Analysis of the treatment of basilar skull fractures with and without antibiotics

Infection Prevention in the Neurointensive Care Unit: A Systematic Review

Hospital-acquired infections are common in neurointensive care units. We sought to review interventions which may reduce infection rates in neurocritically ill populations. We conducted a systematic review of studies targeting adult patients in neuro-intensive care units (neuro-ICUs) with an intervention designed to prevent ICU-acquired infections. Our outcome of interest was change in the prevalence or rates of infection between active and control arms of these studies. We excluded studies based on the following criteria: no English full-text version available; pediatric population; non-neurosciences ICU population; pre- or intraoperative methods to prevent infection; lack of discrete data for infection rates/prevalence; studies that were purely observational in nature and did not test an intervention; and studies performed in resource limited settings. We initially retrieved 3716 results by searching the following databases: PubMed/MEDLINE, EMBASE via Ovid, and Cochrane CENTRAL via Ovid. No date or language limits were used in the search. Computerized deduplication was conducted using EndNote followed by a confirmatory manual review resulting in 3414 citations. An additional 19 manuscripts were identified through review of references. The screening process followed a standard protocol, using two screeners at the title/abstract level to determine relevance and at the full-text level to determine eligibility for inclusion. The 3427 titles/abstracts were independently screened by two board-certified neurointensivists to determine relevance for full-text review, and 3248 were rejected. The remaining 179 abstracts were reviewed in full text using predetermined inclusion/exclusion criteria. Ultimately, 75 articles met our inclusion criteria and were utilized in the final analysis. The reviewed literature highlights the need for collaborative, multi-disciplinary, and multi-pronged approaches to reduce infections. Rates of VRI, SSI, VAP, CAUTI, and CLABSI can approach zero with persistence and a team-based approach.

Treatment of Temporal Bone Fractures

Traumatic injury to the temporal bone can lead to significant morbidity or mortality and knowledge of the pertinent anatomy, pathophysiology of injury, and appropriate management strategies is critical for successful recovery and rehabilitation of such injured patients. Most temporal bone fractures are caused by motor vehicle accidents. Temporal bone fractures are best classified as either otic capsule sparing or otic capsule disrupting-type fractures, as such classification correlates well with risk of concomitant functional complications. The most common complications of temporal bone fractures are facial nerve injury, cerebrospinal fluid (CSF) leak, and hearing loss. Assessment of facial nerve function as soon as possible following injury greatly facilitates clinical decision making. Use of prophylactic antibiotics in the setting of CSF leak is controversial; however, following critical analysis and interpretation of the existing classic and contemporary literature, we believe its use is absolutely warranted.

Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures

BACKGROUND

Basilar skull fractures predispose patients to meningitis because of the possible direct contact of bacteria in the paranasal sinuses, nasopharynx or middle ear with the central nervous system (CNS). Cerebrospinal fluid (CSF) leakage has been associated with a greater risk of contracting meningitis. Antibiotics are often given prophylactically, although their role in preventing bacterial meningitis has not been established.

OBJECTIVES

To evaluate the effectiveness of prophylactic antibiotics for preventing meningitis in patients with basilar skull fractures.

SEARCH METHODS

We searched CENTRAL (2014, Issue 5), MEDLINE (1966 to June week 1, 2014), EMBASE (1974 to June 2014) and LILACS (1982 to June 2014). We also performed an electronic search of meeting proceedings from the American Association of Neurological Surgeons (1997 to September 2005) and handsearched the abstracts of meeting proceedings of the European Association of Neurosurgical Societies (1995, 1999 and 2003).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any antibiotic versus placebo or no intervention. We also identified non-RCTs to perform a separate meta-analysis in order to compare results.

DATA COLLECTION AND ANALYSIS

Three review authors independently screened and selected trials, assessed risk of bias and extracted data. We sought clarification with trial authors when needed. We pooled risk ratios (RRs) for dichotomous data with their 95% confidence intervals (CIs) using a random-effects model. We assessed the overall quality of evidence using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.

