Orthopaedic procedures in children - Guideline for Antimicrobial Prophylaxis

Publication: 06/01/2012  
Last review: 20/07/2018  
Next review: 20/07/2021  
Clinical Guideline
CURRENT 
ID: 2682 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for antimicrobial prophylaxis during orthopaedic procedures in children

  1. Summary table of routine recommendations
  2. Background information
  3. Special antimicrobial prophylaxis recommendations

1. Summary table of routine recommendations

Procedure

Prophylaxis recommended

Evidence level

Prophylaxis intended to reduce

NNT

Antimicrobial dose/route
1 hours before procedure or tourniquet application

Routine

True penicillin allergy

MRSA risk

clean bone/joint surgery with metalwork insertion           (includes K-wires  and external fixators)

YES

A 1-3

SSI

28

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin * 50mg/kg iv single dose (max 1g)

Teicoplanin electronic Medicines Compendium information on Teicoplanin 10mg/kg iv  single dose (max 400mg)

Teicoplanin electronic Medicines Compendium information on Teicoplanin 10mg/kg iv  single dose (max 400mg)

Open fracture –  initial prophylaxis (including unsalvageable limb amputation).  NB contact microbiology if wound contaminated by stagnant water.

YES

C

Wound infection

-

Start ASAP after injury
Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav IV 30mg/kg (max 1.2g)9 (or oral where appropriate). Continue for 72 hours after initial debridement or until definitive skin closure. 

Clindamycin electronic Medicines Compendium information on Clindamycin 6.25mg/kg IV 6-hourly (max 600mg) plus
Gentamicin
2.5mg/kg. Continue Clindamycin electronic Medicines Compendium information on Clindamycin for 72 hours after initial debridement or until definitive skin closure.

Discuss with microbiology

Open fracture – at time of skeletal stabilization and definitive soft tissue closure.

       

Teicoplanin electronic Medicines Compendium information on Teicoplanin10mg/kg iv  single dose (max 400mg) plus Gentamicin 2.5mg/kg iv both single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 10mg/kg iv  single dose (max 400mg) plus Gentamicin 2.5mg/kg iv both single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 10mg/kg iv  single dose (max 400mg) plus Gentamicin 2.5mg/kg iv both single dose

Spinal surgery (with or without metalwork insertion)

YES

B1-3

SSI

28

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin* 50mg/kg iv (max 1g) plus Gentamicin 2.5mg/kg iv both single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 10mg/kg iv  single dose (max 400mg) iv  plus Gentamicin 2.5mg/kg iv both single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin 10mg/kg iv  single dose (max 400mg) plus Gentamicin 2.5mg/kg iv both single dose

Percutaneous bone biopsy

NO

-

-

-

-

-

-

Joint injection/aspiration/arthroscopy

NO

-

-

-

-

-

-

*redose flucloxacillin at 4 hours if operation is ongoing.

Back to top

2. Background information

This guideline concerns the prevention of infection following orthopaedic surgical procedures in children (>4months to 16 years) and does not apply to children with established infection (see below).  These recommendations are mostly extrapolated from adult data but are felt to fairly represent the situation in children. The only proviso being that children will fare better than adults because of healthier soft and bony tissue, better healing capacity and lack of co-morbidities.  Because of the increasingly recognised adverse effects of antimicrobial use, prophylaxis should only be used where there is clear evidence or consensus that the benefits outweigh the risks.

Guidelines for prevention of infection following bite injuries can be found in Guideline for the prevention of infection following animal or human bites (including antimicrobial prophylaxis) in children

Children with cellulitis or suspected necrotising fasciitis should be initially managed according to: Guideline for management of cellulitis in children >4 week to <16 years old (including necrotising fasciitis)

Children with suspected septic arthritis should be initially managed according to: Guideline for the management of septic arthritis in children - 2332.

Children with suspected osteomyelitis should be initially managed according to: Guideline for the management of osteomyelitis in children and infants [>4 weeks and <16 years old] excluding spinal infection

Children having temporary bladder catheterization and without underlying urinary tract problems do not require antibiotic prophylaxis to cover this procedure. In other cases refer to microbiology/urology.

Pathogenesis
Any trauma or surgical procedure can introduce bacteria into a wound which, if allowed to persist, may result in soft tissue or bone infection. This is influenced by:

  • the loading dose of infected material,
  • balance of host immunity and organism virulence,
  • presence/nature of residual foreign material in the wound,
  • vitality of bone and the soft tissue cover.

For example, a fit young child with normal immunity undergoing elective fixation of a low energy closed distal radial fracture will be much less at risk of infection than a child with multiple injuries and a grossly contaminated open tibial fracture with devitalised bone fragments.

