Guideline/Protocol Title | Prophylactic Antibiotics for Traumatic Open Fracture in Pediatrics |
Authors | Katelyn Camera, PharmD, BCPS Katie Olney, PharmD, BCIDP Joel Howard, MD Abby Bailey, PharmD, BCCCP Jaryd Zummer, MD, FACEP, FAAEM Andrea Doud, MD |
Committee Review | Pediatric CPT/IDTQA Committee Antimicrobial Stewardship Subcommittee Pharmacy and Therapeutics Committee |
Target Population | Pediatric patients with traumatic open fractures being seen for initial fracture management. |
Overview | This guideline provides clinicians with protocols for prophylactic antibiotic management as well as pertinent vaccination administration in the setting of traumatic open fractures. |
Effective Date | July 2021 |
Expiration Date | July 2026 |
Revised Date | July 2023 |
Schedule for Periodic Review | Every 3 years |
Implementation Strategy | Education to pharmacists and physicians |
Education Strategy | Protocol will be posted to CareWeb under Antimicrobial Stewardship orders/protocols, added to the Antimicrobial Stewardship Application, and the Trauma Care Guidelines (Pediatric) |
Primary Outcome(s) | Standardize antimicrobial prophylaxis for pediatric open fractures. |
Outcome Assessment Plan | N/A |
Information Technology Needs | Access to CareWeb under Antimicrobial Stewardship orders/protocols, add to Antimicrobial Stewardship Application, and updated in current Trauma Care Guidelines (Pediatric) |
PROPHYLACTIC ANTIBIOTICS FOR TRAUMATIC OPEN FRACTURE IN PEDIATRICS | |||
Antimicrobial prophylaxis should be administered in the trauma bay as soon as possible, ideally within 1 hour of injury. Doses and frequencies listed detail/describe open fracture prophylaxis while awaiting closure. For antibiotic dosing prior to any operative incision and intraoperative dosing frequency, see surgical prophylaxis guidelines on CareWeb. Contact pharmacy with dosing questions. | |||
Fracture or Wound Type ɣ | Suggested Regimen Initiate ASAP and within 1 hour of arrival to UK | DURATION | |
Primary | Type I (Anaphylactic) Penicillin Allergy | ||
Type I, II, or III Blunt or Penetrating (including GSW) | Cefazolin 30 mg/kg IV Q8H Maximum per dose 2000 mg (if >120 kg max 3000 mg) | Clindamycin 10 mg/kg IV Q6H | Until soft-tissue coverage, and no longer than 24 hours from injury |
Soil or Fecal Contamination Type I, II, or III
Farm-related injury or fecal contamination | Cefazolin 30 mg/kg IV Q8H Maximum per dose 2000 mg (if >120 kg max 3000 mg) PLUS Penicillin G Potassium 66,667 units/kg IV Q4H Maximum per dose 4 million units | *Clindamycin 10 mg/kg IV Q6H | Until soft-tissue coverage, and no longer than 24 hours from injury |
Dog or Cat Bite Leading to Open Fracture | Ampicillin/Sulbactam 75 mg/kg IV Q6H Maximum per dose ampicillin 2000 mg
May consider de-escalation to amoxicillin/clavulanate 20 mg/kg/dose (max: 500 mg) TID following 24 hours of IV ampicillin/sulbactam | Doxycycline 2.2 mg/kg IV/PO Q12H Maximum per dose 100 mg | 3 days |
FRESH Water Injury Leading to Open Fracture | Levofloxacin 10 mg/kg IV/PO Maximum per dose 750 mg PLUS Graded Fracture Antibiotics | Levofloxacin 10 mg/kg IV/PO Maximum per dose 750 mg PLUS Graded Fracture Antibiotics | Until soft-tissue coverage, and no longer than 24 hours from injury |
SALT Water Injury Leading to Open Fracture | Doxycycline 2.2 mg/kg IV/PO Q12H Maximum per dose 100 mg PLUS Ceftriaxone 50 mg/kg IV Q24H Maximum per dose 2000 mg | CONSULT Pediatric AMS# | Until soft-tissue coverage, and no longer than 24 hours from injury |
Open Mandible+ or Open Facial Fracture | Ampicillin/Sulbactam 50 mg/kg IV Q6H | Clindamycin 10 mg/kg IV Q6H | Until soft-tissue coverage, and no longer than 24 hours from injury |
Open Skull Fracture | NONE unless grossly contaminated If grossly contaminated, prophylaxis as above for soil or fecal contamination | NONE unless grossly contaminated If grossly contaminated, prophylaxis as above for soil or fecal contamination | Until soft-tissue coverage, and no longer than 24 hours from injury |
CSF Leak, Closed Facial Fracture, Sinus, Anterior, or Posterior Table | NONE PLUS Pneumococcal Vaccination Prior to Dischargeᶲ | NONE PLUS Pneumococcal Vaccination Prior to Dischargeᶲ | Until soft-tissue coverage, and no longer than 24 hours from injury |
Antibiotics should be continued until soft-tissue coverage, and no longer than 24 hours total from injury, regardless of when antibiotics are initiated. | |||
Patients with isolated hand injuries or GSW to foot or transabdominal pathway into Hip/Pelvis/Spine should receive routine graded antibiotic prophylaxis.