MAIN RESULTS

In this update we did not identify any new trials for inclusion. We included five RCTs with 208 participants in the review and meta-analysis. We also identified 17 non-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention in patients with basilar skull fractures. Most trials presented insufficient methodological detail. All studies included meningitis in their primary outcome. When we evaluated the five included RCTs, there were no significant differences between antibiotic prophylaxis groups and control groups in terms of reduction of the frequency of meningitis, all-cause mortality, meningitis-related mortality and need for surgical correction in patients with CSF leakage. There were no reported adverse effects of antibiotic administration, although one of the five RCTs reported an induced change in the posterior nasopharyngeal flora towards potentially more pathogenic organisms resistant to the antibiotic regimen used in prophylaxis. We performed a subgroup analysis to evaluate the primary outcome in patients with and without CSF leakage. We also completed a meta-analysis of all the identified controlled non-RCTs (enrolling a total of 2168 patients), which produced results consistent with the randomised data from the included studies.Using the GRADE approach, we assessed the quality of trials as moderate.

AUTHORS' CONCLUSIONS

Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with basilar skull fractures, whether there is evidence of CSF leakage or not. Until more research is available, the effectiveness of antibiotics in patients with basilar skull fractures cannot be determined because studies published to date are flawed by biases. Large, appropriately designed RCTs are needed.

Systematic review of the literature and evidence-based recommendations for antibiotic prophylaxis in trauma: results from an Italian consensus of experts

BACKGROUND

Antibiotic prophylaxis is frequently administered in severe trauma. However, the risk of selecting resistant bacteria, a major issue especially in critical care environments, has not been sufficiently investigated. The aim of the present study was to provide guidelines for antibiotic prophylaxis for four different trauma-related clinical conditions, taking into account the risks of antibiotic-resistant bacteria selection, thus innovating previous guidelines in the field.

METHODS

The MEDLINE database was searched for studies comparing antibiotic prophylaxis to controls (placebo or no antibiotic administration) in four clinical traumatic conditions that were selected on the basis of the traumatic event frequency and/or infection severity. The selected studies focused on the prevention of early ventilator associated pneumonia (VAP) in comatose patients with traumatic brain injury, of meningitis in severe basilar skull fractures, of wound infections in long-bone open fractures. Since no placebo-controlled study was available for deep surgical site-infections prevention in abdominal trauma with enteric contamination, we compared 24-hour and 5-day antibiotic prophylaxis policies. A separate specific research focused on the question of antibiotic-resistant bacteria selection caused by antibiotic prophylaxis, an issue not adequately investigated by the selected studies. Randomised trials, reviews, meta-analyses, observational studies were included. Data extraction was carried out by one author according to a predefined protocol, using an electronic form. The strength of evidence was stratified and recommendations were given according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

Uncertain evidence deserving further studies was found for two-dose antibiotic prophylaxis for early VAP prevention in comatose patients. In the other cases the risk of resistant-bacteria selection caused by antibiotic administration for 48 hours or more, outweighed potential benefits.

CONCLUSIONS

When accounting for antibiotic-resistant bacteria selection we found no evidence in favour of antibiotic prophylaxis lasting two or more days in the studied clinical conditions.

Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures

BACKGROUND

Basilar skull fractures (BSF) predispose patients to meningitis because of the possible direct contact of bacteria in the paranasal sinuses, nasopharynx or middle ear with the central nervous system (CNS). Cerebrospinal fluid (CSF) leakage has been associated with a greater risk of contracting meningitis. Antibiotics are often given prophylactically, although their role in preventing bacterial meningitis is not established.

OBJECTIVES

To evaluate the effectiveness of prophylactic antibiotics for preventing meningitis in patients with BSF.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register, MEDLINE (1966 to February 2011), EMBASE (1974 to February 2011) and LILACS (1982 to February 2011). We also performed an electronic search of meeting proceedings from the American Association of Neurological Surgeons (1997 to September 2005) and handsearched the abstracts of meeting proceedings of the European Association of Neurosurgical Societies (1995, 1999 and 2003).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any antibiotic versus placebo or no intervention. We also identified non-RCTs to perform a separate meta-analysis to compare results.

DATA COLLECTION AND ANALYSIS

At least two authors independently appraised trial quality and extracted data for each trial.

