Short-course antibiotic prophylaxis in penetrating abdominal injuries: ceftriaxone versus cefoxitin

Antibiotic prophylaxis in trauma: Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and World Society of Emergency Surgery guidelines

Trauma is a complex disease, and the use of antibiotic prophylaxis (AP) in trauma patients is common practice. However, considering the increasing rates of antibiotic resistance, AP use should be questioned and limited only to specific cases. Antibiotic stewardship is of paramount importance in fighting resistance spread. Definitive rules or precise indications about AP in trauma remain unclear. The present article describes the indications of AP in traumatic lesions to the head, brain, torso, maxillofacial, extremities, skin, and soft tissues endorsed by the Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and World Society of Emergency Surgery.

Prophylactic antibiotics for penetrating abdominal trauma: duration of use and antibiotic choice

BACKGROUND

Penetrating abdominal trauma (PAT) is a common type of trauma leading to admission to hospital, which often progresses to septic complications. Antibiotics are commonly administered as prophylaxis prior to laparotomy for PAT. However, an earlier Cochrane Review intending to compare antibiotics with placebo identified no relevant randomised controlled trials (RCTs). Despite this, many RCTs have been carried out that compare different agents and durations of antibiotic therapy. To date, no systematic review of these trials has been performed.

OBJECTIVES

To assess the effects of antibiotics in penetrating abdominal trauma, with respect to the type of agent administered and the duration of therapy.

SEARCH METHODS

We searched the following electronic databases for relevant randomised controlled trials, from database inception to 23 July 2019; Cochrane Injuries Group's Specialised Register, CENTRAL, MEDLINE Ovid, MEDLINE Ovid In-Process & Other Non-Indexed Citations, MEDLINE Ovid Daily and Ovid OLDMEDLINE, Embase Classic + Embase Ovid, ISI Web of Science (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), and two clinical trials registers. We also searched reference lists from included studies. We applied no restrictions on language or date of publication.

SELECTION CRITERIA

We included RCTs only. We included studies involving participants of all ages, which were conducted in secondary care hospitals only. We included studies of participants who had an isolated penetrating abdominal wound that breached the peritoneum, who were not already taking antibiotics.

DATA COLLECTION AND ANALYSIS

Two study authors independently extracted data and assessed risk of bias. We used standard Cochrane methods. We aggregated study results using a random-effects model. We also conducted trial sequential analysis (TSA) to help reduce type I and II errors in our analyses.

MAIN RESULTS

We included 29 RCTs, involving a total of 4458 participants. We deemed 23 trials to be at high risk of bias in at least one domain. We are uncertain of the effect of a long course of antibiotic prophylaxis (> 24 hours) compared to a short course (≤ 24 hours) on abdominal surgical site infection (RR 1.00, 95% CI 0.81 to 1.23; I² = 0%; 7 studies, 1261 participants; very low-quality evidence), mortality (Peto OR 1.67, 95% CI 0.73 to 3.82; I² = 8%; 7 studies, 1261 participants; very low-quality evidence), or intra-abdominal infection (RR 1.23, 95% CI 0.84 to 1.80; I² = 0%; 6 studies, 111 participants; very-low quality evidence). Based on very low-quality evidence from fifteen studies, involving 2020 participants, which compared different drug regimens with activity against three classes of gastrointestinal flora (gram positive, gram negative, anaerobic), we are uncertain whether there is a benefit of one regimen over another. TSA showed the majority of comparisons did not cross the alpha adjusted boundary for benefit or harm, or reached the required information size, indicating that further studies are required for these analyses. However, in the three analyses which crossed the boundary for futility, further studies are unlikely to show benefit or harm.

AUTHORS' CONCLUSIONS

Very low-quality evidence means that we are uncertain about the effect of either the duration of antibiotic prophylaxis, or the superiority of one drug regimen over another for penetrating abdominal trauma on abdominal surgical site infection rates, mortality, or intra-abdominal infections. Future RCTs should be adequately powered, test currently used antibiotics, known to be effective against gut flora, use methodology to minimise the risk of bias, and adequately report the level of peritoneal contamination encountered at laparotomy.

