Antibiotics in Trauma???

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Antibiotics in Trauma???

• Tim Hardcastle
• Trauma Service
• Tygerberg Hospital / Stellenbosch University

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Introduction

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

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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

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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

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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
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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

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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
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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
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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
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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
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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
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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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