Are We on the Same Page? Defining Consensus for Pediatric Open Fracture Management Among Level 1 Pediatric Trauma...

Open fractures require urgent management, including timely prophylactic antibiotics, to minimize infection and morbidity. Most pediatric treatment protocols are extrapolated from adult data, resulting in practice variation at pediatric centers regarding antibiotic timing and selection. In this study, we aimed to identify consensus regarding open fracture management protocols at Level-1 Pediatric Trauma Centers across the United States.

A survey was administered to 17 institutions participating in "Children's Orthopaedic Trauma and Infection Consortium for Evidence-Based Study" (CORTICES), representing ~25% of all Level-I Pediatric Trauma Centers nationwide. Data analysis was conducted using descriptive statistics with responses presented as frequencies and percentages.

In 9/17 (53%) of participating centers, antibiotics for open fractures are ordered by Emergency Department (ED) physicians exclusively. All 17 centers (100%) surveyed have formal protocols to give IV antibiotics <1 hour of presentation to the ED. Fifteen of 17 centers (88%) monitored antibiotic administration success rates regularly, through a hospital or trauma quality committee. Success rates of <1 hour antibiotic administration in the last year were 21% to 40% in 2/15 centers (13%), 41% to 60% in 3/15 centers (20%), 61% to 80% in 3/15 centers (20%), and 81% to 100% in 7/15 centers (47%). Of 17 sites surveyed, 15 (88%) have formal protocols for Gustilo-Anderson (GA) type-based antibiotic selection. Most centers with antibiotic selection policies (13/15, 87%) involved multiple departments in policy development, primarily infectious disease, orthopaedic surgery, ED, pharmacy, and pediatrics in descending order. Across sites, antibiotic selection showed consensus for GA-type 1 (cefazolin) and near-complete consensus for GA-type 2 (14/15, 93% cefazolin), allergy alternatives for GA-type 1 (14/15, 93% clindamycin), and allergy alternatives for GA-type 2 (13/15, 87% clindamycin). There was minimal consensus in antibiotic recommendations for GA-type 3 (standard or allergy alternatives) or for soil/water contamination.

While most surveyed Level-1 Pediatric Trauma Centers have formal protocols for timing and GA-type-dependent antibiotic selection, there is substantial variation among centers in success rates of prompt antibiotic administration and in selection of antibiotics for GA-type 3 open fractures. This variability highlights the need for pediatric-specific research to establish standardized evidence-based protocols, especially for severe injuries that carry a greater morbidity risk.