Introduction

Gunshot injuries, particularly those resulting from low-velocity projectiles, present unique challenges to healthcare providers, with 84,258 recorded incidents of non-fatal gunshot wounds (GSW) in the USA in 2013 (Fowler, Dahlberg, Haileyesus, & Annest, 2015). Gunshot wounds result in around $48 billion in medical expenses and lost wages annually [1, 2]. Local infection related to the penetrating projectile is a frequent long-term consequence of gunshot-induced trauma [3]. In the treatment of open fractures caused by blunt trauma and high-velocity gunshot-induced fracture, the addition of antibiotic therapy to adequate wound debridement is well-established [4,5,6]. However, variations in treatment approaches, including the use of different types of antibiotics or the absence of antibiotic therapy altogether, have given rise to uncertainty regarding the most effective treatment strategy [7, 8].

It has been postulated that bullets are automatically disinfected upon firing; however, this has been disproven. Yet, it has led some to conclude that gunshot-induced fractures pose a minimal risk for infection [8]. This has resulted in a debate about the appropriate treatment for LVGF. Historically, gunshot-induced fractures have been categorized as either low- or high-velocity injuries, with the difference often established between projectile speeds of 1,000 and 2,000 feet per second (ft/s) [7, 9]. High-velocity injuries almost always need surgical treatment, including antibiotic prophylaxis [7].

Hence, the question is that among the two options of antibiotic treatment versus no antibiotic treatment, which one leads to improved clinical outcomes, including infection rates and complication rates in patients with low-velocity gunshot fractures (LVGFs). Also, it is beneficial to understand variations in antibiotic prescription patterns and the factors influencing treatment decisions among orthopaedic surgeons. Papasoulis et al. published the last systematic review on antibiotic treatment in low-velocity gunshot injuries in 2013, where they conducted a post hoc analysis of 23 papers, with a total of 1156 LVGFs, and found a trend towards decreased infections when antibiotics were administered [10].

To address this critical issue, we conducted an updated review to explore antibiotic treatment’s impact on clinical outcomes in patients with LVGF. Our review question specifically addresses whether antibiotic treatment, compared to no antibiotic treatment or alternative antibiotic regimens, leads to improved clinical outcomes, encompassing infection rates, complication rates, and fracture healing. In addition, we also aim to explore the current practice of antibiotic use in LVGF across different limb regions. Our second question seeks to understand the variations in antibiotic prescription patterns and the factors influencing treatment decisions.

Methods

On January 31, 2023, a comprehensive search was conducted across multiple electronic databases, including PubMed, Embase, and Web of Science. To facilitate the article selection process, we used Covidence, a web-based software platform that streamlines the screening and selection of relevant articles.

The inclusion criteria were studies published in English that investigated the use of antibiotics to treat LVGFs in human patients, studies involving patients with LVGF, those that compared antibiotic treatment with no antibiotic treatment or different types of antibiotics, and those that report relevant clinical outcomes (infection rates, complication rates, or fracture healing), and all published after the latest published systematic review in 2013. The exclusion criteria were studies that did not focus on LVGFs, did not involve human patients, did not investigate the use of antibiotics, were not original research articles, and were not available in full text. Animal studies, case reports, review articles, editorials, letters, and conference abstracts were also excluded.

In this review, we did not involve a meta-analysis due to the lack of quantitative clinical trial studies but rather employed a narrative synthesis approach to analyze and present the findings from the included primary studies, which involves a descriptive summary of the study characteristics, interventions, and outcomes, enabling a comprehensive understanding of the current evidence on antibiotic treatment in patients with LVGF. To minimize the impact of publication bias, a comprehensive search strategy was employed to identify both published and unpublished literature (please see Appendix). “””””Multiple electronic databases were searched, including gray literature and conference proceedings. The protocol for this study has been registered in the PROSPERO register (ID = CRD42023397381).

Results

A total of 511 studies were excluded from 578 articles, and after a thorough evaluation of the remaining 67 publications, we included 17 studies that met the inclusion criteria in our review.

