Prospective alterations in therapy for penetrating abdominal trauma

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.

The use of Prophylactic Antibiotics in Trauma

Infection is an important cause of morbidity and mortality in trauma. In this literature review, the microbiological profiles and the use of prophylactic antibiotics in various traumatic situations are discussed. This review includes abdominal and chest trauma, craniocerebral trauma, long bone fractures, open globe injuries and animal bite injuries.

Skin closure after trauma laparotomy in high-risk patients: opening opportunities for improvement

BACKGROUND

Although many surgeons leave laparotomy incisions open after colon injury to prevent surgical site infection (SSI), other injured patient subsets are also at risk. We hypothesized that leaving trauma laparotomy skin incisions open in high-risk patients with any enteric injury or requiring damage control laparotomy (DCL) would not affect superficial SSI and fascial dehiscence rates.

METHODS

Patients who underwent trauma laparotomy (2004-2008) at two Level I centers were reviewed. To ensure a high-risk sample, only patients with transmural enteric injuries or need for DCL surviving 5 days or more were included. SSIs were categorized by the CDC (Centers for Disease Control and Prevention) criteria and risk factors were analyzed by skin closure (open vs. any closure). Significant (p < 0.05) univariate variables were applied to two multivariate analyses examining superficial SSI and fascial dehiscence.

RESULTS

Of 1,501 patients who underwent laparotomy, 503 met inclusion criteria. Patients were young (median, 28.0 years; range, 22.0-40.0 years) with penetrating (74%) or enteric (80%) injuries, and DCL (36%) and SSI (44%; superficial, 25%; deep, 3%; organ/space, 25%) were common. While no difference in superficial SSI after loose (n = 136) or complete skin closure (n = 224) was detected (p = 0.64), superficial SSIs were less common with open skin incisions (9.8%), despite multiple risk factors, than with any skin closure (31.1%, p < 0.001). Predictors of superficial SSIs and fascial dehiscence were each evaluated with multiple-variable logistic regression analysis. After adjusting for multiple potential confounding variables, any skin closure increased the risk of superficial SSIs approximately nine times (odds ratio, 8.6; p < 0.001) and fascial dehiscence six times (odds ratio, 5.7; p = 0.013).

CONCLUSION

Management of skin incisions takes careful consideration like any other step of a laparotomy. Our results suggest that the decision to leave skin open is one simple method to improve outcomes in high-risk patients.

LEVEL OF EVIDENCE

Therapeutic study, level III.

"SCIP"ping antibiotic prophylaxis guidelines in trauma: The consequences of noncompliance

OBJECTIVE

The Surgical Care Improvement Project (SCIP) established surgical antibiotic prophylaxis guidelines as part of a national patient safety initiative aimed at reducing surgical complications such as surgical site infection (SSI). Although these antibiotic prophylaxis guidelines have become well established in surgical patients, they remain largely unstudied in patients with injury from trauma undergoing operative procedures. We sought to determine the role of these antibiotic prophylaxis guidelines in preventing SSI in patients undergoing trauma laparotomy.

METHODS

A retrospective review of all patients who underwent emergency trauma laparotomy at two Level I trauma centers (2007-2008) revealed 306 patients who survived more than 4 days after injury. Demographics and clinical risk SSI factors were analyzed, and patients were compared on the basis of adherence to the following SCIP guidelines: (1) prophylactic antibiotic given, (2) antibiotic received within 1 hour before incision, (3) correct antibiotic selection, and (4) discontinuation of antibiotic within 24 hours after surgery. The primary study end point was the development of SSI.

