Consensus Regarding the Use of Antibiotics in Pediatric Orthopedic Trauma Patients

Original Date: 12/2010 | Supersedes: 12/2010, 06/2014, 06/2017, 09/21 | Last Review Date: 09/2023
Purpose: To provide antibiotic coverage recommendations for pediatric patients with orthopedic trauma.

Closed Fractures:

  • 1st generation cephalosporin* IV (Ancef 30mg/kg) maximum 2 grams for patients less than 100 kg, Maximum 3 grams for patients over 100 kg, single perioperative dose for patients with internal hardware status post closed reduction and percutaneous fixation.
  • 1st generation cephalosporin* IV (Ancef 30mg/kg) 3-4 divided doses 24 hours post-operative in all patients with internal hardware status post open reduction and internal fixation.

Open Fractures:

Fracture Type First-line Antibiotics Second-line Antibiotics Duration Comments
I or II Cefazolin, IV
30 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

 For severe penicillin or
cephalosporin allergy
Clindamycin IV
10 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

OR

Ceftriaxone
50mg/Kg/dose every 12 hours
Maximum: 2000mg/dose

 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 Ceftriaxone, IV
50mg/kg/dose every 12 hours; maximum: 2000mg/dose
AND

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: 1000 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

 For severe penicillin or
cephalosporin allergy
Clindamycin IV
10 mg/kg/dose every 8 hours; Maximum: 900 mg/dose

ADD

Gentamicin IV
2.5 mg/kg/dose q 8 hours

OR

Ceftriaxone
50mg/Kg/dose every 12 hours
Maximum: 2000mg/dose

 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

References:

Best Practices in the Management of Orthopedic Trauma: https://www.facs.org/media/mkbnhqtw/ortho_guidelines.pdf Retrieved 07/27/2023

Children’s Hospital of Philadelphia: Antibiotic Recommendation for Open Long Bone Fractures: https://www.chop.edu/clinical-pathway/patient-suspected-long-bone-fracture-antibiotic-recommendations Retrieved 07/27/2023