Due to the lack of quantitative clinical trial studies, we employed a narrative synthesis approach to analyze and present the findings from the included primary studies. To facilitate comparison across studies, we categorized the outcomes based on the anatomical location of the LVGFs. Table 1 presents the data extraction of the 17 included articles. The table shows the author, year of publication, study design, sample size, fracture location, antibiotic regimen, infection rate, and follow-up period for each study. All the studies included received a score of 5 or greater on the Newcastle-Ottawa Scale.

Table 1 Summary of included studies on antibiotic treatment for low-velocity gunshot fractures
Full size table

Humeral fractures

In 2014, Vaidya et al. [11] conducted a retrospective case series involving 54 patients who had sustained humerus fractures due to LVGFs. Among the cohort of 54 patients, 29 received non-operative intervention, which involved secondary intention wound healing and intravenous administration of antibiotics. Non-operative treatment was initiated with a coaptation splint followed by functional bracing. Wounds were treated by applying a sterile dressing as a primary approach, rather than opting for formal exploration and bullet fragment removal unless they were superficial to be easily removed. In such cases, the wounds were intentionally left open to heal through secondary intention. Furthermore, oral antibiotics (cephalexin) were administered for three to five days. Of all patients, 25 received operative treatment, which included patients with polytrauma, vascular injury, obese women who had difficulty with functional bracing, or large soft tissue defects. The operation included open reduction and internal fixation using a plate and screws, an external fixator, or an intramedullary rod; two patients had irrigation and debridement (I&D) followed by fracture immobilization using a brace. All patients who underwent operative treatment were administered IV cephazolin for 48 h. Finally, infection was reported in just two patients (4%); both underwent surgical intervention.

Forearm injuries

In 2018, Mehta [12] reported a retrospective series of 56 cases of LVBF of forearm bone over five years. They reported no deep infection; eight patients did not receive prophylactic antibiotics upon admission, and two did not receive post-operative antibiotics.

Veltre et al. [13] conducted a multicenter study, which included 198 cases of forearm fractures, involving 168 patients across nine level 1 trauma centres. Of the total number of cases, 167 (85%) were caused by low-velocity, which led to 13 cases (8%) of infection during the follow-up period. One hundred fifty-two patients were administered antibiotics, while 16 (10%) were not. The operative treatment included an initial I&D followed by some form of internal fixation such as plates, screws, or intramedullary nails. Cefazolin was the most commonly administered antibiotic. The study reported a 10% infection rate. Interestingly, there was no statistical difference in infection between patients given antibiotics and those not given antibiotics, and shorter time to antibiotics was not associated with decreased infection. The article highlights the multifactorial nature of the radius or ulna infection after a GSW, which combines fracture characteristics, patient characteristics, and surgical decision-making.

Hip injuries

Of the 55 joint injuries evaluated in a retrospective review by Nguyen et al. [14, 15] on patients with intra-articular GSW, 19 injuries were found in the hip joint, most receiving antibiotic prophylaxis. The incidence of deep infection was low, with only two joints developing deep infections, both of which had associated vascular injuries. The study concluded that routine antibiotic prophylaxis was an effective preventive measure against deep infections. Intra-articular gunshot injuries without intra-articular pathology do not require surgical debridement to decrease the risk of infection However, based on injury pattern and surgeon preference, joints were either treated nonoperatively, with surgical debridement only, or with surgical debridement, fracture fixation, and/or neurovascular repair. Although two of 19 patients required exploratory laparotomy and primary repair due to small bowel injuries, both hips were treated nonoperatively without complications. The higher incidence of hip joint injuries highlights the importance of appropriate wound care and antibiotic use in managing low-velocity gunshot injuries involving the hip joint to reduce the risk of a joint infection or to manage an existing joint infection.