MAIN RESULTS

We identified five RCTs and 17 non-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention in patients with BSF. Most trials presented insufficient methodological detail. All studies included meningitis in their primary outcome. Overall, we evaluated 208 participants from the five RCTs that were considered suitable for inclusion in the meta-analysis. There were no significant differences between antibiotic prophylaxis groups and control groups in terms of reduction of the frequency of meningitis, all-cause mortality, meningitis-related mortality, and need for surgical correction in patients with CSF leakage. There were no reported adverse effects of antibiotic administration, although one of the five RCTs reported an induced change in the posterior nasopharyngeal flora towards potentially more pathogenic organisms resistant to the antibiotic regimen used in prophylaxis. We performed a subgroup analysis to evaluate the primary outcome in patients with and without CSF leakage. We also completed a meta-analysis of all the identified controlled non-RCTs (enrolling a total of 2168 patients), producing results consistent with the randomised data.

AUTHORS' CONCLUSIONS

Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with BSF, whether there is evidence of CSF leakage or not. Until more research is completed, the effectiveness of antibiotics in patients with BSF cannot be determined because studies published to date are flawed by biases. Large, appropriately designed RCTs are needed.

Prophylactic antibiotics and anticonvulsants in neurosurgery

The prophylactic administration of antibiotics to prevent infection and the prophylactic administration of anticonvulsants to prevent first seizure episodes are common practice in neurosurgery. If prophylactic medication therapy is not indicated, the patient not only incurs the discomfort and the inconvenience resulting from drug treatment but is also unnecessarily exposed to adverse drug reactions, and incurs extra costs. The main situations in which prophylactic anticonvulsants and antibiotics are used are described and those situations we found controversial in the literature and lack further investigation are identified: anticonvulsants for preventing seizures in patients with chronic subdural hematomas, antiepileptic drugs for preventing seizures in those suffering from brain tumors, antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures, and antibiotic prophylaxis for the surgical introduction of intracranial ventricular shunts.In the following we present systematic reviews of the literature in accordance with the standard protocol of The Cochrane Collaboration to evaluate the effectiveness of the use of these prophylactic medications in the situations mentioned. Our goal was to efficiently integrate valid information and provide a basis for rational decision-making.

Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures

BACKGROUND

Basilar skull fractures (BSF) predispose patients to meningitis because of the possible direct contact of bacteria in the paranasal sinuses, nasopharynx or middle ear with the central nervous system (CNS). Cerebrospinal fluid (CSF) leakage has been associated with a greater risk of contracting meningitis. Antibiotics are often given prophylactically, although their role for preventing bacterial meningitis is not established.

OBJECTIVES

To evaluate the effectiveness of prophylactic antibiotics for preventing meningitis in patients with BSF.

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to September 2005), EMBASE (1974 to June 2005), and LILACS (1982 to September 2005). We also performed an electronic search of meeting proceedings from the American Association of Neurological Surgeons (1997 to September 2005) and handsearched the abstracts of meeting proceedings of the European Association of Neurosurgical Societies (1995, 1999 and 2003).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any antibiotic versus placebo or no intervention. We also identified non-RCTs to perform a separate meta-analysis to compare results.

DATA COLLECTION AND ANALYSIS

At least two authors independently appraised the quality and extracted the data of each trial.

MAIN RESULTS

Five RCTs and 17 non-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention in patients with BSF were identified. Most trials presented insufficient methodological detail. All studies included meningitis in their primary outcome. Overall, we evaluated 208 participants from the four RCTs that were considered suitable for inclusion in the meta-analysis. There were no significant differences between antibiotic prophylaxis groups and control groups in terms of reduction of the frequency of meningitis, all-cause mortality, meningitis-related mortality, and need for surgical correction in patients with CSF leakage. We performed a subgroup analysis to evaluate the primary outcome in patients with and without CSF leakage. We also completed a meta-analysis of all the identified controlled non-RCTs (enrolling a total of 2168 patients), producing results consistent with the randomised data.

AUTHORS' CONCLUSIONS

Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with BSF, whether there is evidence of CSF leakage or not. Until more research is completed, the effectiveness of antibiotics in patients with BSF cannot be determined because studies published to date are flawed by biases. Large, appropriately designed RCTs are needed.

Prophylactic administration of ceftriaxone for the prevention of meningitis after traumatic pneumocephalus: results of a clinical trial

OBJECT

The purpose of this study was to compare the efficacy of the prophylactic use of ceftriaxone for the prevention of meningitis in patients with acute traumatic pneumocephalus.

