O2158: Are We on the Same Page? Defining Consensus for Pediatric Open Fracture Management Among Level 1 Pediatric Trauma Centers

Background: Open fractures require urgent management, including timely prophylactic antibiotics, to minimize infection and morbidity risk. Evidence-based guidance for treating open fractures in children is limited, as most data is extrapolated from adults. Even in adults, there is substantial practice variation surrounding timing and selection of intravenous (IV) antibiotics depending on Gustilo and Anderson (GA) injury type. In this study, we aimed to identify consensus regarding open fracture management protocols at Level 1 Pediatric Trauma Centers.

Methods: A survey was administered to all 18 Children’s Orthopaedic Trauma and Infection Consortium for Evidence-Based Study (CORTICES) institutions, all Level I Pediatric Trauma Centers, representing ~25% of Level I Pediatric Trauma Centers nationwide. Data analysis was conducted using descriptive statistics with survey responses presented as frequencies and percentages.

Results: In 50% of the centers, antibiotics for open fractures are ordered by Emergency Department (ED) physicians exclusively. Twelve of 18 centers have a formal protocol for the timing of IV antibiotics administration, and 15/18 sites have a formal protocol for GA type-based antibiotic selection. Most centers (13/15) involved multiple departments in policy development, primarily infectious disease, orthopedic surgery, emergency department, pharmacy, and pediatrics in descending order.

Among 12 sites with timing protocols, two administered antibiotics < 1 hour of injury, seven in < 1 hour of ED presentation, two did so “as soon as possible,” and one in < 3 hours of ED arrival or outside hospital (OSH) arrival. Ten centers monitored antibiotic administration success-rates, predominantly through hospital quality committees (5/10) and trauma committees (4/10). Of the nine sites aiming to administer antibiotics < 1 hour of injury of ED admission, five achieved success rates exceeding 80%.

Antibiotic selection showed consensus for GA-type 1 (cefazolin) and near-complete consensus for GA-type 2 (14/15 cefazolin), allergy alternatives for GA-type 1 (14/15 clindamycin) and allergy alternatives for GA-type 2 (13/15 clindamycin). There was almost no consistency in antibiotic recommendations for GA type 3 (standard or allergy alternatives) or for soil/water contamination (Figure 1).

Conclusion: While most surveyed Level 1 Pediatric Trauma Centers have audited policies on timing and GA type dependent selection of antibiotic, there is substantial variation among centers in timing of antibiotics and in selection of antibiotics for GA type 3 pediatric open fractures. Decreasing practice variation and adopting evidence-based best practices for management of GA type 3 pediatric open fractures can improve the quality, safety and value of the care we deliver to children.