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Peer-reviewedCC BY-NC 4.0Neurotrauma Reports

Antimicrobial Strategies for Open Depressed Skull Fractures: A 60-Year Scoping Review and Path Forward

  • Ruan Grobler1
  • Zandre Calitz2
  • Adriaan J. Vlok3
  1. 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.
  2. 2Paarl Provincial Hospital, Paarl, Western Cape, South Africa.
  3. 3Division of Neurosurgery, University of Stellenbosch, Cape Town, Western Cape, South Africa.
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Abstract

Open depressed skull fractures (DSFs) carry a high risk of intracranial sepsis, yet antimicrobial prophylaxis lacks standardized protocols. This scoping review synthesizes 60 years of evidence to map regimen variability, assess evidence quality, and propose strategies for reducing sepsis through targeted antimicrobial use and stewardship. Following PRISMA-ScR guidelines, we searched PubMed, Scopus, Embase, Web of Science, AANS abstracts, and ClinicalTrials.gov (1965–2025) for studies on open DSFs with sample sizes >20, focusing on antibiotic regimens and infection outcomes. Data on agents, dosage, timing, duration, and sepsis rates were extracted. Study quality was assessed using the Newcastle–Ottawa Scale and Cochrane Risk of Bias Tool. Heterogeneity was evaluated to determine the meta-analysis feasibility. Of 1,286 records, 46 studies were included, with 90% retrospective and Newcastle–Ottawa scores of 3–7 out of 9. Only 28% reported dosage, 19% timing, and none used standardized protocols. Infection rates were 8.5% (95% confidence interval [CI]: 6.2–10.8) for single-agent and 6.8% (95% CI: 4.9–8.7) for multi-agent regimens. High heterogeneity (I2 > 75%) precluded meta-analysis. Terminological ambiguity (e.g., prophylaxis vs. preemptive treatment) further complicated evidence synthesis. Persistent variability and poor reporting in DSF antimicrobial prophylaxis underscore the need for standardized protocols and precise terminology. Prospective trials and stewardship-focused guidelines are critical to reduce sepsis and optimize outcomes.

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Cite

BibTeXRIS
BibTeX
@article{grobler2026antimicrobial,
  title = {{Antimicrobial Strategies for Open Depressed Skull Fractures: A 60-Year Scoping Review and Path Forward}},
  author = {Ruan Grobler and Zandre Calitz and Adriaan J. Vlok},
  journal = {Neurotrauma Reports},
  year = {2026},
  month = sep,
  doi = {10.1177/2689288x261434450},
  url = {https://doi.org/10.1177/2689288x261434450},
  note = {CC BY-NC 4.0},
}
RIS
TY  - JOUR
TI  - Antimicrobial Strategies for Open Depressed Skull Fractures: A 60-Year Scoping Review and Path Forward
AU  - Ruan Grobler
AU  - Zandre Calitz
AU  - Adriaan J. Vlok
PY  - 2026
DA  - 2026/09/20
JO  - Neurotrauma Reports
DO  - 10.1177/2689288x261434450
UR  - https://doi.org/10.1177/2689288x261434450
AB  - Open depressed skull fractures (DSFs) carry a high risk of intracranial sepsis, yet antimicrobial prophylaxis lacks standardized protocols. This scoping review synthesizes 60 years of evidence to map regimen variability, assess evidence quality, and propose strategies for reducing sepsis through targeted antimicrobial use and stewardship. Following PRISMA-ScR guidelines, we searched PubMed, Scopus, Embase, Web of Science, AANS abstracts, and ClinicalTrials.gov (1965–2025) for studies on open DSFs with sample sizes >20, focusing on antibiotic regimens and infection outcomes. Data on agents, dosage, timing, duration, and sepsis rates were extracted. Study quality was assessed using the Newcastle–Ottawa Scale and Cochrane Risk of Bias Tool. Heterogeneity was evaluated to determine the meta-analysis feasibility. Of 1,286 records, 46 studies were included, with 90% retrospective and Newcastle–Ottawa scores of 3–7 out of 9. Only 28% reported dosage, 19% timing, and none used standardized protocols. Infection rates were 8.5% (95% confidence interval [CI]: 6.2–10.8) for single-agent and 6.8% (95% CI: 4.9–8.7) for multi-agent regimens. High heterogeneity (I2 > 75%) precluded meta-analysis. Terminological ambiguity (e.g., prophylaxis vs. preemptive treatment) further complicated evidence synthesis. Persistent variability and poor reporting in DSF antimicrobial prophylaxis underscore the need for standardized protocols and precise terminology. Prospective trials and stewardship-focused guidelines are critical to reduce sepsis and optimize outcomes.
SN  - 2689-288X
ER  -