METHODS

In this prospective, single-institution, randomized clinical trial, 109 patients with mild head injury and traumatic pneumocephalus were randomly assigned to receive or not receive an antibiotic medication (ceftriaxone, 1 g given twice a day) until occurrence of meningitis or at least 5 days after trauma. The patients were followed up for 1 month posttrauma. The 109 patients were divided into two groups: 53 were assigned to the prophylactic antibiotics therapy group and 56 to the control group. The overall rate of meningitis was 20.1% and the rates of meningitis in the two groups were not significantly different. The results were the same when adjusted for the patient's Glasgow Coma Scale score, sex, and age, as well as for an intradural location of air, air volume, presence of cerebrospinal fluid (CSF) rhinorrhea or CSF otorrhea, radiological sign of a skull base fracture, or intracranial hemorrhage.

CONCLUSIONS

The results of this study do not substantiate the efficacy of ceftriaxone used in the prevention of meningitis in patients with traumatic pneumocephalus after mild head injury or in any specific subgroup of these patients. Cerebrospinal fluid rhinorrhea and intracranial hemorrhage may be considered primary risk factors for the development of meningitis in patients with posttraumatic pneumocephalus and, in the absence of these symptoms, intradural location of air and air volume greater than 10 ml may be considered secondary risk factors. Further studies in this area are warranted.

Non-observance of guidelines for surgical antimicrobial prophylaxis and surgical-site infections

OBJECTIVE

A prospective multicentre study was conducted to assess major aspects of surgical prophylaxis and to determine whether inappropriate antimicrobial prophylaxis was a factor associated (risk or protective factor) with surgical site infection (SSI).

METHOD

Surgical prophylaxis practices were assessed by analysing four variables: indication, antimicrobial agent, timing and duration. Univariate and multivariate analyses were carried out to identify predictors of SSI among patient-specific, operation-specific and antimicrobial prophylaxis-specific factors.

RESULTS

The frequency of SSI was 2.7% (13 SSI in 474 observations). Total compliance of the prescription with guidelines was observed in 41.1% of cases (195 prescriptions). Of the 139 patients who received an inappropriate drug, 126 (90.6%) received a drug with a broader spectrum than the recommended drug. Prophylaxis was prolonged in 71 (87.7%) of the 81 patients who received prophylaxis for inappropriate lengths of time and 43 (61.4%) of the 70 patients who did not receive prophylaxis at the optimal moment were treated too late. Multivariate analysis clearly demonstrated that SSI was associated with multiple procedures (relative risk 8.5), short duration of prophylaxis (relative risk 12.7) and long-term therapy with antimicrobial agents during the previous year (relative risk 8.8).

CONCLUSIONS

The ecological risk of the emergence of resistance associated with the frequent use of broad-spectrum antibiotics and prophylaxis for longer periods was not offset by individual benefit to the patients who received inappropriate prophylaxis.

[Antibiotic prophylaxis and surgery. Prescription compliance in Franche-Comté with the national reference system]

AIM OF THE STUDY

To evaluate the practice of antibiotic prophylaxis for surgery in the Franche-Comté region of France.

MATERIALS AND METHODS

A total of 36 surgical teams (72 pairs surgeons/anaesthesists) participated in data collection. Five variables describing practices concerning antibiotic prophylaxis for surgery were compared to national recommendations: did the surgical procedure require antibiotic prophylaxis and was it carried out? Was the antibiotic used appropriately? Was the timing of the first injection optimal? Was the total duration of the treatment correct? Was the dose correct?

RESULTS

Among the 687 operations for which data were collected, 513 (74.7%) that corresponded to class 1 or 2 Altemeier operations for which the Société Française d'Anesthésie et Réanimation (SFAR) had drawn up recommendations were analysed in order to answer these questions. The overall frequency of conformity with the regulations was 40% for these 513 operations. Of the 156 patients who did not receive the recommended antibiotic, 133 (85.5%) received an antibiotic with an activity range wider than that of the recommended antibiotic. The duration of prophylaxis was longer than recommended in 80 (87.9%) out of the 91 patients for whom the duration of antibiotic prophylaxis did not respect the recommendations.

CONCLUSIONS

This prospective surveillance showed that less than 50% of patients received an antibiotic prophylaxis that was conformed to the regulations. To ensure the efficiency of prophylaxis and to prevent deleterious effects, such as the emergence of antibiotic-resistant bacteria, the recommendations must be regularly respected. Frequent audits of practices should be carried out by the teams responsible for fighting nosocomial infections.