RESULTS

The study sample varied by age (mean [SD], 32 [16] years) and injury mechanism (gunshot wound 44%, stab wound 27%, blunt trauma 30%). When patients with perioperative antibiotic management complying with the four SCIP antibiotic guidelines (n = 151) were compared with those who did not comply (n = 155), no difference between age, shock, small bowel or colon resection, damage control procedures, and skin closure was detected (p > 0.05). After controlling for injury severity score, hypotension, blood transfusion, enteric injury, operative duration, and other potential confounding variables in a multivariate analysis, complete adherence to these four SCIP antibiotic guidelines independently decreased the risk of SSI (odds ratio, 0.43; 95% confidence interval, 0.20-0.94; p = 0.035). Patients adhering to these guidelines less often developed SSI (17% vs. 33%, p = 0.001) and had shorter overall hospital duration of antibiotics (4 [6] vs. 9 [11] days, p < 0.001) and hospital length of stay (14 [13] vs. 19 [23] days, p = 0.016), although no difference in mortality was detected (p > 0.05).

CONCLUSIONS

Our results suggest that SCIP antibiotic prophylaxis guidelines effectively reduce the risk of SSI in patients undergoing trauma laparotomy. Despite the emergent nature of operative procedures for trauma, efforts to adhere to these antibiotic guidelines should be maintained.

Preventing surgical site infections

Over the past 50 years, increased interest in the discipline of surgical infection has resulted in advances in post-surgical infection control. Early investigations focused on the importance of anaerobic microflora to postoperative infection and paved the way for significant improvements in prophylactic and therapeutic antibiotic treatment of surgical patients. Later research centered on the identification of risk factors to better predict postoperative infection rates. This article reviews the evolution of postoperative infection control and highlights antibiotic prophylaxis in specific clinical situations.

The role of beta-lactam antimicrobials as single agents in treatment of intra-abdominal infection

Broad-spectrum beta-lactam antibiotics have several advantages in the treatment of intra-abdominal infections. These agents are effective against gram-negative rods and anaerobes, reach therapeutic levels rapidly after parenteral administration, and, in the absence of penicillin allergy, generally exhibit low toxicity. The second-generation cephalosporins (e.g., cefoxitin, cefotetan) are used widely in surgical prophylaxis, trauma, and treatment of mild-to-moderate community-acquired infections, but limitations in their spectra and microbial resistance restrict their utility in more serious infections. Extended-spectrum penicillin/beta-lactamase-inhibitor combinations are effective in the treatment of intra-abdominal infections and include enterococci in their spectrum. Gram-negative aerobe resistance has developed to ampicillin/sulbactam. Piperacillin/tazobactam, a ureidopenicillin with increased gram-negative coverage and enhanced antipseudomonal activity, has proved to be effective in clinical trial therapy for intra-abdominal infections. The very broad spectrum carbapenems--imipenem/cilastatin and meropenem--are effective for serious infections or resistant organisms and are often used in the intensive care unit or for nosocomial intra-abdominal infection. These classes of beta-lactams comprise a range of antimicrobials that can be targeted effectively as single agents to both prevention and treatment of intra-abdominal infection.

Antibioticoterapia no trauma abdominal penetrante com lesão gastrintestinal: estudo comparativo entre dois esquemas terapêuticos

OBJETIVO: Comparar a eficácia de dois esquemas terapêuticos de antibióticos em vítimas de trauma penetrante de abdome com lesão gastrintestinal. MÉTODO: O estudo selecionou de forma prospectiva e randomizada, vítimas de trauma abdominal penetrante com lesão gastrintestinal, dividindo-os em dois grupos, conforme o esquema terapêutico: cefoxitina perioperatória exclusivamente (Grupo 1) e associação de gentamicina e metronidazol por cinco dias (Grupo 2). Os grupos foram estratificados em três níveis de acordo com o Abdominal Trauma Index (ATI) e os desfechos analisados foram complicações infecciosas em nível de sitio cirúrgico e não cirúrgico. Escores de trauma e diversas variáveis foram coletadas, como mecanismo e intervalo trauma - tratamento, choque à admissão, volume transfundido, tempo cirúrgico e lesões de cólon. RESULTADOS: Ambos os grupos foram semelhantes e perfeitamente comparáveis, demonstrando não haver diferença na eficácia entre os esquemas antibióticos. CONCLUSÃO: Para vítimas de trauma abdominal penetrante com lesão gastrintestinal, o uso de cefoxitina restrito ao perioperatório é perfeitamente válido.