+ PLUS chlorhexidine rinses PO QID for mandible fractures; ǂ In obese patients (>125% IBW) utilize dosing body weight (DBW) for gentamicin; DBW = Ideal BW + 0.4 (Actual BW-Ideal BW); ᶲ See Table III; ɣ If fracture caused by animal bite consider rabies vaccination and immunoglobulin; #: Pediatric AMS may be reached via Epic secure chat (Katie Olney, PharmD and Joel Howard, MD)
Table IA: Gustilo Open Fracture Classification
Gustilo Grade | Definition |
I | Clean wound <1 cm in length |
II | Wound > 1 cm without extensive soft-tissue damage, flaps, avulsions |
III | Extensive soft-tissue laceration, damage, or loss or an open segmental fracture. |
IIIA | Adequate periosteal coverage despite the extensive soft-tissue laceration or damage |
IIIB | Extensive soft-tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination. Will often need further soft-tissue coverage procedure (i.e. free or rotational flap) |
IIIC | Arterial injury requiring repair, irrespective of degree of soft-tissue injury |
Table II: Tetanus Recommendations
History of Tetanus Vaccination | Last Dose | Wound Type | DTaP, Tdap or Td† | TIG‡ |
Unknown or <3 doses |
| Clean, minor wound | Yes | No |
| All other wounds* | Yes | Yes | |
≥3 doses | <5 years | All wounds | No | No |
5-10 years | Clean, minor wounds | No | No | |
5-10 years | All other wounds* | Yes | No | |
≥10 years | All wounds | Yes | No |
Abbreviations: DTaP = Diphtheria and Tetanus toxoids and acellular pertussis vaccine; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; Td = tetanus and diphtheria toxoids; TIG = Tetanus immune globulin
*Such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite; † DTaP is recommended for children <7 years of age. Tdap is preferred to Td for persons aged 11 years or older who have not previously received Tdap. Persons aged 7 years or older who are not fully immunized against pertussis, tetanus, or diphtheria should receive one dose of Tdap (preferably the first) for wound management and as part of the catch-up series; if additional tetanus toxoid-containing doses are required, either Td or Tdap vaccine can be used; ‡ People with HIV infection or severe immunodeficiency who have contaminated wounds (including minor wounds) should also receive TIG, regardless of their history of tetanus immunizations.
Table III: Pneumococcal Vaccination in Patients with CSF Leak
Age <2 years | |
Continue primary series (see Table 2 in the ACIP pneumococcal vaccine recommendations for complete schedule details) | |
Age 2 to <6 years | |
Received any complete# series: | |
Previously received ≥1 PCV-20 dose | No additional dose of pneumococcal vaccine needed |
Previously received <1 PCV-20 dose | Administer 1 dose of PCV-20 |
No previous PCV dose history or any incomplete# series: | |
Administer 1 dose of PCV-20 now*
| |
Age ≥6 to 18 years | |
Previously received ≥1 PCV-20 dose | No additional dose of pneumococcal vaccine needed |
Previously received <1 PCV-20 dose | Administer 1 dose of PCV-20 |
#Incomplete series = Not having received all doses in either the recommended series or an age-appropriate catch-up series. See Tables 8, 9, and 11 in the in the ACIP pneumococcal vaccine recommendations (https://www.cdc.gov/mmwr/pdf/rr/rr5911.pdfpdf icon) or visit https://www2a.cdc.gov/vaccines/m/pneumo/pneumo.html for complete schedule details; ¥Ensure at least 8 weeks after any prior PCV13 or PPSV23 dose.
References:
Hoff, William S. MD, FACS; Bonadies, John A. MD, FACS; Cachecho, Riad MD, FACS, FCCP; Dorlac, Warren C. MD, FACS East Practice Management Guidelines Work Group: Update to Practice Management Guidelines for Prophylactic Antibiotic Use in Open Fractures, The Journal of Trauma: Injury, Infection, and Critical Care: March 2011 - Volume 70 - Issue 3 - p 751-754 doi: 10.1097/TA.0b013e31820930e5.
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Dellinger EP, Caplan ES, Weaver LD, et al. Duration of Preventive Antibiotic Administration for Open Extremity Fractures. Arch Surg. 1988;123(3):333–339. doi:10.1001/archsurg.1988.01400270067010
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Buckman SA, Forrester JD, Bessoff KE, Parli SE, Evans HL, Huston JM. Surgical Infection Society Guidelines: 2022 Updated Guidelines for Antibiotic Use in Open Extremity Fractures. Surg Infect (Larchmt). 2022 Nov;23(9):817-828. doi: 10.1089/sur.2022.206. PMID: 36350736.