Post-traumatic meningitis: histomorphological findings, postmortem microbiology and forensic implications

Infections of the leptomeninges with the infectious agent gaining access to the intracranial compartment by traumatic means are termed post-traumatic. In cases with fatal outcome, the manner of death has to be classified as non-natural. Six cases of post-traumatic meningitis as the cause of death from the archives of the Institute of Legal Medicine in Hamburg, Germany with histological and microbiological investigations are presented. There were all males, age varying between 24 and 90 years (mean 58 years); range of the interval between original trauma and beginning of symptoms was 2 days up to 8 years; in 50% of the cases meningeal swabs yielded Streptococcus pneumoniae. Findings concerning origin and mechanism of post-traumatic meningitis as well as microbiological studies are compared with selected cases from the literature.

Pediatric temporal bone fractures

OBJECTIVE

To examine the etiology, presentation, and management of temporal bone fractures in children.

STUDY DESIGN

Case control.

METHOD

Retrospective review of a level I pediatric trauma center from July 1, 1990 to November 1, 1996 identified 680 patients. Inclusion criteria of age less than 14 years and only blunt temporal bone trauma identified 122 patients, with 97 charts available for review. The criteria for temporal bone fracture consisted of both clinical and radiologic information. Only patients with temporal bone fractures confirmed by computed tomography, a complete otolaryngology examination, and audiometric evaluations were included in the study. The data were analyzed with the Kruskal-Wallis analysis of variance (ANOVA) for examining the three separate age groups of fractures. Chi-squared analysis was used to compare these data with previously published adult and pediatric temporal bone fracture series and to examine the three separate age groups of fractures.

RESULTS

The review identified 72 children with 79 temporal bone fractures: 47 boys and 25 girls. The patients ranged from 6 months to 14 years of age, with a bimodal distribution of patients with peaks at 3 years and 12 years of age. The most common causes of fractures were motor vehicle accidents (47%), falls (40%), biking accidents (8%), and blows to the head (7%). Common presenting signs and symptoms included hearing loss (82%), hemotympanum (81%), loss of consciousness (63%), intracranial injuries (58%), bloody otorrhea (58%), extremity fractures (8%), and facial nerve weakness (3%). The most common causes of temporal bone fractures were falls and motor vehicle accidents. Forty-two patients were noted to have bloody otorrhea and possible cerebrospinal fluid leak. Twenty-four received intravenous antibiotics. No patient developed prolonged otorrhea or meningitis during hospitalization and the follow-up period. The classification of fracture patterns was longitudinal, 54%; transverse, 6%; oblique, 10%; squamous, 27%; and other, 3%. Hearing loss was found in 59 patients, with conductive hearing loss being the most common finding in 56% of the patients, followed by sensorineural hearing loss in 17% and mixed hearing loss in 10%.

CONCLUSIONS

Pediatric temporal bone fractures are associated with falls and motor vehicle accidents. There is a high incidence of associated intracranial injuries and hearing loss, but facial nerve injuries are uncommon. Timely management minimizes complications.

[Severe trauma in children]

Trauma are responsible for approximately 50% of the deaths of the pediatric population between 1-15 years of age. This high mortality rate, associated with frequent sequelae, leading sometimes to severe handicaps, is a major problem of public health in the developed countries. Pediatric trauma have some particularities, due to anatomical and physiological differences, and to specific injury mechanisms. Management of a patient with severe trauma is best performed by trained physicians, working in a multidisciplinary team with a two steps approach: 1) emergency rapid clinical assessment and resuscitation. 2) a secondary complete clinical evaluation associated with medical imaging, mainly based on CT scan. Head injuries are frequent and represent the main prognosis factor, mass lesions being less frequent and cerebral oedema more frequent in children, than in adult; brain swelling appears to be less frequent than initially reported. Management of head trauma has evolved in recent years, and is now largely directed towards the prevention of secondary ischemic brain injury: new monitoring devices are proposed to pursue that goal: transcranial doppler and continuous jugular vein oxygen saturation monitoring. Spinal cord injuries are rare but may be severe: cervical and spinal cord injuries without radiological abnormality (SC/WORA) appear to be more frequent than in adult. Most often, abdominal plain viscera injuries are treated with a conservative non operative approach. Among chest injuries, pulmonary contusion is the most frequent, with a favorable outcome in most cases within 3-4 days. Child abuse must be suspected in any case where there is no clear injury mechanism or when there is a discrepancy between the severity of the injury and the alleged mechanism.