Infection in Penetrating Abdominal Trauma: Risk Factors and Preventive Antibiotics

Infection remains the greatest risk for victims of penetrating abdominal injury with major infections occurring in 10 to 15 per cent. Attributable mortality is approximately 30 per cent of those who develop major abdominal infections. In addition to this morbidity infection adds approximately $43,000.00 of hospital charges per infected patients. This article addresses two significant areas: risk factors and antibiotic utilization. The most important risk factor is the presence of hollow viscus injury; colonic wounding carries the highest incidence of infection relative to intra-abdominal organs injured. Pancreatic and liver injuries significantly increase infection risk when combined with hollow viscus wounds. The degree of injury as measured by the volume of hemorrhage and the presence of shock as well as the anatomic degree of injury likewise correlates with the incidence of septic morbidity. Antibiotic utilization is addressed by the three issues of antibiotic agents of choice, duration of administration, and optimal dosing. Regimens of choice should include anaerobic coverage. Twenty-four hours of antibiotic administration is satisfactory with currently available agents. Evidence-based medicine analyses from the Eastern Association for the Surgery of Trauma have addressed those two issues. There are few data on optimal dosing. Increased volumes of distribution and rates of excretion have been demonstrated in trauma patients. This would suggest that higher-than-normal doses should be used. Laboratory studies would support such an approach. However, significant clinical research is desirable to address issues of concentration-dependent bacterial killing and time-dependent killing. Those pharmo-dynamic considerations are variable among antibiotic classes.

The quality of measurement of surgical wound infection as the basis for monitoring: a systematic review

Comparison of postoperative surgical wound infection rates between institutions and over time is only valid if standard, valid and reliable definitions are used. The aim of this review was to assess evidence of validity and reliability of the definition and measurement of surgical wound infection. A systematic review was undertaken of prospective studies of surgical wound infection published over a seven-year period; 1993-1999. The information extracted from individual studies included: definition of surgical wound infection; details of wound assessment scale, scoring or grading scale systems; and evidence of assessment of validity, reliability and feasibility of identified definitions and grading systems. Two independent reviewers appraised 112 prospective studies, 90 of which were eligible for inclusion; eight studies assessed validity and/or reliability. Forty-one different definitions of surgical wound infection were identified, five of which were 'standard' definitions proposed by multi-disciplinary groups. Presence of pus was the most frequently used single component of any definition; the CDC definitions of 1988 and 1992 were the most widely implemented standard definitions; and the ASEPSIS wound assessment scale was the most frequently used quantitative grading tool. Only two formal validations of a definition were found, and six studies of reliability. This review highlights the extent of variation in definition of surgical wound infection used in clinical practice, and the need for validation of both content and organization of a surveillance system. However, realistically, there will have to be a balance between the quality of the measurement and the practicality of surveillance.

Preventing surgical site infections: a surgeon's perspective

Wound site infections are a major source of postoperative illness, accounting for approximately a quarter of all nosocomial infections. National studies have defined the patients at highest risk for infection in general and in many specific operative procedures. Advances in risk assessment comparison may involve use of the standardized infection ratio, procedure-specific risk factor collection, and logistic regression models. Adherence to recommendations in the 1999 Centers for Disease Control and Prevention guidelines should reduce the incidence of infection in surgical patients.

Does the Centers for Disease Control's NNIS system risk index stratify patients undergoing cardiothoracic operations by their risk of surgical-site infection?

BACKGROUND

In 1991, the Centers for Disease Control and Prevention devised the National Nosocomial Infection Surveillance (NNIS) System risk index to stratify populations of surgical patients by the risk of acquiring surgical-site infections (SSIs).