Femur fractures

Donahue, Heimke, Cho, Furdock, and Vallier [16] conducted a study to compare outcomes, including infection rates, between patients with femoral shaft fractures secondary to LVGFs and those with blunt trauma-induced fractures. All fractures were treated with intramedullary nails, and patients received intravenous antibiotics within an hour of skin incision, which was continued for 24 h post-surgery. The displaced fractures were aligned and immobilized using skeletal traction in preparation for later intramedullary nailing through a conventional approach. The study cohort included 345 patients: 197 in the blunt trauma group and 148 in the GSW group. Infection rates were categorized as superficial or deep to fascia infections. The blunt trauma group had four superficial and three deep infections, while the GSW-induced fracture cohort had no superficial infections and one deep infection. The findings suggest that GSW-induced femoral shaft fractures may have a lower risk of superficial infection than blunt trauma-induced fractures. However, the study may be limited by the relatively small sample size and the short-term follow-up.

Patch et al. [17] conducted a retrospective cohort study in 2021, wherein they compared the outcomes of intramedullary fixation for three groups of patients: those with LVGFs of femoral shaft (n = 140), blunt close femoral shaft fracture (n = 317), and blunt open femoral shaft fracture (n = 71). In the emergency room, it was reported that all fractures induced by gunshot wounds received care with gram-positive coverage antibiotics. However, for blunt open fractures, Gram-negative coverage antibiotics were also administered. All patients were administered antibiotics for 24 h following their surgical procedure. No statistically significant variation in fracture-associated infection was observed among the groups.

Knee injuries

According to the study conducted by Nguyen et al. [14, 15], knee joint injuries were the most common type of intra-articular gunshot wounds, accounting for 20 out of 55 joints (36.4%). Injuries to the knee joint can be particularly challenging due to the complex anatomy and the potential for significant soft tissue damage. The study found that antibiotic prophylaxis effectively reduced the incidence of deep infection after intra-articular gunshot injuries, and may be particularly important in managing knee joint injuries. In cases of significant soft tissue damage or joint involvement, antibiotics may be indicated to reduce the risk of infection.

Shultz, Schrader, Garbrecht, DeCoster, and Veitch [18] aimed to evaluate the occurrence of septic arthritis in patients with intraarticular, low-velocity GSW treated operatively versus non-operatively. No patients developed septic arthritis, and the infection rate was low regardless of the type of treatment. One patient in each group developed a superficial infection. Patients in the nonoperative group received an average of 2.4 doses of cefazolin at 8-h intervals, followed by a five day course of cephalexin. The authors suggest that equal outcomes in infection prevention can be achieved nonoperatively, indicating that the goal of preventing infection may not single-handedly justify operative treatment with I&D of intra-articular GSW. They concluded that I&D may not always be necessary, especially in patients with minimal soft tissue injury and minimal wound contamination due to further morbidities like stiffness.

In a survey of OTA members (Nguyen, Como, Golob Jr, Reich, & Vallier, 2018), the majority (99%) of participants recommended some form of antibiotic treatment for GSWs that traverse the knee joint. However, there was an almost equal split regarding the need for joint exploration in cases where the GSW traversed the joint with no retained bullet fragment. Fifty-four percent of the respondents routinely explored the joint, while 44% opted for antibiotic treatment alone.

Tibia and fibula fractures

Lee et al. [19] conducted a study to determine the proportion of patients who developed complications after treatment for LVGFs of tibia. This cohort consisted of 121 patients treated operatively with different methods such as debridement, external fixation, IMN, and/or ORIF with a median follow-up of nine months. Surgical debridement was conducted in cases when the presence of foreign bodies, contamination, or necrotic tissue necessitated intervention. External fixation was used when the soft tissue damage was deemed unsuitable for rapid internal fixation. The study revealed that 14% of the patients developed a deep infection associated with patients who underwent deep debridement. However, the study found no association between deep infection and fracture location in the tibia, nor association with IV antibiotic use in the ED, topical antibiotic use, or post-operative IV antibiotic duration, and they may not be reliable predictors of infection risk in these patients.

The OTA survey also revealed that 68% of the OTA members treat tibial shaft fractures from GSWs like an open fracture with surgical debridement with or without prolonged perioperative antibiotics. On the other hand, 28% of the participants opted for tibia fixation without I&D of the GSWs and fracture site with 24 h of perioperative IV antibiotics [20].

