Prophylactic antibiotics adversely affect nosocomial pneumonia in trauma patients

Antimicrobial Prophylaxis in Trauma Patients

INTRODUCTION

In the era of rising antimicrobial resistance and successful protocols for empiric and prophylactic antimicrobial therapy in elective surgical procedures, it is important to consider the specific needs of the trauma population based on injury location, severity, and environmental exposures. In this study, we aim to compare outcomes of high-activation trauma patients who received antibiotics during initial evaluation with those who did not.

METHODS

A retrospective chart review of patients focusing on antimicrobial administration who presented as the highest trauma activation criteria during the year 2021 was conducted at a single urban institution. Patient demographic, injury, and outcome data ere collected through manual data abstraction from our institutional trauma registry.

RESULTS

Nearly half of all trauma patients in our study received antibiotics after initial evaluation and age was found to be significantly associated with antibiotic administration within the first 1.5 h. Young men with penetrating injuries were more likely to receive antibiotic treatment. Seventy-eight percent of patients who received early antibiotics underwent a procedure, while 61% of those who did not receive early antibiotics did not (P < 0.001).

CONCLUSIONS

These findings emphasize the importance of individualizing antibiotic treatment based on the patient's age and specific injury pattern. They also underscore the need for trauma providers to prioritize antibiotic stewardship.

Association of antimicrobial use and incidence of hospital-acquired pneumonia in critically ill trauma patients with pulmonary contusion: an observational study

BACKGROUND

Pneumonia occurs in about 20% of trauma patients with pulmonary contusions. This study aims to evaluate the association between empirical antibiotic therapy and nosocomial pneumonia in this population.

METHODS

Retrospective cohort of adult patients admitted to a trauma-surgical ICU. The Antibiotic Therapy Group (ATG) was defined by intravenous antibiotic use for more than 48 h starting on hospital admission, while the Conservative Group (CG) was determined by antibiotic use no longer than 48 h. Primary outcome was microbiologically documented nosocomial pneumonia within 14 days after hospital admission. Logistic regression was used to estimate the association between group allocation and primary outcome. Exploratory analyses evaluating the association between resistant strains in pneumonia and antibiotic use were performed.

RESULTS

The study included 177 patients with chest trauma and pulmonary contusion on CT scan. ATG were more severely ill than CG, as shown by higher Injury Severity Score, SAPS3, SOFA score, higher rates, and longer duration of mechanical ventilation. In the multivariate analysis, ATG was associated with a lower incidence of primary outcome (OR = 0.25, 95% CI 0.09-0.64; p < 0.01). Similar results were found in the sensitivity analysis with another set of variables. However, each day of antibiotic use was associated with an increased risk of pneumonia by resistant bacteria (OR = 1.18 per day, 95% CI 1.05-1.36; p < 0.01).

CONCLUSIONS

Empiric antibiotic therapy was independently associated with lower incidence of nosocomial pneumonia in critically ill patients with pulmonary contusion. However, each day of antibiotic use was associated with increased resistant strains in infected patients.

Antimicrobial prophylaxis is not indicated for horses undergoing general anaesthesia for elective orthopaedic MRI

BACKGROUND

Post-anaesthetic fever is a known complication of general anaesthesia, however, its incidence in horses undergoing elective magnetic resonance imaging (MRI) is unknown.

OBJECTIVE

To determine the incidence of post-anaesthetic fever in horses undergoing elective orthopaedic MRI and determine whether prophylactic antimicrobial therapy would be associated with a reduction in the incidence of post-anaesthetic fever. We hypothesised that prophylactic antimicrobials would be associated with a reduction in the incidence of post-anaesthetic fever.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

This retrospective study included 791 elective orthopaedic MRIs in systemically healthy horses between June 2006 and March 2020 that recovered from general anaesthesia and did not undergo surgery or intensive medical therapy soon after recovery. Potential factors associated with post-anaesthetic fever were evaluated using multivariable logistic regression. Case signalment, travel time, preanaesthetic haematology and fibrinogen abnormalities, use of prophylactic antimicrobials, peri-anaesthetic nonsteroidal anti-inflammatories, anaesthesia time and recovery time were all evaluated for association with post-anaesthetic fever.

RESULTS

Of 791 MRI cases, 44 (5.6%) developed a post-anaesthetic fever. Horses that received prophylactic antimicrobials were [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.98-7.46; p ≤ 0.001] more likely to develop a post-anaesthetic fever than those that did not receive antimicrobials. Young horses (1-4 years of age) were (OR 2.8, 95% CI 1.26-6.17; p = 0.01) more likely to develop fever compared with adult horses (≥5 years of age).

MAIN LIMITATIONS

Limitations of this study pertain to retrospective analysis including nonrandomised case selection and incomplete data records.

CONCLUSIONS

While fever may indicate infection, the majority of early post-anaesthetic fevers resolved before discharge from the hospital with no identified cause. The use of prophylactic antimicrobials to reduce the risk of post-anaesthetic fever for elective MRI is not supported by this study.

Fibrinolysis Resistance After Injury Is a Risk Factor for a Hospital-Acquired Pneumonia-Like Disease Pattern

