Tag Archives: antibiotics

Best of AAST #6: Antibiotics For Chest Tubes??

For as long as I can remember (nearly 50 years worth of literature) there has been some debate about giving antibiotics after chest tube insertion to decrease the infection rate. The pendulum moved back and forth for decades, never getting very far into the “give antibiotics” side. It’s been quite a while since I remember any new papers on this, and I thought the debate had been resolved in favor of never using them.

But then I see an abstract from the AAST multi-institutional trials group studying presumptive antibiotics after chest tube insertion! They conducted a prospective, observational study at 22 Level I trauma centers, enrolling nearly 2,000 patients. They matched patients in antibiotic and no antibiotic groups, arriving at (only) 272 patients in each group.

Here are the results:

Bottom line: First, it’s a little disappointing that the numbers were so low with a trial that includes 22 trauma centers. Did they have a hard time finding centers that would give antibiotics? Or was it just hard to match patients for the variables they were looking at? Regardless, there were no significant differences in infectious complications, and a non-clinically significant difference in ICU stay with antibiotics.

Why won’t this die? If there are so few papers that show an actual benefit from giving antibiotics after chest tube insertion with 50 years of data, then it’s very unlikely that it will ever be shown to be necessary!

Reference: Presumptive antibiotics for tube thoracostomy for traumatic pneumothorax. Session XXII Paper 49, AAST 2018.

EAST 2016: (F)utility Of Antibiotic Use In Facial Fractures

The majority of
trauma patients presenting with facial fractures are managed without surgery.
Dogma in the facial fracture literature indicates that antibiotics should be
administered for some period of time, typically 7-10 days, for fractures that
involve one of the sinuses.

Although this idea
and practice have been around for a long time, there is no good literature out
there to support it
. Most medical professionals are now aware of the downside
to giving unnecessary antibiotics, including allergic reactions, C. Diff infections,
and promotion of antibiotic resistance.

A group at Geisinger
Medical Center in Danville, PA, performed a four-year retrospective review of
their registry data involving nonoperatively managed facial fractures. They
stratified their patients into three groups: no antibiotics, brief antibiotics
(1-5 days), and prolonged antibiotics (>5 days). A total of 289 patients
were studied.

Here are the factoids:

  • 17% received no antibiotics, 22% received a short course, and 61% got them
    for more than 5 days (!)
  • There were no soft tissue infections in any of the groups
  • There was 1 C. Diff infection, which occurred in the prolonged
    antibiotic group. This was not statistically significant.

Bottom
line: Granted, this was a small, retrospective study. But absolutely no difference
in soft tissue infections was seen, and fear of infection is the usual
justification for the use of antibiotics in these patients. A single case of C.
Diff colitis was noted, and it just happened to occur in the prolonged
antibiotic group. It’s time that we consider abandoning the blanket use of
antibiotics for facial fractures involving the sinuses.

Reference: Utility of
prophylactic antibiotics for non-operative facial fractures. EAST 2016 Poster
abstract #11.

SCIP: Importance Of Prophylactic Antibiotics In Trauma Laparotomy

Quite a lot of research has been done on the efficacy of prophylactic antibiotics in the prevention of infectious complications after surgical procedures. Antibiotics are now routinely given prior to most elective surgical procedures. In the US, the Centers for Medicare and Medicaid Services has formalized this into part of the Surgical Care Improvement Project (SCIP), which mandates the use of an appropriate antibiotic within 1 hour preop and stopping it within 24 hours postop.

But what about emergent cases, like trauma laparotomy? Ensuring timely antibiotic administration is difficult due to the rapid events leading up to the operation. And sometimes it is not clear whether a hollow viscus injury has occurred until after start of operation, so the antibiotic choice may change in the middle of the case.

Two busy urban trauma centers with high penetrating injury rates looked at one year of experience in patients undergoing trauma laparotomy. They compared surgical site infections (SSI) in patients who received SCIP-compliant antibiotic administration vs those who did not.

Here are the factoids:

  • Patient mix was 30% blunt, 44% gunshot, 27% stab wounds
  • There were 151 SCIP-compliant patients and 155 noncompliant ones
  • Half of the noncompliant group did not receive the appropriate antibiotic (usually Cefazolin in hollow viscus injury), and half had antibiotics given for more than 24 hours
  • SCIP-compliant patients had significantly fewer wound infections and shorter length of stay. Mortality was the same.