Donnally III, Lawrie, Sheu, Gunder, and Quinnan [21] aimed to evaluate whether performing I&D at the time of fixation for LVGF tibia fractures would affect the infection rate. The study included two cohorts of patients. Cohort 1 comprised 23 patients who underwent I&D and fixation, while Cohort 2, which comprised 16 patients, underwent fixation only. All patients were given 2 g of IV ceftriaxone and continued for three days postoperatively. The results showed that cohort 1 experienced a higher infection rate, with ten out of 23 patients.

In comparison, only one patient in cohort 2 developed a deep infection. The study found that undergoing I&D in addition to final fixation was associated with a higher rate of superficial infection but not deep infection. The study concluded that performing I&D during fixation for gunshot-induced tibia fractures may not be necessary as it does not reduce the rate of deep infections and may even increase the rate of superficial infections. The study also found that antibiotic prophylaxis with ceftriaxone was effective in reducing infection rates in both cohorts.

A study by Su, Nguyen, O’Donnell, and Vallier (2018) reported patients with open tibia fractures who received intravenous antibiotics upon presentation to the emergency department, with cefazolin and gentamicin being the drugs of choice. Clindamycin was administered to patients with penicillin allergy. Intravenous antibiotics were continued postoperatively for 24–48 h, depending on the fracture type. The results showed that infections after LVGF tibia fractures were uncommon, with only one case of deep infection observed (2.3%), which was similar to the infection rates in patients with high-energy closed fractures (4.8%) or low-energy closed fractures (2.4%). The study also found that proper management of open fractures, including prompt administration of appropriate antibiotics, can help to prevent infections in GSW tibia fractures. The infection rates in open Gustilo type II and III tibia fractures due to blunt trauma were significantly higher than those in GSW tibia fractures, indicating that open fractures resulting from blunt trauma may pose a higher risk of infection compared to GSWs. The study highlights the importance of timely and appropriate antibiotic management in patients with open fractures, including those caused by GSWs, to reduce the risk of infections and improve patient outcomes.

Foot and ankle injuries

Husain, Schmid, and Lombardo [22] examined the functional outcomes of 27 patients who sustained gunshot injuries to the foot and ankle, with the majority being LVGFs. Treatment modalities included I&D, external fixation, ORIF, amputation, or arthrodesis, with all patients receiving IV antibiotics and some receiving oral antibiotics as well. Antipseudomonal coverage was provided to patients if the bullet went through the sole, but no cases of Pseudomonas infection were reported. The study found no significant correlation between antibiotic use and functional outcomes. The authors concluded that early surgical intervention and appropriate antibiotic therapy could improve functional outcomes in patients with gunshot wounds to the foot and ankle.

A study by Shelton et al. [23] aimed to investigate the risk of infection following gunshot wound fractures to the foot and ankle. The study was conducted retrospectively across multiple centers and included 244 patients. The study found that administering antibiotics at initial presentation did not significantly affect the likelihood of developing an infection in nonoperatively managed patients, with infection rates being 15.6% for those who received antibiotics and 13.0% for those who did not. Antibiotics were given to 67.6% of patients managed nonoperatively and 94.1% of those managed operatively. The study suggests that antibiotic administration at initial presentation may not significantly affect infection rates in nonoperatively managed patients with GSW fractures to the foot and ankle.

Unspecified anatomical location

Bauhahn et al. conducted a study to investigate the occurrence of malunion in patients suffering from LVGFs of long bones in the Democratic Republic of Congo [24]. The study included a cohort of 181 patients who were treated following the International Committee of the Red Cross (ICRC) guidelines, which involve wound debridement, 5 days of antibiotic prophylaxis, and delayed primary closure of wounds. Out of the 181 patients included in the study, six developed infections. However, the study showed that adherence to ICRC guidelines for wound management resulted in a low incidence of infection.