Background: Pneumonia is associated with increased morbidity and costs in the intensive care unit (ICU). Its early identification is key for optimal outcomes, but early biomarkers are lacking. Studies suggest that fibrinolysis resistance (FR) after major abdominal surgery is linked to an increased risk of infection. Patients and Methods: Patients in a randomized controlled trial for hemorrhagic shock were evaluated for FR. Fibrinolysis resistance was quantified by thrombelastography with exogenous tissue plasminogen activator (tPA-TEG) at 24- and 48-hours post-injury and measuring LY30 (%). A receiver-operating characteristics (ROC) curve analysis was used to identify a cutoff for increased risk of pneumonia, which was then validated in ICU patients at risk for venous thromboembolism (VTE). Multivariable logistic regression was used to control for confounders. Results: Forty-nine patients in the hemorrhagic shock cohort had tPA-TEGs at 24- and 48-hours (median ISS, 27; 7% pneumonia). A composite tPA-TEG LY30 of less than 4% at 24 and 48 hours was found to be the optimal cutoff for increased risk of pneumonia. This cohort had a seven-fold increased rate of pneumonia (4% vs. 28%; p = 0.048). Eighty-eight patients in the VTE cohort had tPA-TEGs at 24 and 48 hours post-ICU admission (median ISS, 28; 6% pneumonia). The tPA-TEG LY30 of less than 4% was associated with a 10-fold increased rate of pneumonia (19% vs. 1.5%; p = 0.002). In patients with traumatic brain injury, the same association was found (33% vs. 3.2%; p = 0.006). Adjusting for confounders, the tPA-TEG persisted as a substantial risk factor for pneumonia (adjusted odds ratio [OR], 35.7; 95% confidence interval [CI], 1.9-682; p = 0.018). Conclusions: Fibrinolysis resistance quantified by tPA-TEG within 48 hours of ICU admission is associated with an increased risk of pneumonia in patients in hemorrhagic shock and those at risk for VTE. Prospective validation of the tPA-TEG LY30 optimal cutoff for pneumonia and further investigation into whether endogenous FR is a cause of an altered immunity is warranted.

Current state of neuroprotective therapy using antibiotics in human traumatic brain injury and animal models

TBI is a leading cause of death and disability in young people and older adults worldwide. There is no gold standard treatment for TBI besides surgical interventions and symptomatic relief. Post-injury infections, such as lower respiratory tract and surgical site infections or meningitis are frequent complications following TBI. Whether the use of preventive and/or symptomatic antibiotic therapy improves patient mortality and outcome is an ongoing matter of debate. In contrast, results from animal models of TBI suggest translational perspectives and support the hypothesis that antibiotics, independent of their anti-microbial activity, alleviate secondary injury and improve neurological outcomes. These beneficial effects were largely attributed to the inhibition of neuroinflammation and neuronal cell death. In this review, we briefly outline current treatment options, including antibiotic therapy, for patients with TBI. We then summarize the therapeutic effects of the most commonly tested antibiotics in TBI animal models, highlight studies identifying molecular targets of antibiotics, and discuss similarities and differences in their mechanistic modes of action.

Risk factors and outcomes associated with ventilator associated pneumonia amongst intubated trauma patients admitted to the general intensive care unit of a major trauma centre

Background

Despite the use of care bundles, ventilator associated pneumonia (VAP) remains a frequently occurring health care-associated infection, increasing costs, length of stay (LOS) and mortality. The incidence is higher amongst trauma patients, although due to variable definitions and study populations risk factors for developing VAP are disputed, with few reports from the UK.

Methods

This 6-year review of intubated trauma patients admitted to the general Intensive Care Unit (ICU) of a UK major trauma centre, collected data on suspected risk factors for VAP, as well as demographic information, outcomes and microbiology. Ninety-nine patients who developed VAP within the first 7 days of admission were compared with 191 patient who did not, with multivariable logistic regression used to control for confounding variables.

Results

Univariable analysis suggested that injury severity score (ISS) (34 v 29), head injury (66.7% v 50.8%), polytrauma (79.8% v 68.1%) and ventilator days (10 v 5) were associated with increased risk of VAP, but after adjustment only ventilator days remained significant (OR 1.04, 95% CI 1.01–1.06). Antibiotics within 24 h of admission were associated with reduced odds of developing VAP, whether this was for pulmonary prophylaxis (OR 0.43, 95% CI 0.22–0.83, p = 0.013) or non-pulmonary reasons (OR 0.27, 95% CI 0.15–0.51, p < 0.001).

Conclusions

Only increasing ventilator days was associated with increased odds of developing VAP. The use of early antimicrobials was associated strongly with a reduction in the odds of developing VAP; this could be explained by unmeasured confounding or a prophylactic effect against aspiration.

Empiric antimicrobial therapy for early-onset pneumonia in severe trauma patients

PURPOSE

The bacterial ecology involved in early pneumonia of severe trauma patients is mostly commensal and would allow wide use of narrow-spectrum antibiotics. We describe risk factors for treatment failure of severe trauma patients' pneumonia with the use of narrow-spectrum antimicrobial therapy in order to develop a score that could help clinicians to determine which patients might be treated with narrow-spectrum antibiotics.

METHODS

A retrospective, observational, monocentric cohort study was conducted of severe trauma patients requiring mechanical ventilation for > 48 h and developing a first episode of microbiologically confirmed pneumonia occurring within the first 10 days after admission.

RESULTS

Overall, 370 patients were included. The resistance rate against narrow-spectrum antibiotics (amoxicillin/clavulanic acid) was 22.7% (84 pneumonia). In a multivariate analysis, two independent risk factors were associated with this resistance: prior antimicrobial therapy ≥ 48 h (OR 4.00; 95 CI [2.39; 6.75]) and age ≥ 30y (OR 2.10; 95 CI [1.21; 3.78]). We created a prediction score that defined patient with one or two risk factors at high risk of resistance. This score presented a sensitivity of 0.92 [0.88; 0.94], a specificity of 0.33 [0.28; 0.38], a positive predictive value of 0.29 [0.24; 0.33] and a negative predictive value of 0.93 [0.90; 0.95].

CONCLUSION

Simple risk factors may help clinicians to identify severe trauma patients at high risk of pneumonia treatment failure with the use of narrow-spectrum antimicrobial therapy and, thus, use better tailored empiric therapy and limit the use of unnecessary broad-spectrum antimicrobial therapy.

Advanced Modeling to Predict Pneumonia in Combat Trauma Patients

BACKGROUND

Tools to assist clinicians in predicting pneumonia could lead to a significant decline in morbidity. Therefore, we sought to develop a model in combat trauma patients for identifying those at highest risk of pneumonia.

METHODS

This was a retrospective study of 73 primarily blast-injured casualties with combat extremity wounds. Binary classification models for pneumonia prediction were developed with measurements of injury severity from the Abbreviated Injury Scale (AIS), transfusion blood products received before arrival at Walter Reed National Military Medical Center (WRNMMC), and serum protein levels. Predictive models were generated with leave-one-out-cross-validation using the variable selection method of backward elimination (BE) and the machine learning algorithms of random forests (RF) and logistic regression (LR). BE was attempted with two predictor sets: (1) all variables and (2) serum proteins alone.

