Antibiotics in Trauma???

Tim Hardcastle

Trauma Service

Tygerberg Hospital / Stellenbosch University

Introduction

• Evidence based review

• Rational antibiotic use in trauma

• Differentiate between:– Prophylaxis (most commonly required)– Therapy

• Propose local guideline

Statement of the problem

• Multitude of studies relating to antibiotic use

• Use different drugs and doses

• Seldom use placebo as control

• Most are studies in “delayed” presentation

What does the evidence reveal?

• Grading according to the “Sacket criteria”

• Level one evidence should be standard of care

• Level two evidence strongly advised as a guideline

• Level three optional clinician choice

Chest drains

• No level 1 evidence to support / deny

• No level 2 evidence

• Level 3 evidence suggests single dose of 1st Generation Cephalosporin (Kefzol 1g IVI push) may decrease the incidence of nosocomial pneumonia, but not empyema

16/05/2005 www.surgicalcritcalcare.net

Fractures

• Two types of fracture: open vs. closed

• Two types of management– Closed reduction and POP– ORIF

• Which antibiotics and how long therapy?

• Is there a difference in fracture severity

Fractures• Open fractures

– Any patient with metalwork– Grade 1 & 2 maximum 24 hours (Level 1)

• First generation cephalosporin• As soon as possible

– Grade 3 (Level 1 & 2)• Cephazolin 1 or 2g alone X 72 hours or wound

cover• Add gram negative and anaerobe cover if

severe contamination

www.east.org Practice management guidelines

Base of skull fractures

• No evidence to support routine antibiotic prophylaxis or empiric therapy in cases without meningitis

• Irrespective of CSF leak

• Other open skull fractures treat as open fracture

Cochrane database systemic review

25 January 2006

Penetrating Abdominal Trauma• All penetrating abdominal trauma: single

dose prophylaxis (“contaminated”):

• Level 1– Must cover G+ and G-– 2nd Generation Cephalosporin

(Cephuroxime) or Augmentin®– Avoid 3rd Generation cephalosporin

• Maximum 24hr course except established infection (Level 2)www.east.org practice management guidelines

De Lalla: Journal of hospital infection 2002 (50) suppl A S9-S12

Penetrating Abdominal Trauma

• Repeat dose every 10 PC with major trauma (Level 3)

• No need for routine Metronidazole

• Avoid aminoglycosides (Level 3)

www.east.org Practice guidelines 2002

Sganga, Journal of Hospital Infection 2001

Vascular injuries

• Level 2 evidence

• Single dose of 1st generation cephalosporin.

• 24 hours if synthetic graft used

• Single dose in endovascular procedures

DSTC Manual: Ed. K D Boffard

The Trauma Patient in ICU

• No empiric therapy without “Septic Screen”• Broad spectrum cover empirically only in

unstable patients (Level 3)• Source-directed therapy in stable patients (Level

3)• De-escalate to culture-directed therapy (Level 3)• Avoid the 3rd Generation Cephalosporins

www.surgicalcriticalcare.net