Systematic Review of the Literature and Evidence-Based Recommendations for Antibiotic Prophylaxis in Trauma: Results from an Italian Consensus of Experts

Abstract

BackgroundAntibiotic prophylaxis is frequently administered in severe trauma. However, the risk of selecting resistant bacteria, a major issue especially in critical care environments, has not been sufficiently investigated. The aim of the present study was to provide guidelines for antibiotic prophylaxis for four different trauma-related clinical conditions, taking into account the risks of antibiotic-resistant bacteria selection, thus innovating previous guidelines in the field.MethodsThe MEDLINE database was searched for studies comparing antibiotic prophylaxis to controls (placebo or no antibiotic administration) in four clinical traumatic conditions that were selected on the basis of the traumatic event frequency and/or infection severity. The selected studies focused on the prevention of early ventilator associated pneumonia (VAP) in comatose patients with traumatic brain injury, of meningitis in severe basilar skull fractures, of wound infections in long-bone open fractures. Since no placebo-controlled study was available for deep surgical site-infections prevention in abdominal trauma with enteric contamination, we compared 24-hour and 5-day antibiotic prophylaxis policies. A separate specific research focused on the question of antibiotic-resistant bacteria selection caused by antibiotic prophylaxis, an issue not adequately investigated by the selected studies. Randomised trials, reviews, meta-analyses, observational studies were included. Data extraction was carried out by one author according to a predefined protocol, using an electronic form. The strength of evidence was stratified and recommendations were given according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.ResultsUncertain evidence deserving further studies was found for two-dose antibiotic prophylaxis for early VAP prevention in comatose patients. In the other cases the risk of resistant-bacteria selection caused by antibiotic administration for 48 hours or more, outweighed potential benefits.ConclusionsWhen accounting for antibiotic-resistant bacteria selection we found no evidence in favour of antibiotic prophylaxis lasting two or more days in the studied clinical conditions.

Multi-Drug–Resistant Gram-Negative Infections in Deployment-Related Trauma Patients

“…Figures 3 and 4 illustrate higher use of several antibiotic agents (e.g., anti-pseudomonal PCN and carbapenems) and that multi-class exposure is common. Poole et al [41] highlight the risk of wound colonization with resistant bacteria in surgical patients after 48 hours of prophylactic antibiotic agents, likely a common circumstance in our patient population. In addition, an analysis of injured service members found that 14% of 2,079 trauma admissions were colonized with MDRGN bacilli at admission to participating hospitals in the United States, of which 98% received antibiotic agents before collection of surveillance swabs (£2 d of hospital admission).…”

Prevención y tratamiento de las infecciones del sitio operatorio en neurocirugía. Estado del arte

“…La profilaxis se ha evaluado considerando las características diferenciales del trauma como lo son el tipo y lugar del trauma, exposición de masa encefálica, trauma penetrante, presencia de fístulas de LCR, fracturas de la base del cráneo o en comunicación con los senos paranasales (49,70,71) . En el metaanálisis realizado por Poole et al, se evaluó el uso de antibióticos profilácticos en fracturas de base de cráneo, estudio en el cual no se demostró beneficio aparente en la instauración de esta medida (71) .…”

Early prevention of trauma-related infection/sepsis

“…Patients with penetrating abdominal trauma and concomitant thoracolumbar or sacral (TLS) fracture receiving prophylactic antibiotics for ≤ 48 hours do not develop spinal infections [29]. Prophylactic antibiotic research is applicable not only at the site of trauma wound infection but also in patients with nosocomial infections (early VAP and Clostridium difficile infection) [30, 31]. …”