Open Fracture Antibiotic Guideline

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    (Gustilo classification)	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  Maximum per dose 900 mg	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  Maximum per dose 900 mg	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   Maximum per dose ampicillin 2000 mg	Clindamycin 10 mg/kg IV Q6H  Maximum per dose 900 mg	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*  Administer additional dose of PCV-20 in ≥8 weeks
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: 

 

1. 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. 

2. Woolum JA, Bailey AM, Dugan A, Agrawal R, Baum RA. Evaluation of infection rates with narrow versus broad-spectrum antibiotic regimens in civilian gunshot open-fracture injury. Am J Emerg Med. 2020 May;38(5):934-939. doi: 10.1016/j.ajem.2019.158358. Epub 2019 Jul 23. PMID: 31402235; PMCID: PMC6980938. 

3. Lloyd BA, Murray CK, Shaikh F, Carson ML, Blyth DM, Schnaubelt ER, Whitman TJ, Tribble DR; Infectious Disease Clinical Research Program Trauma Infectious Disease Outcomes Study Group. Early infectious outcomes after addition of fluoroquinolone or aminoglycoside to posttrauma antibiotic prophylaxis in combat-related open fracture injuries. J Trauma Acute Care Surg. 2017 Nov;83(5):854-861. doi: 10.1097/TA.0000000000001609. PMID: 28570348; PMCID: PMC5656510. 

4. Hauser CJ, Adams CA Jr, Eachempati SR; Council of the Surgical Infection Society. Surgical Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline. Surg Infect (Larchmt). 2006 Aug;7(4):379-405. doi: 10.1089/sur.2006.7.379. PMID: 16978082. 

5. 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 

6. Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. doi: 10.1086/425368. Epub 2004 Oct 6. PMID: 15494903. 

7. Garner MR, Sethyraman SA, Schade MA, Boateng H. Antibiotic prophylaxis in open fractures: evidence, evolving issues, and recommendations. J Am Acad Orthop Surg. 2020,28:309-315. doi: 10.5435/JAAOS-D-18-00193.  

8. 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.