Antibiotics in Trauma Tim Hardcastle Trauma Service Tygerberg

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 1 st Generation Cephalosporin (Kefzol 1 g 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 2 g 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– 2 nd Generation Cephalosporin (Cephuroxime) or Augmentin® – Avoid 3 rd Generation cephalosporin • Maximum 24 hr course except established infection (Level 2) www. east. org practice management guidelines De Lalla: Journal of hospital infection 2002 (50) suppl A

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 1 st 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 3 rd Generation Cephalosporins www. surgicalcriticalcare. n et