RESULTS

Incidence of pneumonia was 12% (n = 9). Different variable sets were produced by BE when considering all variables and just serum proteins alone. BE selected the variables ISS, AIS chest, and cryoprecipitate within the first 24 h following injury for the first predictor set 1 and FGF-basic, IL-2R, and IL-6 for predictor set 2. Using both variable sets, a RF was generated with AUCs of 0.95 and 0.87-both higher than LR algorithms.

CONCLUSION

Advanced modeling allowed for the identification of clinical and biomarker data predictive of pneumonia in a cohort of predominantly blast-injured combat trauma patients. The generalizability of the models developed here will require an external validation dataset.

Incidence, Risk Factors, and Outcomes of Ventilator-Associated Pneumonia in Traumatic Brain Injury: A Meta-analysis

Ventilator-associated pneumonia (VAP) is one of the most severe complications in patients with traumatic brain injury (TBI) and is considered a risk factor for poor outcomes. However, the incidence of VAP among patients with TBI reported in studies varies widely. What is more, the risk factors and outcomes of VAP are controversial. This study estimates the incidence, risk factors, and outcomes of VAP in patients with TBI and provides evidence for prevention and treatment. PubMed, EMBASE, Cochrane Library, and Web of Science databases were searched from the earliest records to May 2018. Data involving the incidence, risk factors, and outcomes were extracted for meta-analysis. The results showed that the incidence of VAP was 36% (95% confidence interval (CI) 31-41%); risk factors analyses showed that smoking [odds ratio (OR) 2.13; 95% CI 1.16-3.92], tracheostomy (OR 9.55; 95% CI 3.24-28.17), blood transfusion on admission (OR 2.54; 95% CI 1.24-5.18), barbiturate infusion (OR 3.52; 95% CI 1.68-7.40), injury severity score (OR 4.65; 95% CI 1.96-7.34), and head abbreviated injury scale (OR 2.99; 95% CI 1.66-5.37) were related to the occurrence of VAP. When patients developed VAP, mechanical ventilation time (OR 5.45; 95% CI 3.78-7.12), ICU length of stay (OR 6.85; 95% CI 4.90-8.79), and hospital length of stay (OR 10.92; 95% CI 9.12-12.72) were significantly increased. However, VAP was not associated with an increased risk of mortality (OR 1.28; 95% CI 0.74-2.21). VAP is common in patients with TBI. It is affected by a series of factors and has a poor prognosis.

Compliance and Related Outcomes of Prophylactic Antibiotics in Traumatic Open Fractures

Purpose: Prophylactic antibiotic therapy is a standard of care for patients who present with open fractures due to the risk of infectious complications. This study was conducted to characterize the use of initial prophylactic antibiotic use in open fractures, guideline compliance, and its impact on care. Methods: Retrospective chart review of adult patients presenting with an open fracture to a Level 1 Trauma Center Emergency Department over a 12-month period was conducted. Results: Of the 202 patients meeting inclusion criteria, overall compliance with guideline recommendations for antibiotic prophylaxis was found to be 33.2%. The duration of prophylactic therapy was significantly longer in the noncompliant group and among those who received a secondary antibiotic (P < .05 for both comparisons). The duration of therapy was found to be significantly longer in those patients who developed an infection (P < .001). Those who developed an infection had a longer hospital length of stay (LOS) (P < .001) and intensive care unit LOS (P = .002). In addition, those who developed an infection had significantly more surgeries (P < .001) and received more red blood cell transfusions (P < .001). Correlation analysis confirmed a significant association between infection and duration of antibiotic prophylaxis (P = .02), number of surgeries (P < .0001), and number of transfusions (P < .0001). Conclusion: Guideline compliance was exceedingly low due to the extended duration of initial antibiotic therapy and did not appear to yield any clinical benefits. Infection was significantly associated with longer duration of initial prophylactic therapy and morbidity. Opportunities exist to elevate compliance with guidelines and to reevaluate prophylactic antimicrobial therapy in this setting.

Prevention of early ventilation-acquired pneumonia (VAP) in comatose brain-injured patients by a single dose of ceftriaxone: PROPHY-VAP study protocol, a multicentre, randomised, double-blind, placebo-controlled trial

INTRODUCTION

Ventilator-associated pneumonia (VAP) is the first cause of healthcare-associated infections in intensive care units (ICUs) and brain injury is one of the main risk factors for early-onset VAP. Antibiotic prophylaxis has been reported to decrease their occurrence in brain-injured patients, but a lack of controlled randomised trials and the risk of induction of bacterial resistance explain the low level of recommendations. The goal of this study is to determine whether a single dose of ceftriaxone within the 12 hours postintubation after severe brain injury can decrease the risk of early-onset VAP.

METHODS AND ANALYSIS

The PROPHY-VAP is a French multicentre, randomised, double-blind, placebo-controlled, clinical trial. Adult brain-injured patients (n=320) with a Glasgow Coma Scale ≤12, requiring mechanical ventilation for more than 48 hours, are randomised to receive either a single dose of ceftriaxone 2 g or a placebo within the 12 hours after tracheal intubation. The primary endpoint is the proportion of patients developing VAP from the 2nd to the 7th day after mechanical ventilation. Secondary endpoints include the proportion of patients developing late VAP (>7 days after tracheal intubation), the number of ventilator-free days, VAP-free days and antibiotic-free days, length of stay in the ICU, proportion of patients with ventilator-associated events and mortality during their ICU stay.

ETHICS AND DISSEMINATION

The initial research project was approved by the Institutional Review Board of OUEST III (France) on 20 October 2014 (registration No 2014-001668-36) and carried out according to the principles of the Declaration of Helsinki and the Clinical Trials Directive 2001/20/EC of the European Parliament relating to the Good Clinical Practice guidelines. The results of this study will be presented in national and international meetings and published in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02265406; Pre-results.

