Suspected Long Bone Open Fracture Clinical Pathway — Emergency

Antibiotic Recommendations for Open Long Bone Fractures

Fracture Type First Line Allergy Duration Common Pathogens
I or II Cefazolin IV
30 mg/kg/dose q 8 hrs
MAX 2g/dose

Concern for soil/fecal/farm contamination
ADD
Penicillin IV
100,000 units/kg/dose q 6 hrs
MAX 4 million units/dose
Clindamycin IV
14 mg/kg/dose q 8 hrs MAX
900 mg/dose

Type II fractures with significant contamination

ADD

Gentamicin IV
2.5 mg/kg/dose q 8 hours
24 hrs Staphylococcus spp.
Streptococcus spp.
Anaerobes (Clostridium spp.) - soil/fecal/farm contamination
III A,B, or C Cefazolin IV
30 mg/kg/dose every 8 hours; max: 2g/dose

AND

Gentamicin IV
2.5 mg/kg/dose q 8 hours

Concern for soil/fecal/farm contamination

ADD penicillin IV

100,000 units/kg/dose q 6 hrs
MAX 4 million units/dose
Clindamycin IV
14 mg/kg/dose q 8 hrs MAX
900 mg/dose

AND

Gentamicin IV
2.5 mg/kg/dose q 8 hours
24 hours

May go up to 72 hours if a delay in repair or incomplete debridement
Staphylococcus spp.
Streptococcus spp.
Gram-negatives
Anaerobes (Clostridium spp.) - soil/fecal/farm contamination

References

Dellinger EP, et al. Duration of Prevention Antibiotic Administration for Open Extremity Fracture. Arch Surg 1988;123:333-339.

Hoff WS, et al. 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 2011;70:751-754.

Trionfo A, et al. Pediatric Open Fractures. Orthop Clin N Am 2016;47:565-578.