Diagnosis and treatment of frontobasal skull fractures

During a five-year-period (January 1990 to December 1994) a total of 67 patients were operated on for frontobasal skull fractures. The indication for surgical treatment was based on the evidence of fractures encroaching paranasal sinuses or the cribriform plate on high-resolution axial or coronal CT scans. The following clinical signs indicating frontobasal trauma were observed: 25 patients (37%) showed rhinoliquorrhea, 14 (21%) had raccoon's eyes, and 2 (3%) had meningitis. Distinct dura laceration was observed intraoperatively in 64 of 67 patients (96%). In our experience, high resolution CT has proven to be a sensitive diagnostic tool for frontobasal skull fractures. With respect to the high coincidence of fractures and dura lacerations, the indication for surgical treatment based on CT findings seems to be justified.

Craniofacial trauma and cerebrospinal fluid leakage: a retrospective clinical study

PURPOSE

The study examines the efficacy of antibiotic treatment in patients with traumatic cerebrospinal fluid (CSF) leakage and identifies a consistent clinical approach for better management of these patients.

PATIENTS AND METHODS

A retrospective study of traumatic CSF leakage in 88 patients with craniofacial fractures was performed. The mechanism of injury, etiology and source of leakage, decision to treat conservatively (without surgery) versus aggressively (with surgery), decision to use early versus late repair, and decision to provide prophylactic antibiotic coverage were recorded. Both timing of repair and the decision to use antibiotics were compared with the incidence of meningitis resulting from CSF leakage.

RESULTS

Of 48 patients treated with antibiotics, 5(10.4%) developed meningitis. In the remaining 40 who were not treated with antibiotics, only one patient acquired meningitis. Five of 53 (9.4%) patients with conservative treatment developed meningitis versus 1 of 35 (2.9%) after aggressive treatment.

CONCLUSION

There was no statistically significant difference in the rate of occurrence of meningitis between the conservative and the aggressive treatment group. However, the data suggest that there may be no benefit in treating these patients with antibiotics to prevent meningitis, whereas aggressive treatment and early repair of facial fractures may, in fact, be helpful.

Actinobacillus ureae meningitis: case report and review of the literature

Actinobacillus urea, formerly known as Pasteurella ureae, is an uncommon commensal of the upper respiratory tract in humans. It has been identified as the primary pathogen in 10 cases of meningitis and several cases of pneumonia, sepsis, and peritonitis. A case is presented that represents another documented case of meningitis due to this rare organism. Risk factors associated with serious infection due to Actinobacillus ureae and basic management approaches to posttraumatic meningitis in general are discussed.

Should prophylactic antibiotics be used in the management of cerebrospinal fluid rhinorrhoea following endoscopic sinus surgery? A review of the literature

This review article investigates whether prophylactic antibiotics should be used in the management of cerebrospinal fluid rhinorrhoea following endoscopic sinus surgery. A medline database was used to retrieve all English articles from 1970 to the present, cross-indexing cerebrospinal rhinorrhoea, antibiotics and endoscopic sinus surgery. All relevant articles retrieved were reviewed together with their bibliographies. The use of prophylactic antibiotics is neither recommended nor condemned by evidence of efficacy. However, their use is cautioned against by evidence of a subsequent change in nasopharyngeal flora to potentially more invasive organisms. The review concludes that, at present, it is usually justifiable to withhold prophylactic antibiotics and to observe for the symptoms and signs of meningitis instituting antibiotic therapy when this complication develops.

Cerebrospinal fluid fistula: the identification and management in pediatric temporal bone fractures

Cerebrospinal fluid (CSF) fistula represents a potentially lethal complication and requires a high index of suspicion to make the diagnosis. A 12-year retrospective study of pediatric basilar skull fractures identified 147 patients with temporal bone fractures, of which 37 patients exhibited evidence of CSF fistula. The diagnosis is made from a combination of clinical, radiographic, and chemical evaluation. The evolution of diagnostic techniques are reviewed, and the more recent and sensitive tests, such as beta-2 transferrin, are emphasized. Treatment of CSF fistula is nonsurgical in most cases. Surgical exploration and mastoid obliteration were required in two patients, and the indications for surgical treatment are explored. The use of antibiotic prophylaxis is controversial and not routinely indicated.