Prophylactic antibiotic use in penetrating abdominal trauma: an Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND

The use of prophylactic antibiotics in penetrating abdominal trauma has resulted in decreased infection rates. The Eastern Association for the Surgery of Trauma (EAST) first published its practice management guidelines (PMGs) for the use of prophylactic antibiotics in penetrating abdominal trauma in 1998. During the next decade, several new prospective studies were published on this topic. In addition, the practice of damage control laparotomy became widely used, and additional questions arose as to the role of prophylactic antibiotics in this setting. Thus, the EAST Practice Management Guidelines Committee set out to update the original PMG.

METHODS

A search of the National Library of Medicine and the National Institutes of Health MEDLINE databases was performed using PubMed (www.pubmed.gov) and specific key words. The search retrieved English language articles regarding the use of antibiotics in penetrating abdominal trauma published from 1973 to 2011. The topics investigated were the need for perioperative antibiotics, the duration of antibiotic therapy, the dose of antibiotics in patients presenting in hemorrhagic shock, and the appropriate duration of antibiotic therapy in the setting of damage control laparotomy.

RESULTS

Forty-four articles were identified for inclusion in this review.

CONCLUSION

There is evidence to support a Level I recommendation that prophylactic antibiotics should only be administered for 24 hours in the presence of a hollow viscus injury. In addition, there are no data to support continuing prophylactic antibiotics longer than 24 hours in damage control laparotomy.

Microbiological profile and antimicrobial susceptibility in surgical site infections following hollow viscus injury

INTRODUCTION

The purpose of this study was to assess the microbiological profile, antimicrobial susceptibility, and adequacy of the empiric antibiotic therapy in surgical site infections (SSI) following traumatic hollow viscus injury (HVI).

METHODS

This is a retrospective study of patients admitted with an HVI from March 2003 to July 2009. SSI was defined as a wound infection or intra-abdominal collection confirmed by positive cultures and requiring percutaneous or surgical drainage.

RESULTS

A total of 91 of 667 (13.6%) patients with an HVI developed an SSI confirmed by positive culture. Mean age was 33.0 +/- 14.1 years, mean Injury Severity Score (ISS) was 17.7 +/- 9.6, 91.2% were male, and 80.2% had sustained penetrating injuries. The SSI consisted of 65 intra-abdominal collections and 26 wound infections requiring intervention. The most commonly isolated species in the presence of a colonic injury was Escherichia coli (64.7%), Enterococcus spp. (41.2%), and Bacteroides (29.4%), and in the absence of a colonic perforation, Enterococcus spp. and Enterobacter cloacae (both 38.9%). Susceptibility rates of E. coli and E. cloacae, respectively, were 38% and 8% for ampicillin/sulbactam, 82% and 4% for cefazolin, 96% and 92% for cefoxitin, with both 92% to piperacillin/tazobactam, and 100% to ertapenem. The initial empirical antibiotic therapy adequately targeted the pathogens in 51.6% of patients who developed an SSI.

CONCLUSION

The distribution of the microorganisms isolated from SSIs differed significantly according to whether or not a colonic injury was present. Empiric antibiotic treatment was inadequate in upwards of 50% of patients who developed an SSI. Further investigation is warranted to determine the optimal empiric antibiotic regimen for reducing the rate of postoperative SSI.

Critical care issues in the early management of severe trauma

Violent trauma and road traffic injuries kill more than 2.5 million people in the world every year, for a combined mortality of 48 deaths per 100,000 population per year. Most trauma deaths occur at the scene or in the first hour after trauma, with a proportion from 34% to 50% occurring in hospitals. Preventability of trauma deaths has been reported as high as 76% and as low as 1% in mature trauma systems. Critical care errors may occur in a half of hospital trauma deaths, in most of the cases contributing to the death. The most common critical care errors are related to airway and respiratory management, fluid resuscitation, neurotrauma diagnosis and support, and delayed diagnosis of critical lesions. A systematic approach to the trauma patient in the critical care unit would avoid errors and preventable deaths.

