GUIDELINE FOR ANTIMICROBIAL PROPHYLAXIS DURING ORTHOPAEDIC PROCEDURES IN CHILDREN

• Recommended routine prophylaxis options
• Background information
• Special antimicrobial prophylaxis recommendations

RECOMMENDED ROUTINE PROPHYLAXIS OPTIONS

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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.

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.

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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.  Osteomyelitis is an uncommon but serious complication

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. 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 (Amoxicillin-Clavulanate) 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. A 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. The same working party and a BSAC MRSA working party recommended a glycopeptides and gentamicin for MRSA colonised/infected patients.