Posttraumatic meningitis: bacteriology, hydrocephalus, and outcome

To investigate the conditions that have developed in the treatment of posttraumatic meningitis with the use of new antibiotics, the authors studied cases with this infection retrospectively for a period of 68 months. Among 860 patients with moderate to severe head injuries, 12 (1.39%) sustained this complication. Of these, nine patients (75%) had a demonstrable basilar skull fracture and seven (58.3%) presented obvious rhinorrhea. Of these seven, four (57.1%) were treated conservatively and three (42.8%) finally underwent surgery for dural repair. The infecting agents were Gram-positive cocci (Staphylococcus haemolyticus, Staphylococcus warneri, Staphylococcus cohnii, Staphylococcus epidermidis, and Streptococcus pneumoniae) in five patients and Gram-negative bacilli in six patients (Escherichia coli in two, Klebsiella pneumoniae in two, and Acinetobacter anitratus in two). In one patient, the culture results were negative. All Gram-negative strains appeared resistant to ampicillin and third-generation cephalosporins, but sensitive to imipenem and to the quinolone ciprofloxacin. Gram-positive strains were sensitive to vancomycin. Hydrocephalus finally developed in the two patients who had received intrathecal infusions of amikacin. No other report of the relation of intrathecal infusion of antibiotics and the development of hydrocephalus was found. All patients survived, indicating that, for the present, posttraumatic meningitis is a nonfatal complication of head injury.

Medical complications of head injury

There are many common and significant medical complications of head injury. These include (1) cardiovascular problems such as hyperdynamic state, myocardial injury, and dysrhythmias; (2) respiratory changes such as neurogenic pulmonary edema, hypoxia, abnormal ventilatory patterns, pulmonary infections, and pulmonary emboli secondary to deep vein thrombosis; (3) consumption coagulopathy; (4) water and electrolyte derangements--hypo- and hypernatremia; (5) hypothalamic/pituitary dysfunction--syndrome of inappropriate secretion of antidiuretic hormone and diabetes insipidus; (6) increased general metabolism with loss of immunocompetence, respiratory compromise, and complications of decreased activity; (7) gastrointestinal difficulties, particularly stress gastritis; and (8) infectious problems including those related to contamination from open wounds and foreign bodies such as monitors.

Antibiotic prophylaxis in unrepaired CSF fistulae

The value of antibiotic prophylaxis in patients with Cerebrospinal Fluid Leakage (CSF) is debatable. The aim of this study was to determine the value of prophylactic antibiotics in these patients. The study population comprised 253 patients with definite CSF leaks, of whom 106 received adequate antibiotic prophylaxis (Group A) and 109 were not treated with antibiotics (Group B). Thirty-eight patients were excluded from the analysis because they received antibiotics for reasons other than the CSF leakage. The two groups were closely matched for age, sex, type of CSF fistula, site, and duration of CSF leakage and presence or absence of skull fractures, but there were more patients with facial fractures and pneumocephalus in those who were treated with antibiotics. The first week meningitis rate was 6.6 and 9.17% in the treated and untreated groups, respectively, while the annual risk of meningitis was 7.6% in the treated and 11.9% in the untreated group. However, these differences did not reach significance (P > 0.05). The survival curves of meningitis-free survival were similar in the two groups, particularly during the first 4 weeks during which antibiotics were given (Log Rank test, p > 0.05). Furthermore, there were more cases of Gram-negative infection and of partially-treated meningitis in the treated group. Although this was a retrospective, non-randomized study, it confirms the conclusions of previous smaller series, that prophylactic antibiotics do not significantly reduce the risk of meningitis in these patients. It is ethically justifiable to withhold antibiotic prophylaxis in patients with CSF fistulae until a prospective controlled double blind trial has settled the question.

How much monitoring is needed for basilar skull fractures?