Antibiotic Use after Free Tissue Reconstruction of Head and Neck Defects: Short Course vs. Long Course

BACKGROUND

Free tissue reconstruction has become the standard of care for most major defects in the head and neck. Surgical site infection (SSI) can lead to vessel thrombosis and eventual flap loss. The use of antibiotics after free tissue reconstruction has not been studied in the current environment of heightened bacterial antibiotic resistance. We compared the use of short-term and longer-term antibiotics in a series of patients receiving free tissue reconstructions.

METHODS

A retrospective review was performed of 147 patients receiving 149 free flaps who were treated with either short-course (≤2 d; n = 149 [43%]) or long-course (>2 d; n = 85 [57%])) post-operative antibiotics from 2009 to 2014. The outcomes examined were infection, return to the operating room, length of hospital stay, and patient death up to six weeks post-surgery. In addition, risk factors associated with SSI were explored.

RESULTS

Surgical site infection, flap dehiscence, flap loss, and length of stay were not different in the two groups. However, those receiving long-course antibiotics had a significantly higher rate of pneumonia (24.7% vs. 10.9%; p = 0.03), although they had a lower rate of urinary tract infection (0.0% vs 9.4%, respectively; p = 0.01). Body mass index remained a statistically significant risk factor in the multivariable analysis (p = 0.005).

CONCLUSION

Prolonged antibiotic use after free flap reconstruction of head and neck defects does not appear to prevent SSI better than short-course treatment in this population. Moreover, long-course antibiotic use was associated with a higher risk of pneumonia.

Hospital-acquired pneumonia is an independent predictor of poor global outcome in severe traumatic brain injury up to 5 years after discharge

BACKGROUND

Long-term outcomes following traumatic brain injury (TBI) correlate with initial head injury severity and other acute factors. Hospital-acquired pneumonia (HAP) is a common complication in TBI. Limited information exists regarding the significance of infectious complications on long-term outcomes after TBI. We sought to characterize risks associated with HAP on outcomes 5 years after TBI.

METHODS

This study involved data from the merger of an institutional trauma registry and the Traumatic Brain Injury Model Systems outcome data. Individuals with severe head injuries (Abbreviated Injury Scale [AIS] score ≥ 4) who survived to rehabilitation were analyzed. Primary outcome was Glasgow Outcome Scale-Extended (GOSE) at 1, 2, and 5 years. GOSE was dichotomized into low (GOSE score < 6) and high (GOSE score ≥ 6). Logistic regression was used to determine adjusted odds of low GOSE score associated with HAP after controlling for age, sex, head and overall injury severity, cranial surgery, Glasgow Coma Scale (GCS) score, ventilation days, and other important confounders. A general estimating equation model was used to analyze all outcome observations simultaneously while controlling for within-patient correlation.

RESULTS

A total of 141 individuals met inclusion criteria, with a 30% incidence of HAP. Individuals with and without HAP had similar demographic profiles, presenting vitals, head injury severity, and prevalence of cranial surgery. Individuals with HAP had lower presenting GCS score. Logistic regression demonstrated that HAP was independently associated with low GOSE scores at follow-up (1 year: odds ratio [OR], 6.39; 95% confidence interval [CI], 1.76-23.14; p = 0.005) (2 years: OR, 7.30; 95% CI, 1.87-27.89; p = 0.004) (5-years: OR, 6.89; 95% CI, 1.42-33.39; p = 0.017). Stratifying by GCS score of 8 or lower and early intubation, HAP remained a significant independent predictor of low GOSE score in all strata. In the general estimating equation model, HAP continued to be an independent predictor of low GOSE score (OR, 4.59; 95% CI, 1.82-11.60; p = 0.001).

CONCLUSION

HAP is independently associated with poor outcomes in severe TBI extending 5 years after injury. This suggests that precautions should be taken to reduce the risk of HAP in individuals with severe TBI.

LEVEL OF EVIDENCE

Prognostic study, level III.

Analysis of Hypoxemia in Early Ventilator-Associated Pneumonia Secondary to Haemophilus in Trauma Patients

BACKGROUND

Haemophilus species bacteria (HSB) are known pathogens responsible for early pneumonia in intubated trauma patients. The primary goal of this study was to examine the incidence and extent of hypoxemia in intubated trauma patients who develop early ventilator-associated pneumonia (VAP) secondary to HSB. On the basis of our clinical experiences, we hypothesized that patients with Haemophilus species bacteria pneumonia (HSBP) would have a high rate of hypoxemia but that the effect would be transient.

METHODS

Retrospective review of intubated trauma patients from an urban level I trauma center with HSBP diagnosed by deep tracheal aspirate or bronchoalveolar lavage from April 2007 to November 2012. Collected variables included day of HSBP diagnosis; PaO2 to FIO2 ratio (P:F) at HSBP diagnosis as well as HSBP day three and HSBP day seven; injury severity score (ISS) and its component parts; admission Glasgow Coma Scale (GCS) score; and mortality. Hypoxemia was defined as P:F <200. χ(2) Tests were utilized to assess factors that differed between hypoxemic and non-hypoxemic patients; data are presented as median (interquartile range, IQR).

RESULTS

Sixty-nine patients were identified (80% male; age, 35 y [range, 24-49]; ISS 27 [9-59]). Diagnosis of HSBP occurred early (hospital day 4 [range, 3-5]). Forty-three percent of patients had acute respiratory distress syndrome (ARDS) on HSBP day 1; this decreased to 26% on day three and to 30% on day seven. Forty patients (77%) had a tracheostomy performed. Patients with hypoxemia were significantly less likely to have a severe head injury (GCS<9), p<0.05. Patients with hypoxemia had similar hospital length of stay and mortality to patients who did not develop hypoxemia.

CONCLUSION

Haemophilus species bacteria pneumonia in trauma patients is associated with high rates of transient hypoxemia and a high tracheostomy rate, although subsequent outcomes are not affected. Patients with head injuries had a lower incidence of hypoxemia from pneumonia.

