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Rational Antibiotic Use in Trauma: Evidence-Based Review & Local Guidelines

Evidence-based review on rational antibiotic use in trauma, proposing local guidelines differentiated between prophylaxis and therapy. Grading based on Sacket criteria, level of evidence, and recommendations for specific types of traumas. Includes recommendations for fractures, chest drains, base of skull fractures, penetrating abdominal trauma, vascular injuries, and trauma patients in ICU.

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Rational Antibiotic Use in Trauma: Evidence-Based Review & Local Guidelines

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  1. Antibiotics in Trauma??? Tim Hardcastle Trauma Service Tygerberg Hospital / Stellenbosch University

  2. Introduction • Evidence based review • Rational antibiotic use in trauma • Differentiate between: • Prophylaxis (most commonly required) • Therapy • Propose local guideline

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

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