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Antibiotics in Trauma???

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.

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Antibiotics in Trauma???

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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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