A study by Nguyen et al. aimed to determine infection rates in low-velocity GSW to the extremities (Nguyen, Savakus, et al., 2017). The retrospective review included 140 patients with extremity-only low-velocity GSW injuries from 2010 to 2014, with 135 having lower extremity injuries and 32 having upper extremity injuries. Most patients (74.3%) received prophylactic antibiotics, with first-generation cephalosporin being the most commonly used antibiotic. The study found that the overall infection rate was 15.7%, with a deep infection rate of 3.6%. None of the 206 excluded patients who were followed for at least a week but less than 90 days had any superficial or deep infections. Two deep infections occurred in nonoperative soft tissue injuries in patients who did not receive antibiotic prophylaxis. In contrast, the other three occurred in patients who underwent surgical interventions and received perioperative antibiotics. Cultures were obtained in all five patients with deep infections. Among the three positive cultures, there was one methicillin-resistant Staphylococcus aureus, one methicillin-sensitive S. aureus, and one Streptococcus pyogenes. The study also found that antibiotic prophylaxis trended towards a lower overall infection rate in soft tissue-only injuries versus no antibiotic prophylaxis (6.1% vs. 25.9%, respectively). However, there was no statistically significant difference in deep infection with or without antibiotic prophylaxis. Also, a single dose of intravenous antibiotics in the emergency department was associated with a lower infection rate than no antibiotics. However, multiple doses of antibiotics did not reduce the infection rate compared to a single dose. No deep infections occurred in patients with nonoperatively treated fractures, regardless of antibiotic administration. All operatively treated fractures received antibiotic prophylaxis and demonstrated superficial and deep infection rates of 15.1% and 5.7%, respectively. The study concluded that infections after low-velocity extremity GSWs are infrequent, and standard perioperative antibiotics should be administered to operatively treated LVGFs. Additionally, the study found that deep infections were more likely to occur in patients who underwent surgical interventions and received perioperative antibiotics.

Woolum et al. compared the effectiveness of three different antibiotic regimens in preventing early infectious outcomes in low-velocity GSW patients [25]. The three groups included a narrow-spectrum group (cefazolin or clindamycin monotherapy), an expanded gram-negative (EGN) group (extended-spectrum beta-lactam or aminoglycoside-containing regimen), and a fluoroquinolone-based (FB) group (with or without additional antimicrobial agents). In total, 252 patients were included in the study, with 126 in the narrow-spectrum group, 49 in the EGN group, and 77 in the FB group. The primary outcome of early infection showed no significant differences between the three groups. The expanded gram-negative regimen was associated with increased hospital length of stay and increased incidence of multidrug-resistant bacteria and methicillin-resistant Staphylococcus aureus colonization. Of the three infections identified, two occurred in the expanded Gram-negative cohort and one in the narrow-spectrum cohort. The study suggests that broad-spectrum antibiotic coverage was not associated with improved post-traumatic infections in low-velocity gunshot trauma patients.

Paediatric population studies

Naranje et al. explored the epidemiology of gunshot-related fractures in paediatric patients [26]. The study retrospectively reviewed clinical and radiographic records at two level 1 paediatric trauma centres. Out of the 49 patients included in the study, two (4%) developed infections requiring multiple I&D procedures. For all patients, standard care involved inpatient admission and antibiotic therapy, either intravenous (42 patients) or oral (7 patients). One patient had a superficial infection caused by Streptococcus Agalactiae (group B), which was treated with a ten day course of oral Bactrim after I&D. The other patient developed a deep infection that grew Staphylococcus aureus on culture and was treated with a six week course of oral clindamycin after I&D. Following the initial debridement and irrigation, the majority of the fractures (71%) were managed nonoperatively using casts, braces, or splints along with intravenous antibiotics.