Basilar skull fractures account for approximately 19% of all skull fractures. There have been little data published concerning the need for intensive care monitoring in this injury. We retrospectively studied 259 patients admitted to our trauma center over an 8-year period with a diagnosis of basilar skull fracture. All patients were evaluated with cranial computed tomographic (CT) scans. These patients were admitted to the trauma service, and neurosurgical consultation was obtained in all cases. The diagnosis was made by clinical signs in 207 patients (80%), by CT scan in 47 (18%), and by plain films in 5 (2%). Ninety-two patients (group I) had intracranial pathology in addition to basilar skull fracture. Twenty-one patients in this group underwent craniotomy. In this group, the morbidity and mortality rates were 11% and 7%, respectively. Forty-four patients (group II) had no intracranial pathology and a Glasgow Coma Score (GCS) of less than 13. The morbidity was 2%, and the mortality was 2%. One hundred twenty-three patients (group III) had no intracranial pathology on CT scan and a GCS of 13 or greater. The complication rate in this group was 1%, and there was no neurologically related mortality. Patients who are admitted with a diagnosis of basilar skull fracture and who have a GCS of 13 or greater with no intracranial pathology on CT can be managed without intensive care monitoring.

Antimicrobial prophylaxis for fractured base of skull in children

The details are reviewed of 50 children who were treated over a 10-year period with clinical signs of fractured base of skull. Two patients died early without signs of sepsis--due to the severity of their head injuries. Of the remainder, 23 received antibiotic prophylaxis and 25 did not. One patient from each of these groups developed pneumococcal meningitis, and they were successfully treated. Our results correlate well with those previously published, confirming the low incidence of infective complications with or without prophylaxis. The need to assemble a large enough series to make statistically significant conclusions regarding this infrequent condition is highlighted throughout the literature, which is reviewed here.

Role of prophylactic antibiotics in open and basilar fractures of the skull: a randomized study

The aim of this study was to investigate the controversial issue of the use of prophylactic antibiotics in open and basilar fractures of the skull. A series of 157 patients were randomized to receive no antibiotics (group A = 46 patients) or ceftriaxone for 3 days (group B = 50 patients), or the combination ampicillin/sulphadiazine for 3 days (group C = 61 patients). The incidence of meningitis was similar in both the antibiotic and non-antibiotic groups. However, the overall incidence of infectious complications in the non-antibiotic group was significantly higher than in the antibiotic group (8.7 per cent vs 0.9 per cent, P < 0.05). There was no significant difference between the ceftriaxone group and the ampicillin/sulphadiazine group. The results of the study suggest that antibiotic prophylaxis has a role in the management of open and basilar fractures.

Cricothyrotomy

Cricothyrotomy is a simple and safe method for obtaining airway control during situations in which endotracheal intubation is difficult or contraindicated. Cricothyrotomy can be a lifesaving procedure. It can be done quickly in emergency situations by nonsurgeons with a minimum of necessary equipment and without requiring an operating room. The anatomy, specific techniques or procedure, indications and contraindications, and the advantages and disadvantages are discussed.

Prophylactic antibiotics in traumatic wounds

There is well-documented evidence justifying, perhaps demanding, the obligatory use of early, anticipatory treatment in open fractures and in penetrating abdominal wounds, and equally convincing evidence that they are not indicated in fractures of the base of the skull with CSF leaks, in thermal injuries, or in simple lacerations. As far as penetrating chest wounds, and bites are concerned, the evidence is perhaps as yet inconclusive, but antibiotics are probably not indicated in these situations.

Recurrent meningitis: a case report

Recurrent meningitis is an uncommon clinical problem. It is most likely to result from head trauma. Streptococcus pneumoniae is the most common infecting pathogen. Computed tomographic techniques are required to identify persistent bony defects in the skull that might predispose to this disorder. Because emergency physicians regularly care for victims of head trauma and meningitis, knowledge of this entity can be useful.

Post-traumatic meningitis in children

A retrospective survey over a 66-month period of children admitted with head injury who subsequently developed meningitis within the same period yielded six cases (five boys, one girl), giving an incidence of 0.38 per cent. Two of the six died, and four survived with no sequelae. Four cases occurred within the first week. One patient, who had received prophylactic antibiotics, developed Escherichia coli meningitis after 14 days and one had meningitis 2 years after the head injury. The most common organism was pneumococcus (four cases). Three patients had periorbital haematomas and none had cerebrospinal fluid leakage. Increasing drowsiness and fever were the most consistent features. Radiography of the skull was of little use in demonstrating fracture of the base of the skull. Two of the four surviving patients had craniotomy with successful dural repair.