Open Long Bone Fracture Clinical Pathway — Emergency Department

General Principles

These recommendations are for prevention of infection in the setting of initial presentation in children with open fractures.
Aim to administer antibiotics within 1 hour of ED arrival.
Consult Infectious Diseases if any concern for active infection, extensive soft tissue injury with delayed closure, or if prolonged antibiotic prophylaxis being considered.

Common Pathogens

Fracture Type	Pathogens
I or II	Staphylococcus spp. Streptococcus spp.
III	Staphylococcus spp. Streptococcus spp. Gram-negatives
Soil, Farm-Related, or Fecal Contamination	Staphylococcus spp. Streptococcus spp. Gram-negatives Anaerobes (Clostridium spp.)

Antibiotic Recommendations for Open Long Bone Fractures

Fracture Type	First-Line Antibiotics	Allergy to First-Line β-Lactam Assess Need for Alternative	Duration of Treatment/Comments
I or II	Cefazolin, IV 30 mg/kg/dose every 8 hours Max: 2,000 mg/dose	Clindamycin, IV 14 mg/kg/dose every 8 hours Max: 900 mg/dose	24 hours after initial surgical washout No additional antibiotics indicated for soil, farm-related, or fecal contamination
III	Piperacillin/Tazobactam, IV 2-9 months 80 mg piperacillin component/kg/dose every 8 hours Infants ≥ 9 months, Children, Adolescents ≤ 40 kg 100 mg piperacillin component/kg/dose every 8 hours Max: 3,000 mg piperacillin component/dose Children, Adolescents > 40 kg 3,000 mg piperacillin component every 6 hours	Cefepime, IV 50 mg/kg/dose every 8 hours Max: 2,000 mg/dose and Metronidazole, IV Infants PMA > 44 weeks, Children, Adolescents, and Adults 7.5 mg/kg/dose IV every 6 hours Max: 500 mg/dose	24 hours after initial surgical washout Consult Infectious Diseases if any concern for active infection, extensive soft tissue injury with delayed closure, or if prolonged antibiotic prophylaxis being considered. First line and alternative antibiotics provide adequate coverage for soil, farm-related, or fecal contamination.
History of MRSA	Add to the above antibiotics Vancomycin, IV Infants ≥ 1 month and children ≤ 50 kg 15 mg/kg/dose every 6 hours Max: 750 mg/dose Children > 50 kg and Adults 15 mg/kg/dose every 8 hours Max: 1,000 mg/dose

Please see the CHOP Formulary for complete drug information.

References

AAOS Clinical Practice Guideline Summary: Prevention of Surgical Site Infection After Major Extremity Trauma

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.