Bottom line: I recommend adhering to SCIP prophylactic antibiotic guidelines for trauma laparotomy. There is no reason why this subset of patients should be treated any differently, and this study presents evidence that it is beneficial. Using the SCIP guidelines in emergent surgery reinforces the usual preop routine in hospitals that have already embraced them. In general, blunt trauma patients undergoing laparotomy should receive prophylaxis that covers skin organisms. Since penetrating trauma has a much higher chance of involving the intestinal tract, broader spectrum antibiotics should be selected. In either case, use the antibiotic that has been selected for this purpose by your hospital. And be sure they are stopped during the first 24 hours.

Reference: “SCIP"ping antibiotic prophylaxis guidelines in trauma: the consequences of noncompliance. J Trauma 73(2):452-456, 2012.

SCIP: Importance Of Prophylactic Antibiotics In Trauma Laparotomy

Quite a lot of research has been done on the efficacy of prophylactic antibiotics in the prevention of infectious complications after surgical procedures. Antibiotics are now routinely given prior to most elective surgical procedures. In the US, the Centers for Medicare and Medicaid Services has formalized this into part of the Surgical Care Improvement Project (SCIP), which mandates the use of an appropriate antibiotic within 1 hour preop and stopping it within 24 hours postop.

But what about emergent cases, like trauma laparotomy? Ensuring timely antibiotic administration is difficult due to the rapid events leading up to the operation. And sometimes it is not clear whether a hollow viscus injury has occurred until after start of operation, so the antibiotic choice may change in the middle of the case.

Two busy urban trauma centers with high penetrating injury rates looked at one year of experience in patients undergoing trauma laparotomy. They compared surgical site infections (SSI) in patients who received SCIP-compliant antibiotic administration vs those who did not. 

Key findings:

  • Patient mix was 30% blunt, 44% gunshot, 27% stab wounds
  • There were 151 SCIP-compliant patients and 155 noncompliant ones
  • Half of the noncompliant group did not receive the appropriate antibiotic (usually Cefazolin in hollow viscus injury), and half had antibiotics given for more than 24 hours
  • SCIP-compliant patients had significantly fewer wound infections and shorter length of stay. Mortality was the same.

Bottom line: I recommend adhering to SCIP prophylactic antibiotic guidelines for trauma laparotomy. There is no reason why this subset of patients should be treated any differently, and this study presents evidence that it is beneficial. Using the SCIP guidelines in emergent surgery reinforces the usual preop routine in hospitals that have already embraced them. In general, blunt trauma patients undergoing laparotomy should receive prophylaxis that covers skin organisms. Since penetrating trauma has a much higher chance of involving the intestinal tract, broader spectrum antibiotics should be selected. In either case, use the antibiotic that has been selected for this purpose by your hospital. And be sure they are stopped during the first 24 hours.

Reference: “SCIP"ping antibiotic prophylaxis guidelines in trauma: the consequences of noncompliance. J Trauma 73(2):452-456, 2012.

Antibiotics For Ventriculostomy

There is some variability in how neurosurgeons manage ventriculostomy when it comes to antibiotic coverage. The catheter can become a conduit for bacterial infections of the meninges or brain, which can be life threatening. Most neurosurgeons will begin coverage at the time of catheter insertion, but the duration of treatment varies. What is the right answer, if any?

As is typical with most things related to head trauma, there are not a lot of good studies out there. Columbia University published a fairly comprehensive review of previous studies last year to help clarify this issue. They applied rigorous criteria to identify 10 relevant studies (3 randomized clinical trials and 7 observational studies) out of a pool of 347. Yes folks, this gives you an idea of how tough it is to answer good clinical questions from the stuff that gets published.

The study found that the use of either prophylactic antibiotics or antibiotic-coated external ventricular drains (EVD) decreased the number of infections by 68%. This result was consistent across both study designs. The authors could not show that one mode of antibiotic administration (systemic vs catheter coating) was better than the other. About half of the studies used antibiotics for the duration of the catheter; the other half did not specify.

Bottom line: Head injury patients with an EVD should receive antibiotics, either systemically or as a coating on the EVD catheter itself. Although not entirely clear, they should probably be given for the entire time the catheter is in place. Judgment must be used if this will be a long time, because there may be other adverse effects from giving long term antibiotics.

Reference: Prevention of Ventriculostomy-Related Infections With Prophylactic Antibiotics and Antibiotic-Coated External Ventricular Drains: A Systematic Review. Neurosurgery 68(4):996-1005, 2011.