The study by Perkins, Scannell, Brighton, Seymour, and Vanderhave [27] encompassed 46 patients with a mean age of 12.7 years who received orthopedic treatment for firearm-related injuries at a major trauma center over eight years. Infection rates were 11%, and fracture non-union occurred in 9% of the cases. Notably, all patients who developed non-unions had experienced deep infections, suggesting a strong association between these complications. Deep surgical site infections were diagnosed in five patients, primarily following low-velocity handgun and high-velocity shotgun injuries. The causative organisms identified included coagulase-negative Staphylococcus, methicillin-sensitive Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, enterobacter, and enterococcus. Despite the use of antibiotics, the timing and duration of antibiotic therapy did not significantly differ between patients who developed infections and those who did not. Of note, all patients with infections had undergone surgical debridement at the time of injury, and most had undergone internal fixation of their fractures. The need for additional surgeries was observed in patients with infections, averaging 2.8 surgeries per patient. However, no infections were reported during long-term follow-up among the patients treated non-operatively.

Discussion

There is no consensus regarding using prophylactic antibiotics in LVGF. Some experts believe that antibiotics are not necessary in all cases of LVGF and that their use should be reserved for cases with a high risk of infection, such as cases with concurrent neurovascular injury. Others believe that prophylactic antibiotics should be administered to all LVGF patients, regardless of the risk of infection. They point out that gunshot injuries can introduce a significant amount of foreign material into the wound, increasing the risk of infection. However, surgical intervention should adhere to well-established prophylactic antibiotic treatment.

The lack of consensus on antibiotic use in managing LVGFs may reflect the limited research on this specific type of injury. However, the clear consensus for antibiotic prophylaxis in patients who have sustained high- or unspecified-velocity GSW-related fractures suggests a general understanding of the risk for infection in these cases [28]. The lack of uniformity in orthopaedic protocols across institutions could lead to variability in patient outcomes and potentially increased rates of infection [20].

A standardized treatment approach for extremity fractures following low-velocity GSW is described as an institutional protocol at MetroHealth Medical Center [29]. The protocol involves administering a single dose of IV antibiotics, tetanus update, and local wound care to all patients. Patients with mechanically stable fractures or other minimally displaced fractures amenable to closed reduction are treated by splinting the affected extremity, protected weight bearing, and no further antibiotics. The protocol does not involve routine surgical debridement of GSW tracts, except in cases where there is retained intra-articular debris or prominent subcutaneous bullet material causing pain. Patients with mechanically unstable fractures and those not amenable to closed management are treated with 24 h of perioperative IV cefazolin following fracture fixation based on surgical prophylactic antibiotic principles.

A survey of members of the Orthopaedic Trauma Association found no consensus on the best approach [20]. The survey found that participants with more than five years of experience were more likely to recommend a single intravenous (IV) antibiotic dose as a standalone treatment for non-operative soft tissue gunshot injuries compared to those with less than five years of experience who opted for IV antibiotics upon presentation and prescribed oral antibiotics upon discharge. These findings suggest that more experienced practitioners may have greater confidence in a more conservative approach. In contrast, less experienced practitioners may be more inclined to administer broader-spectrum antibiotics as a precautionary measure.

The choice of antibiotic may depend on various factors, including the location of the injury, its severity, and the patient’s individual risk factors. However, the most commonly used antibiotics for prophylaxis in this setting include first-generation cephalosporins (such as cefazolin) and penicillin (such as ampicillin-sulbactam or piperacillin-tazobactam). Studies have shown that patients who receive broad-spectrum antibiotics have a higher rate of non-union and wound complications [30]. Expanded Gram-negative spectrum antibiotics may also negatively impact bone and soft tissue healing [31]. Based on the available data, using narrow-spectrum antibiotics is a suitable choice for treating low-grade LVGF, unless there is a specific justification for using broad-spectrum antibiotics.

A study by Nguyen et al. entitled “Costs of Care for Low-Velocity Extremity Gunshot Injuries are Reduced With Standardized Treatment” [32] aimed to determine the treatment costs associated with low-velocity GSW to the extremity and estimate the cost savings associated with a single-dose IV antibiotic strategy administered in the emergency room for patients with simple GSWs. The authors concluded single-dose antibiotic care pathway would have saved an average of $1436 per patient with simple GSWs in actual facility expenses. The single-dose antibiotic care pathway can optimize care delivery and patient outcomes. In addition, the single-dose antibiotic care pathway eliminates invasive procedures and the potential side effects and bacterial resistance associated with prolonged antibiotic use. The study recommended that for simple GSWs, an outpatient treatment course with a single dose of IV antibiotics and local wound care seems to minimize costs. Studies looking at infection as the outcome has supported that simple extremity low-velocity GSWs, including soft-tissue only injuries, nonoperative fractures, and GSWs traversing a joint without intra-articular pathology or retained bullet, can be treated with a single prophylactic antibiotic dose, wound care, and outpatient follow-up.

