)[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42560574/#short-view-affiliation-4 "Universidad de Las Américas, Quito, Ecuador."), [Daniela Ramos Bueno Rivas](https://pubmed.ncbi.nlm.nih.gov/?term=Rivas+DRB&cauthor_id=42560574)[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42560574/#short-view-affiliation-5 "Prefeitura da Cidade do Rio de Janeiro, Rio de Janeiro, Brazil."), [Igors Terjajevs](https://pubmed.ncbi.nlm.nih.gov/?term=Terjajevs+I&cauthor_id=42560574)[ 6 ](https://pubmed.ncbi.nlm.nih.gov/42560574/#short-view-affiliation-6 "Spitalzentrum Oberwallis, Glis, Switzerland."), [Vincenzo Giordano](https://pubmed.ncbi.nlm.nih.gov/?term=Giordano+V&cauthor_id=42560574)[ 7 ](https://pubmed.ncbi.nlm.nih.gov/42560574/#short-view-affiliation-7 "Prefeitura da Cidade do Rio de Janeiro, Rio de Janeiro, Brazil. v_giordano@me.com.") ### Affiliations * 1 Afya Centro Universitário Itaperuna, Itaperuna, Brazil. * 2 Hospital São Vicente de Paulo, Rio de Janeiro, Brazil. * 3 Hospital Ortopédico do Estado da Bahia, Salvador, Brazil. * 4 Universidad de Las Américas, Quito, Ecuador. * 5 Prefeitura da Cidade do Rio de Janeiro, Rio de Janeiro, Brazil. * 6 Spitalzentrum Oberwallis, Glis, Switzerland. * 7 Prefeitura da Cidade do Rio de Janeiro, Rio de Janeiro, Brazil. v_giordano@me.com. * PMID: **42560574** * DOI: [ 10.1007/s00590-026-04882-z ](https://doi.org/10.1007/s00590-026-04882-z) Item in Clipboard Cite Display options Display options Format Abstract PubMed PMID ## Abstract **Aims:** Fracture-related infection (FRI) remains a significant public health issue. Intrawound vancomycin and tobramycin powder achieve high local antibiotic concentrations, yet their efficacy and safety remain uncertain. We aimed to evaluate the effect of prophylactic topical antibiotic powder in patients undergoing operative treatment for pelvic and lower-limb fractures. **Methods:** PubMed, Embase, and the Cochrane Library were systematically searched for randomized controlled trials (RCTs) and observational studies comparing intrawound antibiotic powder (vancomycin and/or tobramycin) with standard systemic prophylaxis in operatively treated pelvic and lower limb fractures. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using random-effects models, and the certainty of evidence was assessed with the GRADE approach. **Results:** Fourteen studies (three RCTs and 11 observational studies) comprising 4906 patients were included, of whom 1779 received topical antibiotic powder. Topical antibiotic powder reduced the odds of FRI (OR 0.63; 95% CI 0.45 to 0.87), with the greatest effect in high-risk and open fractures (OR 0.54 and 0.49, respectively). No significant effect was observed on superficial surgical site infection (OR 0.79; 95% CI 0.51 to 1.21) or nonunion (OR 1.03; 95% CI 0.64 to 1.66). Gram-negative organisms were more frequent in the intervention group (OR 2.52; 95% CI 1.24 to 5.14), whereas the trend for Gram-positive organisms favored the intervention (OR 0.42; 95% CI 0.16 to 1.08). No significant difference was found for acute kidney injury (AKI) (OR 0.94; 95% CI 0.44 to 2.02) or length of hospital stay (MD - 1.72 days; 95% CI - 4.05 to 0.61). **Conclusion:** Moderate-certainty evidence, derived predominantly from observational studies, indicates that intrawound antibiotic powder is associated with a 37% reduction in FRI without an increase in nonunion or AKI. However, the safety outcomes were informed by a few studies with low to very low certainty and should be interpreted with caution; the observed shift toward Gram-negative infections warrants further investigation. **Keywords:** Antibiotic prophylaxis; Bone fracture; Fracture-related infection; Lower extremity; Powder; Topical administration. © 2026. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature. [PubMed Disclaimer](https://pubmed.ncbi.nlm.nih.gov/disclaimer/) ## Conflict of interest statement Declarations. Competing Interests: The authors declare no competing interests. Ethical approval: Ethical approval is not required for this study as it is based on previously published data. ## References 1. 1. Berríos-Torres SI, Umscheid CA, Bratzler DW et al (2017) Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 152(8):784. - [DOI](https://doi.org/10.1001/jamasurg.2017.0904) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/28467526/) 2. 