Systemic manifestations of traumatic brain injury

Traumatic brain injury (TBI) affects functioning of various organ systems in the absence of concomitant non-neurologic organ injury or systemic infection. The systemic manifestations of TBI can be mild or severe and can present in the acute phase or during the recovery phase. Non-neurologic organ dysfunction can manifest following mild TBI or severe TBI. The pathophysiology of systemic manifestations following TBI is multifactorial and involves an effect on the autonomic nervous system, involvement of the hypothalamic-pituitary axis, release of inflammatory mediators, and treatment modalities used for TBI. Endocrine dysfunction, electrolyte imbalance, and respiratory manifestations are common following TBI. The influence of TBI on systemic immune response, coagulation cascade, cardiovascular system, gastrointestinal system, and other systems is becoming more evident through animal studies and clinical trials. Systemic manifestations can independently act as risk factors for mortality and morbidity following TBI. Some conditions like neurogenic pulmonary edema and disseminated intravascular coagulation can adversely affect the outcome. Early recognition and treatment of systemic manifestations may improve the clinical outcome following TBI. Further studies are required especially in the field of neuroimmunology to establish the role of various biochemical cascades, not only in the pathophysiology of TBI but also in its systemic manifestations and outcome.

Prevention of combat-related infections: antimicrobial therapy in battlefield and barrier measures in French military medical treatment facilities

Infection is a major complication associated with combat-related injuries. Beside immobilization, wound irrigation, surgical debridement and delayed coverage, post-injury antimicrobials contribute to reduce combat-related infections, particularly those caused by bacteria of the early contamination flora. In modern warfare, bacteria involved in combat-related infections are mainly Gram-negative bacteria belonging to the late contamination flora. These bacteria are frequently resistant or multiresistant to antibiotics and spread through the deployed chain of care. This article exposes the principles of war wounds antimicrobial prophylaxis recommended in the French Armed Forces and highlights the need for high compliance to hygiene standard precautions, adapted contact precautions and judicious use of antibiotics in French deployed military medical treatment facilities (MTF).

Prophylactic Antibiotic Therapy in Contaminated Traumatic Wounds: Two Days versus Five Days Treatment

INTRODUCTION

Emergency department manages several kinds of wounds including simple, non-bite traumatic wounds and lacerations. Prophylactic antibiotic therapy is one of pre-scribed treatment in these conditions. We aimed to compare the clinical efficacy of the two day regimen of prophylactic antimicrobial agents with the five day regimen in simple traumatic but highly contaminated wounds.

METHODS

Between January 2010 and May 2010, patients presenting with simple traumatic wounds or lacerations in different parts of the body, highly contaminated with soil, debris or feces in emergency department of a referral educational hospital in Tehran (Rasul-Akram hospital), Iran, went for primary closure. All of the patients were provided prophylactic antibiotic, however, prescribed for one group (A) of patients for 2 days and other group (B) received for 5 days, according to the physician concerned. As these treatments were routine, we selected 70 patients from each group using table of random numbers. The patients were warned about the signs of infection including long-lasting erythema, purulent discharge and inflammation and were supposed to inform the concerned physician in any of such alarming situations. Oral Cephalexin 500 mg qid was prescribed for all patients enrolled for prophylaxis treatment.

RESULTS

On follow-up 11 (8.2%) patients were found to develop sutured site infection (6 out of 70 (8.57%) in group A, and five out of 70 (7.14%) in group B (P=0.31)). There was no statistical difference between infection rates between men (8.6%) in comparison to women (6.25%) (P>0.05; CI=95%).

CONCLUSION

Our study showed that 2-day prophylactic antibiotic therapy using Cephalexin is at least as effective as a 5-day regimen in relation to development of surgical site infection in patients with simple traumatic contaminated wounds or lacerations.

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

Prevention of infections associated with combat-related extremity injuries

During combat operations, extremities continue to be the most common sites of injury with associated high rates of infectious complications. Overall, ∼ 15% of patients with extremity injuries develop osteomyelitis, and ∼ 17% of those infections relapse or recur. The bacteria infecting these wounds have included multidrug-resistant bacteria such as Acinetobacter baumannii, Pseudomonas aeruginosa, extended-spectrum β-lactamase-producing Klebsiella species and Escherichia coli, and methicillin-resistant Staphylococcus aureus. The goals of extremity injury care are to prevent infection, promote fracture healing, and restore function. In this review, we use a systematic assessment of military and civilian extremity trauma data to provide evidence-based recommendations for the varying management strategies to care for combat-related extremity injuries to decrease infection rates. We emphasize postinjury antimicrobial therapy, debridement and irrigation, and surgical wound management including addressing ongoing areas of controversy and needed research. In addition, we address adjuvants that are increasingly being examined, including local antimicrobial therapy, flap closure, oxygen therapy, negative pressure wound therapy, and wound effluent characterization. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Antimicrobial prophylaxis in open lower extremity fractures

Clinical question:

Based on the grade of open fracture, which antibiotic should be selected for antimicrobial prophylaxis, and what is the optimal timing and duration of administration?

Results:

For Grade I and II open fractures, a first-generation cephalosporin (eg, cefazolin) should be administered within 3 hours of initial injury and be continued for 24 hours after initial injury. Grade III open fractures require coverage with an aminoglycoside in addition to a first-generation cephalosporin within 3 hours of initial injury, and antibiotics should be continued for 48–72 hours after initial injury but no more than 24 hours after wound closure. If a fracture is at risk of contamination with clostridium species, such as a farm-related injury, penicillin should be added to the antibiotic regimen.

Implementation:

Pitfalls to avoid when using antibiotics for infection prophylaxis in open fractures include utilizing cultures immediately postinjury to direct choice of agent for antimicrobial prophylaxis, because infecting pathogens do not typically correlate to pathogens initially cultured after injury; failure to consider patients’ medication allergy history or reconcile allergy records; and failure to obtain a thorough history to determine injury exposure (eg, farm, water).

Prevention and treatment of infected foot and ankle wounds sustained in the combat environment

Combat injuries to the foot and ankle are challenging to treat due to frequent high-energy mechanisms, environmental contamination, and soft tissue and bony damage. Prevention and treatment of infections in injuries to the foot and ankle are critical to achieving the goals of tissue healing and restoration of function. The guidelines for treatment of these foot and ankle injuries are similar to those in place for civilians; however, allowances must be made for the realities of combat including an often austere environment, the need for evacuation, and limitations on resources available for treatment.