A national registry system for gunshot injuries, antibiotics, and infections would be a valuable resource for collecting and analyzing data on these important healthcare issues. A key benefit of a registry would be the ability to capture and analyze data on a large scale, which could help identify trends, patterns, and potential risk factors associated with gunshot injuries and their subsequent management. This could enable researchers to gain insights into the effectiveness of different treatment protocols, including antibiotic usage, and their impact on infection rates. Another advantage would be the ability to monitor and track changes in infection rates over time, including the emergence of antibiotic-resistant infections. This would help identify trends and patterns that may require adjustments in treatment protocols or public health policies. Additionally, a registry could facilitate collaborative research efforts among different institutions and countries, allowing for a broader and more diverse dataset that could lead to more robust findings and recommendations. Furthermore, a registry could support surveillance and monitoring efforts related to public health and safety. For example, by collecting data on the circumstances surrounding gunshot injuries, such as the location, type of firearm, and intent, a registry could provide valuable information for developing and implementing targeted injury prevention strategies.

It is common for reviews to encounter limitations due to factors such as sample size, study design, or data quality. Most studies reported low infection rates, which may have resulted from small sample sizes, where a larger sample size would have potentially been needed to detect a significant difference between groups. Additionally, most of the studies were retrospective and observational, which may have introduced bias and confounding factors that were not accounted for in the analysis. Furthermore, there was significant heterogeneity in the patient populations, fracture types, and treatment protocols across the studies, which may have influenced the results. Future studies with larger sample sizes and more standardized treatment protocols are needed to evaluate further the efficacy of different management strategies for this type of injury. It is evident that a lack of standardization in managing gunshot injuries, including the use of antibiotics and prophylaxis, exists. This variability in practice makes it difficult to conduct high-quality studies that can provide clear guidelines for management. We also acknowledge the potential for publication bias in the included studies, where studies with positive results are more likely to be published than those with neutral or negative findings.

Conducting a prospective study in the context of low-velocity GSW injuries and antibiotic use can be ethically challenging. It may be difficult to design a study that involves withholding antibiotics from patients with gunshot injuries, even if it is a non-operatively treated fracture considering that withholding antibiotics could be seen as putting the patient at unnecessary risk. In such cases, it may be difficult to obtain informed consent from patients, particularly if they believe that antibiotics are necessary for their care. Therefore, performing a randomized controlled trial that involves withholding antibiotics from certain patients with gunshot injuries may not be feasible or ethical.

In conclusion, the current recommendations for antibiotic prophylaxis in LVGFs suggest a short duration of 48–72 h, or longer in the presence of significant soft tissue damage, contamination, or involvement of the joint, bone, or central nervous system. However, there is a lack of studies comparing the specific location of injury and antibiotic type, dose, or duration. Starting antibiotics early in the emergency department and using a first-generation cephalosporin for 24 h may be an effective approach for extra-articular fractures. However, further research is needed to determine the optimal prophylactic antibiotic regimen for intra-articular injuries caused by gunshot wounds. Clinicians should carefully assess the individual patient and the specific characteristics of their injury to determine the appropriate prophylactic antibiotic therapy.

The use of antibiotics in LVGF should not be seen as a substitute for proper wound care and management. All gunshot wounds, regardless of velocity, require prompt and appropriate medical attention to minimize the risk of complications. The decision to use antibiotics in LVGF should be made on a case-by-case basis, considering the specific circumstances of the injury and the patient's overall health. Factors such as location and severity of injury, presence of foreign material, and patient immunocompetence should all be considered when determining whether antibiotics are necessary.