A ten-year study of penetrating injuries of the colon

BACKGROUND

Colon injury has been associated with a high risk of septic complications and mortality. We prospectively studied the pattern, management, outcome, and prognostic factors in patients who sustained penetrating colon injuries.

PATIENTS AND METHODS

Sixty patients who presented to our hospital with penetrating colon injuries over a ten-year period (1992 to 2001) were studied.

RESULTS

Colon wounds were caused by gunshots in 55 (91.7 percent) patients and knife stabs in 5 (8.3 percent). There was a delay of more than 12 hours before laparotomy in 30 (50 percent) patients. Moderate or major fecal contamination of the peritoneal cavity occurred in 58 (96.7 percent) patients. The average penetrating abdominal trauma index score was 25.9 and 20 (33.3 percent) patients sustained Flint Grade 3 colon injury. Associated intra-abdominal injuries occurred in the small bowel (73.3 percent), liver (25 percent), stomach (23.3 percent), and mesentery (16.7 percent). Right colon wounds (35) were managed by primary repair in 24 (68.6 percent) patients and proximal diverting colostomy in 11 (31.4 percent), whereas left colon wounds (25) were managed by diverting colostomy in 22 (88.0 percent) patients and primary repair in 3 (12.0 percent) patients. Common complications included wound infection (56.7 percent), septicemia (31.7 percent), and enterocutaneous fistula (16.7 percent). The overall mortality rate was 33.3 percent and colon injury-related mortality was 21.7 percent. Presence of destructive colon injury was associated with a greater than fourfold increased incidence of death. Other significant risk factors included shock on admission, major fecal contamination, duration of operation more than four hours, penetrating abdominal trauma index score >25, and more than two postoperative complications. There was no difference in outcome between patients who had primary repair and those undergoing diverting colostomy. Colostomy closure-related morbidity was 21 percent and mortality was 5.3 percent.

CONCLUSION

A more liberal use of primary repair is required in our patients with penetrating injuries of the colon.

Ceftriaxone versus Other Antibiotics for Surgical Prophylaxis

OBJECTIVE

To investigate possible differences in prophylaxis with ceftriaxone compared with other antimicrobial agents for surgical-site infections and remote infections such as respiratory tract infections (RTIs) and urinary tract infections (UTIs).

METHODS

The efficacy of ceftriaxone was compared with that of other antibiotics in the perioperative prophylaxis of local (surgical wound) and remote (RTIs and UTIs) infections in a meta-analysis of randomised controlled trials published between 1984 and 2003. The analysis was based on a 2 x 2 contingency table with classification by treatment and number of infections obtained from individual studies.

RESULTS

Evaluations were performed on 48 studies, for a total of 17 565 patients. Overall, 406 patients (4.8%) in the ceftriaxone group and 525 (6.3%) in the comparator group developed a surgical-site infection (log odds ratio [OR] -0.30 [CI -0.50 to -0.13]; p < 0.0001). RTIs were observed in 292 (6.01%) patients in the ceftriaxone group and in 369 (7.6%) patients in the comparator group, (log OR -0.30 [CI -0.55 to -0.09]; p = 0.0013). UTIs were reported for 2.2% of the ceftriaxone prophylaxis patients compared with 3.74% of the comparator group patients (log OR -0.54 [CI -1.18 to -0.16]; p < 0.0001). Overall, in clean surgery 195 (5.1%) and 234 (6.2%) patients developed a surgical site infection in the ceftriaxone and comparator groups, respectively (log OR -0.22 [CI -0.51 to 0.01]; p = 0.0476). RTIs were prevented for all but 1.57% of patients in the ceftriaxone group and 2.62% of patients in the comparator group (p = 0.01) in clean surgery, and for 9.54% of the ceftriaxone group versus 11.6% of the comparator group (p = 0.01) in clean-contaminated surgery. While results observed in clean surgery did not show statistically significant superiority of ceftriaxone in preventing UTI insurgence (log OR -0.21 [CI 0.0-0.65]; p = 0.7702), this was clearly shown in the clean-contaminated surgery. In fact, 4.47% of patients in the ceftriaxone group versus 7.52% of patients in the comparator group developed a UTI (log OR -0.56 [CI -1.25 to -0.16]; p < 0.0001). Adverse events were observed in a similar proportion in the ceftriaxone prophylaxis and the comparator groups (0.35% and 0.23%, respectively). Duration of prophylaxis did not influence outcome of infection.

