Suspected Long Bone Fracture — Antibiotic Recommendations — Clinical Pathway: Emergency

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
  • 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
  • Up to 24 hours after washout
  • No additional antibiotics indicated
    for soil, farm-related, or fecal contamination
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
  • Up to 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