Strategies to prevent ventilator-associated pneumonia in acute care hospitals

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.

1. Occurrence of VAP in acute care facilities.

a. VAP is one of the most common infections acquired by adults and children in intensive care units (ICUs).

i. In early studies, it was reported that 10%-20% of patients undergoing ventilation developed VAP. More-recent publications report rates of VAP that range from 1 to 4 cases per 1,000 ventilator-days, but rates may exceed 10 cases per 1,000 ventilator-days in some neonatal and surgical patient populations. The results of recent quality improvement initiatives, however, suggest that many cases of VAP might be prevented by careful attention to the process of care.

2. Outcomes associated with VAP

a. VAP is a cause of significant patient morbidity and mortality, increased utilization of healthcare resources, and excess cost.

i. The mortality attributable to VAP may exceed 10%.

ii. Patients with VAP require prolonged periods of mechanical ventilation, extended hospitalizations, excess use of antimicrobial medications, and increased direct medical costs.

Determinants and impact of multidrug antibiotic resistance in pathogens causing ventilator-associated-pneumonia

INTRODUCTION

The idea that multidrug resistance (MDR) to antibiotics in pathogens causing ventilator-associated pneumonia (VAP) is an independent risk factor for adverse outcome is still debated. We aimed to identify the determinants of MDR versus non-MDR microbial aetiology in VAP and assessed whether MDR versus non-MDR VAP was independently associated with increased 30-day mortality.

METHODS

We performed a retrospective analysis of a prospectively registered cohort of adult patients with microbiologically confirmed VAP, diagnosed at a university hospital intensive care unit during a three-year period. Determinants of MDR as compared with non-MDR microbial aetiology and impact of MDR versus non-MDR aetiology on mortality were investigated using multivariate logistic and competing risk regression analysis.

RESULTS

MDR pathogens were involved in 52 of 192 episodes of VAP (27%): methicillin-resistant Staphylococcus aureus in 12 (6%), extended-spectrum beta-lactamase producing Enterobacteriaceae in 28 (15%), MDR Pseudomonas aeruginosa and other non-fermenting pathogens in 12 (6%). Multivariable logistic regression identified the Charlson index of comorbidity (odds ratio (OR) = 1.38, 95% confidence interval (CI) = 1.08 to 1.75, p = 0.01) and previous exposure to more than two different antibiotic classes (OR = 5.11, 95% CI = 1.38 to 18.89, p = 0.01) as predictors of MDR aetiology. Thirty-day mortality after VAP diagnosis caused by MDR versus non-MDR was 37% and 20% (p = 0.02), respectively. A multivariate competing risk regression analysis showed that renal replacement therapy before VAP (standardised hazard ratio (SHR) = 2.69, 95% CI = 1.47 to 4.94, p = 0.01), the Charlson index of comorbidity (SHR = 1.21, 95% CI = 1.03 to 1.41, p = 0.03) and septic shock on admission to the intensive care unit (SHR = 1.86, 95% CI = 1.03 to 3.35, p = 0.03), but not MDR aetiology of VAP, were independent predictors of mortality.

CONCLUSIONS

The risk of MDR pathogens causing VAP was mainly determined by comorbidity and prior exposure to more than two antibiotics. The increased mortality of VAP caused by MDR as compared with non-MDR pathogens was explained by more severe comorbidity and organ failure before VAP.

Evidence-based algorithms for diagnosing and treating ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia (VAP) is widely recognized as a serious and common complication associated with high morbidity and high costs. Given the complexity of caring for heterogeneous populations in the intensive care unit (ICU), however, there is still uncertainty regarding how to diagnose and manage VAP.

OBJECTIVE

We recently conducted a national collaborative aimed at reducing health care-associated infections in ICUs of hospitals operated by the Hospital Corporation of America (HCA). As part of this collaborative, we developed algorithms for diagnosing and treating VAP in mechanically ventilated patients. In the current article, we (1) review the current evidence for diagnosing VAP, (2) describe our approach for developing these algorithms, and (3) illustrate the utility of the diagnostic algorithms using clinical teaching cases.

DESIGN

This was a descriptive study, using data from a national collaborative focused on reducing VAP and catheter-related bloodstream infections.

SETTING

The setting of the study was 110 ICUs at 61 HCA hospitals.

INTERVENTION

None.

MEASUREMENTS AND RESULTS

We assembled an interdisciplinary team that included infectious disease specialists, intensivists, hospitalists, statisticians, critical care nurses, and pharmacists. After reviewing published studies and the Centers for Disease Control and Prevention VAP guidelines, the team iteratively discussed the evidence, achieved consensus, and ultimately developed these practical algorithms. The diagnostic algorithms address infant, pediatric, immunocompromised, and adult ICU patients.

CONCLUSIONS

We present practical algorithms for diagnosing and managing VAP in mechanically ventilated patients. These algorithms may provide evidence-based real-time guidance to clinicians seeking a standardized approach to diagnosing and managing this challenging problem.

Prevention and management of infections associated with combat-related extremity injuries

Orthopedic injuries suffered by casualties during combat constitute approximately 65% of the total percentage of injuries and are evenly distributed between upper and lower extremities. The high-energy explosive injuries, environmental contamination, varying evacuation procedures, and progressive levels of medical care make managing combat-related injuries challenging. The goals of orthopedic injury management are to prevent infection, promote fracture healing, and restore function. It appears that 2% to 15% of combat-related extremity injuries develop osteomyelitis, although lower extremity injuries are at higher risk of infections than upper extremity. Management strategies of combat-related injuries primarily focus on early surgical debridement and stabilization, antibiotic administration, and delayed primary closure. Herein, we provide evidence-based recommendations from military and civilian data to the management of combat-related injuries of the extremity. Areas of emphasis include the utility of bacterial cultures, antimicrobial therapy, irrigation fluids and techniques, timing of surgical care, fixation, antibiotic impregnated beads, wound closure, and wound coverage with negative pressure wound therapy. Most of the recommendations are not supported by randomized controlled trials or adequate cohorts studies in a military population and further efforts are needed to answer best treatment strategies.

Principles of antimicrobial therapy: what should we be using?