1. Giordano V, Giannoudis PV (2024) Biofilm formation, antibiotic resistance, and infection (BARI): the triangle of death. J Clin Med 13(19):5779. - [DOI](https://doi.org/10.3390/jcm13195779) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/39407838/) - [PMC](https://pmc.ncbi.nlm.nih.gov/articles/11476620/) 3. 1. Moriarty TF, Metsemakers WJ, Morgenstern M et al (2022) Fracture-related infection. Nat Rev Dis Primers 8(1):67. - [DOI](https://doi.org/10.1038/s41572-022-00396-0) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/36266296/) 4. 1. Natoli RM, Marchand LS, Bzovsky S et al (2025) Infection and nonunion rates in open fractures: description of 6,042 fractures from the FLOW and PREP-IT trials. J Bone Joint Surg Am 107(22):2541–2553. - [DOI](https://doi.org/10.2106/jbjs.24.01055) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/41315040/) - [PMC](https://pmc.ncbi.nlm.nih.gov/articles/12614385/) 5. 1. Mills LA, Aitken SA, Simpson AHRW (2017) The risk of non-union per fracture: current myths and revised figures from a population of over 4 million adults. Acta Orthop 88(4):434–439. - [DOI](https://doi.org/10.1080/17453674.2017.1321351) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/28508682/) - [PMC](https://pmc.ncbi.nlm.nih.gov/articles/5499337/) Show all 51 references ## Publication types * Systematic Review Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Systematic+Review%22%5Bpt%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Systematic+Review) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) * Meta-Analysis Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Meta-Analysis%22%5Bpt%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Meta-Analysis) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) * Review Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Review%22%5Bpt%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Review) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) ## MeSH terms * Administration, Topical Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Administration%2C+Topical%22%5BMeSH%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Administration%2C+Topical) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) * Anti-Bacterial Agents* / administration & dosage Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Anti-Bacterial+Agents%2Fadministration+and+dosage%22%5BMAJR%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Anti-Bacterial+Agents) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) * Antibiotic Prophylaxis* / methods Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Antibiotic+Prophylaxis%2Fmethods%22%5BMAJR%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Antibiotic+Prophylaxis) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) * Fractures, Bone* / complications Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Fractures%2C+Bone%2Fcomplications%22%5BMAJR%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Fractures%2C+Bone) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) * Fractures, Bone* / surgery Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Fractures%2C+Bone%2Fsurgery%22%5BMAJR%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Fractures%2C+Bone) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) * Fractures, Open / surgery Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Fractures%2C+Open%2Fsurgery%22%5BMeSH%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Fractures%2C+Open) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) * Humans Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Humans%22%5BMeSH%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Humans) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) * Pelvic Bones* / injuries Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Pelvic+Bones%2Finjuries%22%5BMAJR%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Pelvic+Bones) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) * Powders Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Powders%22%5BMeSH%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Powders) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42560574/) * Surgical Wound Infection* / prevention & control Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Surgical+Wound+Infection%2Fprevention+and+control%22%5BMAJR%5D&sort=date&sort_order=desc) * [ Search in MeSH ](https://www.ncbi.nlm.nih.gov/mesh?term=Surgical+Wound+Infec
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