OBJECTIVE

To determine whether the NNIS risk index adequately stratifies a population of cardiothoracic surgery patients by the risk of developing SSI.

DESIGN

Case-control study.

SETTING

The University of Iowa Hospitals and Clinics, a 900-bed, midwestern, tertiary-care hospital.

PATIENTS

201 patients with SSIs identified by prospective infection control surveillance and 398 controls matched by age, gender, type of procedure, and date of procedure. All patients underwent cardiothoracic operative procedures between November 1990 and January 1994.

RESULTS

The SSI rate was 7.8%. Seventy-four percent of cases and 80% of controls had a NNIS risk index score of 1; 24% of cases and 16% of controls had a score of 2 (P=.05). Patients with a NNIS risk score > or =2 were 1.8 times more likely to develop an SSI than those with a NNIS score <2 (odds ratio, 1.83; 95% confidence interval, 1.14-2.94, P=.01). The duration of the procedure was the only component of the index that stratified the population by risk of SSI.

CONCLUSIONS

The risk of SSI after cardiothoracic operations increases as the NNIS risk index score increases. However, this index only dichotomized the patient population on the basis of the procedure duration. More research is needed to develop a risk index that adequately stratifies the risk of SSI after cardiothoracic operations.

Persistent occult hypoperfusion is associated with a significant increase in infection rate and mortality in major trauma patients

OBJECTIVE

To investigate the hypothesis that occult hypoperfusion (OH) is associated with infectious episodes in major trauma patients.

METHODS

Data were collected prospectively on all adult trauma patients admitted to the Surgical/Trauma Intensive Care Unit from November of 1996 to December of 1998. Treatment was managed by a single physician according to a defined resuscitation protocol directed at correcting OH (lactic acid [LA] > 2.4 mmol/L).

RESULTS

Of a total of 381 consecutive patients, 118 never developed OH and 263 patients exhibited OH. Seventeen patients were excluded because their LA never corrected, and they all subsequently died. One hundred seventy-six infectious episodes occurred in 97 of the 364 patients remaining. The infection rate in patients with no elevation of LA was 13.6% (n = 118) compared with 12.7% (n = 110) in patients whose LA corrected by 12 hours, 40.5% (n = 79; p < 0.01 compared with all other groups) in patients whose LA corrected between 12 and 24 hours, and 65.9% (n = 57; p < 0.01 compared with all other groups) in patients who corrected after 24 hours. Among the patients with infections, there were 276 infection sites with 42% of infections involving the lung and 21% involving bacteremia. There was no difference in proportion of infections occurring at each site between groups. The mortality rate of patients who developed infections was 7.9% versus 1.9% in patients without infections (p < 0.05). Of the patients who developed infections, 69.8% versus 25.8% (p < 0.001) did not have their lactate levels normalized within 12 hours of emergency room admission. Logistic regression demonstrated that both the Injury Severity Score and OH > 12 hours were independently predictive of infection.

CONCLUSION

A clear increase in infections occurred in patients with OH whose lactate levels did not correct by 12 hours, with an associated increase in length of stay, days in surgical/trauma intensive care unit, hospital charges, and mortality.

Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee

EXECUTIVE SUMMARY The "Guideline for Prevention of Surgical Site Infection, 1999" presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.1,2 Part I, "Surgical Site Infection: An Overview," describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis. Part II, "Recommendations for Prevention of Surgical Site Infection," represents the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) regarding strategies for the prevention of SSIs.3 Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, there are a limited number of studies that clearly validate risk factors and prevention measures for SSI. By necessity, available studies have often been conducted in narrowly defined patient populations or for specific kinds of operations, making generalization of their findings to all specialties and types of operations potentially problematic. This is especially true regarding the implementation of SSI prevention measures. Finally, some of the infection control practices routinely used by surgical teams cannot be rigorously studied for ethical or logistical reasons (e.g., wearing vs not wearing gloves). Thus, some of the recommendations in Part II are based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific knowledge.It has been estimated that approximately 75% of all operations in the United States will be performed in "ambulatory," "same-day," or "outpatient" operating rooms by the turn of the century.4 In recommending various SSI prevention methods, this document makes no distinction between surgical care delivered in such settings and that provided in conventional inpatient operating rooms. This document is primarily intended for use by surgeons, operating room nurses, postoperative inpatient and clinic nurses, infection control professionals, anesthesiologists, healthcare epidemiologists, and other personnel directly responsible for the prevention of nosocomial infections. This document does not: Specifically address issues unique to burns, trauma, transplant procedures, or transmission of bloodborne pathogens from healthcare worker to patient, nor does it specifically address details of SSI prevention in pediatric surgical practice. It has been recently shown in a multicenter study of pediatric surgical patients that characteristics related to the operations are more important than those related to the physiologic status of the patients.5 In general, all SSI prevention measures effective in adult surgical care are indicated in pediatric surgical care. Specifically address procedures performed outside of the operating room (e.g., endoscopic procedures), nor does it provide guidance for infection prevention for invasive procedures such as cardiac catheterization or interventional radiology. Nonetheless, it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures. Specifically recommend SSI prevention methods unique to minimally invasive operations (i.e., laparoscopic surgery). Available SSI surveillance data indicate that laparoscopic operations generally have a lower or comparable SSI risk when contrasted to open operations.6-11 SSI prevention measures applicable in open operations (e.g., open cholecystectomy) are indicated for their laparoscopic counterparts (e.g., laparoscopic cholecystectomy). Recommend specific antiseptic agents for patient preoperative skin preparations or for healthcare worker hand/forearm antisepsis. Hospitals should choose from products recommended for these activitie

Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee

The “Guideline for Prevention of Surgical Site Infection, 1999” presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.

Part I, “Surgical Site Infection: An Overview,” describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis.

Basics of surgical-site infection surveillance

Surgical-site infections, the third most common class of nosocomial infections, cause substantial morbidity and mortality and increase hospital costs. Surveillance programs can lead to reductions in surgical-site infection rates of 35% to 50%. Herein, we will discuss the practical aspects of implementing a hospital-based surveillance program for surgical-site infections. We will review surveillance methods, patient populations that should be screened, and interventions that could reduce infection rates.

A multivariate analysis of the prognostic factors in severe liver trauma

To examine the significance of physiologic and biochemical variables in liver trauma quantitatively, and to establish the early predictors of mortality according to the causes of death, 36 consecutive patients who underwent surgery for liver trauma between 1984 and 1993 were retrospectively studied. A univariate analysis revealed that shock, preoperative systolic blood pressure (SBP), preoperative alanine aminotransferase (ALT), the number of associated organ injuries, the Glasgow Coma Score (GCS), blood replacement requirements, and postoperative blood urea nitrogen (BUN) were significant prognostic factors of survival after liver trauma. However, a multivariate analysis indicated that GCS, postoperative BUN, the number of associated organ injuries, preoperative ALT, and SBP were independent prognostic factors. Because the causes of death after liver trauma can be divided into early hemorrhage and late sepsis, a multiple regression analysis of preoperative and postoperative variables was performed for each cause. The prognostic factors for hemorrhagic death were preoperative ALT, base excess, and the platelet count, whereas those for death due to sepsis were preoperative SBP and the presence of gastrointestinal injuries. These results suggest the value of measuring the preoperative serum level of ALT as a new independent prognostic factor for predicting overall and hemorrhagic death following severe liver trauma.

Granulocyte colony-stimulating factor for gastrointestinal perforation in patients with leukopenia

OBJECTIVE

Leukopenia in the setting of widespread infection may predispose to sepsis, which is associated with a poor prognosis. Granulocyte colony-stimulating factor (G-CSF), which restores polymorphonuclear leukocyte function and count, has been shown to have protective effects in animal models of sepsis and burns. The aim of this retrospective study was to determine whether G-CSF can reduce the morbidity and mortality gastrointestinal perforation with leukopenia.