Gustilo and Anderson’s classification of open tibial fractures is widely accepted and is useful in assessing the wound/fracture severity and likelihood of late infection.  It guides the clinician in managing the injury, particularly with regard to the management of the soft tissues and whether plastic reconstructive surgery or even amputation should be considered. Its use is extrapolated with validity to other anatomical sites.

Antimicrobial prophylaxis is just one of many strategies for the prevention of surgical site infection, in the case of obviously contaminated wounds, adequate debridement of cleansing of the wound to reduce the load of contaminating bacteria is important.

Microbiology
The likely pathological organism influences the choice of prophylactic antimicrobial agent.  The most common cause of surgical site infection after clean orthopaedic surgery in children is Staphylococcus aureus, 90% of which are sensitive to flucloxacillin.  The same organism is responsible for a similar proportion of infection in open contaminated wounds.

Less common organisms include Streptococcus pyogenes and Enterobacteriaceae (“coliforms”).  Anaerobes including Clostridium tetani and perfringens are very rare but are potentially devastating causes of infection and should be covered by prophylaxis in traumatic wounds (e.g. open fractures on sports field or following vehicle-relating injury).  Stagnant water (ponds, drainage ditches etc) may be a source of Aeromonas spp. which can cause severe soft tissue infection and would not be covered by routine prophylaxis.

Antimicrobial choice and duration
It is recommended to use a single pre-operative dose of prophylaxis in most situations to reduce the risks related to antimicrobial use while gaining maximum benefit from prophylaxis 2 3

Expert guidelines from the British Society for Antimicrobial Chemotherapy recommends use of glycopeptides prophylaxis in patients with a history of MRSA colonisation or infection 4.

These guidelines should be applicable to the majority of children.  Where the recommendations in these guidelines do not seem appropriate for a particular patient, the surgeon or cardiologist is advised to discuss the case with a microbiologist.

Back to top

3. Special antimicrobial prophylaxis recommendations

Open fractures
Infection following open tibial fracture fixation is not uncommon, for example infection occurred in 6% of 70 cases over a 20-year period from 1985 to 2005 in one institution. 5 Osteomyelitis is an uncommon but serious complication 5

BAPRAS/BOA guidelines recommend co-amoxiclav or cefuroxime given as soon as possible after injury and repeated 8-hrly until surgical debridement has been done 6. A dose is given at the time of first debridement and continued until soft tissue cover is achieved for or 72hrs (whichever is the sooner). Gentamicin and either vancomycin or teicoplanin are recommended at the time of skeletal stabilization and definitive soft tissue closure. Antibiotics are discontinued after definitive cover is achieved. Clindamycin should replace co-amoxiclav in penicillin allergic patients though cephalosporins are safe in those with lesser allergic reactions (sic).

Spinal surgery
SIGN guidelines recommend prophylaxis for spinal surgery in children extrapolated from evidence in adults. 2A BSAC working party has recommended use of a first or second generation cephalosporin for spinal surgery but this recommendation was made in spite of the lack of evidence that Gram negative cover makes a difference to outcome and prior to the efforts to control C. difficile infection by reducing cephalosporin use 7. The same working party and a BSAC MRSA working party recommended a glycopeptides 4 and gentamicin 7 for MRSA colonised/infected patients.

Provenance

Record: 2682
Objective:

Aim

  • To standardize and offer optimal treatment to avoid musculo-skeletal (and catheter) related infection in infants and children.

This guideline applies to all healthcare professionals involved in the care of children undergoing orthopaedic procedures.

Clinical condition:

Orthopaedic procedures in children

Target patient group: Children undergoing orthopaedic procedures
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

Evidence for the efficacy of prophylaxis, A; choice of agents, D

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus [no national guidelines exist, guidelines from different learned bodies   contradict each other, or no evidence exists]

References

  1. Barker FG, 2nd. Efficacy of prophylactic antibiotic therapy in spinal surgery: a meta-analysis. Neurosurgery 2002;51(2):391-400; discussion 00-1.
  2. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh, 2008.
  3. Leaper D, Collier M, Evans D, Farrington M, Gibbs E, Gould K, et al. Surgical site infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor: Royal College of Obstetrics and Gynaecology, Press, 2008.
  4. Gemmell CG, Edwards DI, Fraise AP, Gould FK, Ridgway GL, Warren RE, et al. Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the UK, 2006:589-608.
  5. Rao P, Schaverien M, Stewart K. Soft tissue management of children's open tibial. Ann R Coll Surg Engl.
  6. Anon. Standards for the management of  open fractures of the lower limb.: British Orthopaedic Association and the British Association of Plastic, Reconstructive and Aesthetic Surgeons, , 2009.
  7. Brown EM, Pople IK, de Louvois J, Hedges A, Bayston R, Eisenstein SM, et al. Spine update: prevention of postoperative infection in patients undergoing spinal surgery. Spine 2004;29(8):938-45.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.