Open Long Bone Fracture Clinical Pathway — Emergency Department

Antibiotic Recommendations for Open Long Bone Fractures
Fracture Type First-line Antibiotics Second-line Antibiotics
For severe penicillin or
cephalosporin allergy
 Duration Comments
I or II
  • Cefazolin IV
  • 35 mg/kg/dose every 8 hours; Maximum: 2,000 mg/dose
  • Significant contamination with soil/fecal/farm material:
    • ADD
    • Penicillin IV
      100,000 units/kg/dose every 6 hours;
      Maximum: 4 million units/dose
  • Clindamycin IV
  • 14 mg/kg/dose q 8 hours;
    Maximum 900 mg/dose
  • Type II fractures with significant contamination:
    • ADD
    • Gentamicin IV
      2.5 mg/kg/dose q 8 hours
 24 hours
  • Common Pathogens
    • Staphylococcus spp.
    • Streptococcus spp.
    • Anaerobes (Clostridium spp.)
      • Soil/fecal/farm contamination
  • If MRSA risk factor(s) present:
    • ADD
    • Vancomycin, IV
    • < 50 kg:
      15 mg/kg/dose every 6 hours;
      Maximum: 750 mg/dose
    • ≥ 50 kg and/or > 18 years: 15 mg/kg/dose every 8 hours;
      Maximum: 1,000 mg/dose
  • MRSA risk factors include:
    • History of prior MRSA infection or carriage
    • Known close/household contact with MRSA
    • Use of IV drugs
III A,B, or C
  • Cefazolin IV
    35 mg/kg/dose every 8 hours;
    Maximum: 2,000 mg/dose
    • AND
    • Gentamicin IV
      2.5 mg/kg/dose every 8 hours
    • Significant contamination with soil/fecal/farm material:
    • ADD
    • Penicillin IV
      100,000 units/kg/dose every 6 hours;
      Maximum: 4 million units/dose
  • Clindamycin IV
  • 14 mg/kg/dose every 8 hours;
    Maximum: 900 mg/dose
    • AND
    • Gentamicin IV
      2.5 mg/kg/dose every 8 hours
  • 24 hours
  • May go up to 72 hours if a delay in repair or incomplete debridement
  • Consider Infectious Diseases consult for antibiotic duration greater than 72 hours
  • Common Pathogens
    • Staphylococcus spp.
    • Streptococcus spp.
    • Gram-negatives
    • Anaerobes (Clostridium spp.)
      • Soil/fecal/farm contamination
  • If MRSA risk factor(s) present:
    • ADD
    • Vancomycin, IV
    • < 50 kg:
      15 mg/kg/dose every 6 hours; Maximum: 750 mg/dose
    • ≥ 50 kg and/or > 18 years: 15 mg/kg/dose every 8 hours;
      Maximum: 1,000 mg/dose
  • MRSA risk factors include:
    • History of prior MRSA infection or carriage
    • Known close/household contact with MRSA
    • Use of IV drugs

Footnote

  • Assess the nature of the penicillin allergy per the Clinical Pathway for the Assessment of Children with a Penicillin Drug Allergy. Patients with non-severe penicillin allergies (including hives) can receive cefazolin. Severe penicillin allergy includes any of the following: anaphylaxis, angioedema, cardiac arrest, respiratory distress, severe cutaneous reaction (for example, Stevens Johnson syndrome, erythema multiforme, DRESS and TEN). All other reactions considered non-severe and should receive the recommended antibiotic.

References