CONCLUSIONS

The meta-analysis showed that ceftriaxone is statistically superior to other antibiotics in preventing both local and remote postoperative infections.

Characteristics of prophylactic antibiotic strategies after penetrating abdominal trauma at a level I urban trauma center: a comparison with the East guidelines

BACKGROUND

Antibiotic prophylaxis, along with surgical intervention, is a key component in reducing infection in patients after penetrating abdominal trauma (PAT). Recent guidelines from the Eastern Association for the Surgery of Trauma (EAST) recommend that prophylaxis for < or = 24 hours is adequate for most patients. We compared antibiotic prophylaxis practices after PAT at our institution with EAST guidelines, quantified the incidence of infection, and identified risk factors for infection.

METHODS

This study was a retrospective review of patients with PAT requiring a therapeutic laparotomy between July 1998 and January 2001.

RESULTS

Antibiotic prophylaxis met EAST guidelines criteria in 21 of 97 patients (22%). There was a trend toward higher infection rates (18 of 76 vs. 3 of 21; = 0.273) when prophylaxis exceeded EAST recommendations. Multivariate analysis revealed blood transfusions to be the only predictor of infection (odds ratio, 6.9; 95% confidence interval, 2.42-19.95).

CONCLUSION

Despite prophylactic antibiotic use often exceeding EAST criteria, many patients still developed infection. Blood transfusion was the only significant risk factor for infection.

Perioperative antibiotic use in high-risk penetrating hollow viscus injury: a prospective randomized, double-blind, placebo-control trial of 24 hours versus 5 days

BACKGROUND

The purpose of this study was to compare the safety and therapeutic efficacy of a 24-hour versus 5-day course of ampicillin/sulbactam for the prevention of postoperative infections in high-risk patients sustaining hollow viscus injury from penetrating abdominal trauma.

METHODS

A total of 317 patients from four Level I trauma centers with penetrating abdominal injuries and at least one hollow viscus perforation each received one preoperative and three postoperative doses of ampicillin/sulbactam 3 g intravenously. After receiving 24 hours of unblinded ampicillin/sulbactam, patients were then randomized into one of two groups. Group 1 received 4 additional days of blinded ampicillin/sulbactam (5 days total of antibiotic), and Group 2 received 4 days of placebo (24 hours of antibiotic). Patients were assessed postoperatively for occurrence of deep surgical-site infections (intra-abdominal abscess, fasciitis, and peritonitis) and superficial (wound) surgical-site infections. Development of nonsurgical-site infections (e.g., pneumonia, urinary tract infection, phlebitis, and cellulitis) was also recorded. Continuous variables were analyzed by analysis of variance and discrete variables by the Cochran-Mantel-Haenszel chi2 test. Multivariate logistic regression analyses were also performed to identify independent risk factors for postoperative infection.