PATIENTS AND METHODS

The studied subjects were 31 patients who had reduced leukocyte and neutrophil counts before undergoing surgery for gastrointestinal perforation, including six gastroduodenal, nine small intestinal, and 16 colonic perforations from 1986 to 1994. The patients were divided into two groups: a G-CSF(+) group (n = 8) that received G-CSF subcutaneously (150 microgram/day) during the perioperative period, and a G-CSF(-) group which did not.

MAIN RESULTS

No significant difference was found in the preoperative and operative factors of the two groups. The postoperative increase in the leukocyte and polymorphonuclear cell counts of the G-CSF(+) group was significantly higher than that of the G-CSF(-) group (p <0.01). Renal, hepatic, and gastrointestinal insufficiency was significantly less common in the G-CSF(+) group than in the G-CSF(-) group. The mean number of organs that failed was reduced from 4.00 +/- 2.50 in the G-CSF(-) group to 1.88 +/- 2.03 in the G-CSF(+) group. One of the eight patients who received G-CSF died of sepsis because of panperitonitis. In contrast, in the G-CSF(-) group, 15 of 23 patients died of sepsis because of panperitonitis. The cause-specific survival rate of the G-CSF(+) group was better than that of the G-CSF(-) group (p <0.05).

CONCLUSION

These results suggested that G-CSF reduced the morbidity and mortality of gastrointestinal perforation in patients with leukopenia and encouraged a prospective randomized study in future.

Surgical antibiotic prophylaxis

Improvements in antibiotic prophylaxis, including the timing of initial administration, appropriate choice of antibiotic agents, and the limiting of the duration of administration, have more clearly defined the value of this technique in many clinical surgical settings. Studies of antibiotic prophylaxis designed during the next decade should strongly consider individual patient risk factors when new antibiotic agents are tested or administration techniques are refined. A concentrated effort should be made in areas of clinical surgery in which the value of antibiotic prophylaxis has not been proven. When in doubt, it appears that a one-dose systemic regimen of an appropriately chosen cephalosporin given during the immediate preoperative period is safe and the indicated practice.

Preventive antibiotic usage in traumatic thoracic injuries requiring closed tube thoracostomy

OBJECTIVE

To evaluate the safety and effectiveness of antibiotics in reducing the infectious complications following closed tube thoracostomy for isolated chest trauma.

DESIGN

Double-blind, randomized clinical trial.

SETTING

Medical school affiliated large urban teaching hospital and trauma center.

PATIENTS

One hundred nineteen of 159 patients over 18 years old presenting to the emergency department requiring closed tube thoracostomy for isolated chest injuries (113 penetrating, 6 blunt).

INTERVENTION

Patients received either placebo or 1 g cefonicid daily intravenously started at chest tube insertion and stopped within 24 h of removal.

MEASUREMENTS AND RESULTS

The development of wound infections, pneumonia (CDC criteria), or empyema; the incidence of adverse events; length of hospitalization. One nonspecific infection was seen in the cefonicid group (1.6 percent) and six respiratory tract infections (10.7 percent) in the placebo group (three empyema, one empyema with pneumonia, two pneumonia) (p = 0.0505; p = 0.0094 [excluding nonspecific infection]). No significant differences with antibiotic use were seen in the duration of chest tube use (p = 0.766), peak WBC counts (p = 0.108), lower peak temperatures (p = 0.063), or length of hospitalization (p = 0.165). Patients who developed infectious complications averaged approximately 8 days longer hospitalization than those without (p < 0.0001).

CONCLUSION

This study showed that patients receiving antibiotics had a significantly reduced rate of infection than did patients administered placebo. No significant adverse events were seen in either group.