Although the use of antimicrobials has had an insurmountable impact on preventing patient morbidity and mortality, problems with antimicrobial resistance and antimicrobial-induced diarrhea are becoming more apparent in human and veterinary medicine. The mortality associated with nosocomial infection with antimicrobial-resistant bacteria in human patients is alarming. Similarly, in veterinary medicine, the morbidity and high cost of treatment of patients with postoperative infection, for example, are concerns. Specifically in equine medicine, the high morbidity and mortality associated with antimicrobial-induced diarrhea have been devastating in many equine practices. Misuse of antimicrobials is extremely common in human and veterinary medicine. All clinicians have the responsibility to consider the appropriateness of their antimicrobial use carefully and, whenever possible, to minimize antimicrobial administration to patients.

Systemic complications after head injury: a clinical review

Non-neurological organ dysfunction is common after traumatic brain injury and is an independent contributor to morbidity and mortality. It represents a risk factor that is potentially amenable to treatment, and early recognition and prompt intervention may improve outcome. This article reviews the current evidence for the mechanisms and treatment of non-neurological organ dysfunction after head injury.

Selective decontamination of the digestive tract reduces bacterial bloodstream infection and mortality in critically ill patients. Systematic review of randomized, controlled trials

A systematic review and meta-analysis of randomized controlled trials (RCTs) of selective decontamination of the digestive tract (SDD) was undertaken to evaluate the impact of this procedure on bacterial bloodstream infection and mortality. Data sources were Medline, Embase, Cochrane Register of Controlled Trials, previous meta-analyses, and conference proceedings, without restriction of language or publication status. RCTs were retrieved that compared oropharyngeal and/or intestinal administration of antibiotics as part of the SDD protocol, with or without a parenteral component, with no treatment or placebo in the controls. The three outcome measures were patients with bloodstream infection, causative micro-organisms, and total mortality. Fifty-one RCTs conducted between 1987 and 2005, comprising 8065 critically ill patients were included in the review; 4079 patients received SDD and 3986 were controls. SDD significantly reduced overall bloodstream infections [odds ratio (OR), 0.73; 95% confidence interval (CI), 0.59-0.90; P=0.0036], gram-negative bloodstream infections (OR, 0.39; 95% CI, 0.24-0.63; P<0.001) and overall mortality (OR, 0.80; 95% CI, 0.69-0.94; P=0.0064), without affecting gram-positive bloodstream infections (OR, 1.06; 95% CI, 0.77-1.47). The subgroup analysis showed an even larger impact of SDD using parenteral and enteral antimicrobials on overall bloodstream infections, bloodstream infections due to gram-negative bacteria and overall mortality with ORs of 0.63 (95% CI, 0.46-0.87; P=0.005), 0.30 (95% CI, 0.16-0.56; P<0.001), and 0.74 (95% CI, 0.61-0.91; P=0.0034), respectively. Twenty patients need to be treated with SDD to prevent one gram-negative bloodstream infection and 22 patients to prevent one death.

The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial

OBJECTIVE

Evaluation of selective decontamination of the digestive tract (SDD) on late mortality in ventilated trauma patients in an intensive care unit (ICU).

METHODS

A multicenter, randomized controlled trial was undertaken in 401 trauma patients with Hospital Trauma Index-Injury Severity Score of 16 or higher. Patients were randomized to control (n=200) or SDD (n=201), using polymyxin E, tobramycin, and amphotericin B in throat and gut throughout ICU treatment combined with cefotaxime for 4 days. Primary endpoint was late mortality excluding early death from hemorrhage or craniocerebral injury. Secondary endpoints were infection and organ dysfunction.

RESULTS

Mortality was 20.9% with SDD and 22.0% in controls. Overall late mortality was 15.3% (57/372) as 29 patients died from cerebral injury, 16 SDD and 13 control. The odds ratio (95% confidence intervals) of late mortality for SDD relative to control was 0.75 (0.40-1.37), corresponding to estimates of 13.4% SDD and 17.2% control. The overall infection rate was reduced in the test group (48.8% vs. 61.0%). SDD reduced lower airway infections (30.9% vs. 50.0%) and bloodstream infections due to aerobic Gram-negative bacilli (2.5% vs. 7.5%). No difference in organ dysfunction was found.

CONCLUSION

This study demonstrates that SDD significantly reduces infection in multiple trauma, although this RCT in 401 patients was underpowered to detect a mortality benefit.

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.

Administration of antibiotics via the respiratory tract for the prevention of ICU-acquired pneumonia: a meta-analysis of comparative trials

Introduction

The administration of prophylactic antibiotics via the respiratory tract is one of several strategies for the prevention of intensive care unit (ICU)-acquired pneumonia. We systematically examined the available evidence regarding the effect of prophylactic antibiotics administered via the respiratory tract on the development of ICU-acquired pneumonia, mortality, colonization of the respiratory tract, emergence of antimicrobial resistance, and toxicity.

Methods

We searched the PubMed database (January 1950 to September 2005) and references from relevant articles to identify trials that provided comparative data regarding the above-mentioned outcomes. Two investigators independently performed the data extraction to calculate the effect of the studied intervention on clinically relevant outcomes.

Results

Our meta-analysis includes 8 comparative trials (5 randomized controlled trials (RCTs) and 3 non-randomized trials) studying gentamicin (3 trials), polymyxins (3 trials), tobramycin (1 trial), and ceftazidime (1 trial) that studied 1,877 patients. Our primary analysis, which included the 5 RCTs, revealed that ICU-acquired pneumonia was less common in the group of patients that received the antibiotic prophylaxis (odds ratio (OR) = 0.49, 95% confidence interval (CI) 0.32–0.76). No difference in mortality was found between the compared groups (OR = 0.86, 95% CI 0.55–1.32). Data were too limited to permit an analysis of colonization with Pseudomonas aeruginosa. A secondary analysis, adding the three non-randomized comparative trials, did not reveal substantially different results regarding ICU-acquired pneumonia and mortality, while fewer patients were colonized with P. aeruginosa in the group that received prophylaxis, compared to the group of patients that received no prophylaxis (OR = 0.51, 95% CI 0.30–0.86). No serious drug-related toxicity was noted. No meaningful systematic analysis of the evidence regarding the emergence of resistance could be performed in the studies included in our meta-analysis.