RESULTS

A total of 159 patients were randomized into Group 1, and 158 patients were randomized into Group 2. The Injury Severity Score and penetrating abdominal trauma index were 18+/-8 and 21+/-13, respectively, for Group 1 and 18+/-9 and 20+/-15, respectively, for Group 2. A total of 162 (51%) patients sustained one or more colon injuries (82 in Group 1 and 80 in Group 2). There were 16 (10%) surgical-site infections in Group 1 and 13 (8%) surgical-site infections in Group 2 (p = 0.74). Group 1 patients experienced 17 (11%) nonsurgical-site infections, whereas Group 2 had 32 (20%) nonsurgical-site infections. This difference, however, was not statistically significant (p = 0.16). Only the total number of blood units transfused and the presence of a PATI score greater than or equal to 25 were found to be independently associated with the development of a postoperative surgical- and nonsurgical-site infections (p = 0.001 and p = 0.003, respectively). Of note, the presence of a colon injury was not found to be an independent risk factor (p = 0.11) for either surgical or nonsurgical site postoperative infection in our study.

CONCLUSION

High-risk patients with colon or other hollow viscus injuries from penetrating abdominal trauma are at no greater risk for surgical-site or nonsurgical-site infection when treated with only a 24-hour course of a broad-spectrum antibiotic.

Factors affecting mortality and morbidity in patients with abdominal gunshot wounds

Risk factors that may independently predict mortality and morbidity in patients with abdominal gunshot wounds have not been fully elucidated. We prospectively studied the effects of 12 potential risk factors on mortality and morbidity in 82 patients with abdominal gunshot wounds who required laparotomy. Univariate analysis of these factors revealed that shock on admission, presence of penetrating colon injury and number of intra-abdominal organs injured (NOI)>2 were associated with greater than threefold increased incidence of death (p<0.05). Penetrating abdominal trauma index (PATI) score>15 was associated with twentyfold increased incidence of death (P<0.0001). Multivariate analysis showed that only PATI (P=0.001), number of postoperative complications per patient (N(comp)) (P=0.023) and presence of shock on admission (P=0. 028) were independently significant in predicting mortality. PATI was the only risk factor that independently predicted the development of postoperative infectious complications and N(comp) (P<0.0001). The type of gun used was not a significant risk factor (P>0.05). The 15 (18.3%) non-survivors were significantly older than survivors (P=0.02), had longer operations (P=0.004) and their NOI, PATI and N(comp) were significantly higher (P<0.001). The uniformly prolonged injury to surgery time in all patients contributed to the high incidence of infectious complications (62.2%) and mortality. PATI score was the most important factor found to be independently associated with mortality and morbidity in our subset of patients with prolonged injury to surgery time and high rate of colon injury.

Early predictors of sepsis in the motor-vehicle crash trauma victim

INTRODUCTION

Sepsis is a major cause of late morbidity and mortality in the victim of trauma. Currently, there is no method that is clinically practical and accurate for predicting the occurrence of sepsis in trauma victims.

METHODS

Data were collected on 3,759 motor-vehicle crash victims from 16 hospitals during a 4 1/2 year period. Retrospective analysis was done to examine the relationship of patient and injury factors known within the first 24 hours of admission on the development of sepsis.

RESULTS

Sepsis developed in 154 patients (4.1%) who had a mortality rate of 17.5%. Significant early predictors of sepsis included: 1) certain pre-existing conditions; 2) blood transfusion required; 3) seven or more injuries; 4) Glasgow Coma Scale score <10 and hypotension [corrected]; 5) major blood vessel injury; 6) head trauma; 7) internal injury of the chest or abdomen; 8) spinal-cord injury; and 9) certain fracture types.

CONCLUSIONS

These predictors might help target high-risk patients and, thus, promote earlier and more effective treatment for those patients.

Gunshot wounds of the colon: role of retained bullets in sepsis

The role in the development of local sepsis of retained bullets that have passed through the colon was investigated. Of 84 patients with gunshot wounds of the colon, the bullet was retained in the body in 40 and had left or was removed from the body in 44. The groups were similar with regard to Revised Trauma Score, Injury Severity Score, Penetrating Abdominal Trauma Index and type of colonic trauma. The incidence of major local complications was 5 per cent in patients with a retained bullet and 7 per cent in those without. These results suggest that retained bullets that have penetrated the colon do not contribute to local septic complications.