Conclusion

The limited available evidence supports that prophylactic administration of antibiotics via the respiratory tract is associated with reduction of occurrence of ICU-acquired pneumonia. However, there is evidence from non-comparative studies that this preventive strategy may lead to an increase in the emergence of resistant bacteria. Thus, further investigation, at least in ICU patients at high risk for development of ICU-acquired pneumonia, is warranted, including a more systematic evaluation of issues related to the emergence of resistance.

Prophylactic Antibiotic Use in Open Fractures: An Evidence-Based Guideline

BACKGROUND

Prolonged courses of broad-spectrum antibiotics are often cited as the standard of care for prevention of infective complications of open fractures. The origins of these recommendations are obscure, however, and multi-drug-resistant systemic infections attributable to antibiotic overuse are common life-threatening problems in current intensive care unit practice.

OBJECTIVE

To review systematically the effects of prophylactic antibiotic administration on the incidence of infections complicating open fractures.

DATA SOURCES

Computerized bibliographic search of published research and citation review of relevant articles.

STUDY SELECTION

All published clinical trials claiming to evaluate, or cited elsewhere as being authoritative regarding, the role of antibiotics in open fracture management were identified and then evaluated according to published guidelines for evidence-based medicine. Only small studies (<20 patients), practice surveys, pharmacokinetic studies, and reviews or duplicative publications presenting primary data already considered were excluded from analysis.

DATA EXTRACTION

Information on demographics, study dates, fracture grade, antibiotic type, duration and route of administration, surgical interventions, infection-related outcomes, and the methodologic quality of the studies was extracted by the authors. The primary results were submitted to the Therapeutic Agents Committee of the Surgical Infection Society for review prior to creation of the final consensus document.

DATA SYNTHESIS

Current antibiotic management of open fractures is based on a small number of studies that generally are more than 30 years old and do not reflect current management priorities in trauma and critical care. With a few noteworthy exceptions, these primary studies suffer from a variety of methodologic problems, including co-mingling of prospective and retrospective data sets, absence of or inappropriate statistical analysis, lack of blinding, or failure of randomization.

CONCLUSIONS

The data support the conclusion that a short course of first-generation cephalosporins, begun as soon as possible after injury, significantly lowers the risk of infection when used in combination with prompt, modern orthopedic fracture wound management. There is insufficient evidence to support other common management practices, such as prolonged courses or repeated short courses of antibiotics, the use of antibiotic coverage extending to gram-negative bacilli or clostridial species, or the use of local antibiotic therapies such as beads. Large, randomized, blinded trials are needed to prove or disprove the value of these traditional approaches. Such trials should be performed in patients with high-grade fractures who (1) are well-stratified according to the degree of local injury and (2) undergo standardized fracture and wound management. Trials also must be powered to study the effects of extended antibiotic coverage on nosocomial infections. Antibiotic regimens confirmed to improve local fracture outcomes in such studies could then be used rationally, balancing the risks of local fracture-related infections and of multi-drug-resistant systemic infections to achieve optimal global outcomes.

Prevention of Postoperative Infections in Horses

The best defense against postoperative infection is to use multiple strategies to minimize wound contamination, maintain wound tissue health, and provide rational antimicrobial strategies that do not promote the development of resistant bacteria and superinfections.

Prevention of pneumonia in the hospital setting

Although the optimal approach to reducing ventilator-associated pneumonia (VAP) is unclear, recent studies indicate that mandatory education of health care workers caring for mechanically ventilated patients can decrease overall VAP rates. Among the available interventions, shortening the duration of mechanical ventilation and providing measures to prevent the aspiration of contaminated secretions are most important. Given the evidence supporting greater morbidity, hospital mortality, and medical care costs among patients who have VAP, the prevention of this nosocomial infection should be an important priority in the hospital setting.

Non-neurologic organ dysfunction in severe traumatic brain injury

OBJECTIVE

To describe the incidence of non-neurologic organ dysfunction and its association with outcome in patients with severe traumatic brain injury admitted to intensive care.

DESIGN

Observational cohort study.

SETTING

Foothills Medical Centre, which is the only neurosurgical service in southern Alberta (population approximately 1.3 million).

PATIENTS

Patients were 209 consecutive patients with severe traumatic brain injury.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Non-neurologic organ dysfunction was measured by the maximum modified multiple organ dysfunction score. Organ system failure was defined as a component score of >/=3 on any day during the patient's intensive care unit stay. One hundred and eighty-five patients (89%) developed dysfunction of at least one non-neurologic organ system. Ninety-six organ system failures were identified in 74 patients (35%). Respiratory failure was the most common non-neurologic organ system failure, occurring in 23% of patients, whereas cardiovascular failure occurred in 18%. Eight patients (4%) had failure of the coagulation system. One patient had renal failure, whereas no patient developed hepatic failure. In a multivariate model, non-neurologic organ dysfunction was independently associated with hospital mortality (odds ratio for hospital mortality, 1.63; 95% confidence interval, 1.34, 1.98 for one maximum modified multiple organ dysfunction score point). Non-neurologic organ dysfunction was also independently associated with dichotomized Glasgow Outcome Score, as a measure of neurologic outcome (odds ratio for unfavorable neurologic outcome, 1.53; 95% confidence interval, 1.22, 1.98 for one maximum modified multiple organ dysfunction score point). The timing of the organ dysfunction did not appear to be important in the prediction of outcome.

CONCLUSIONS

Non-neurologic organ dysfunction is common in patients with severe traumatic brain injury and is independently associated with worse outcome.

Antibiotic prophylaxis of early onset pneumonia in critically ill comatose patients. A randomized study

OBJECTIVE

To evaluate if a 3-day ampicillin-sulbactam prophylaxis can reduce the occurrence of early-onset pneumonia (EOP) in comatose mechanically-ventilated patients.

DESIGN

This was a single-centre, prospective, randomised, open study.

SETTING

A 10-bed general-neurological ICU in a 2,000-bed university hospital.

PATIENTS AND PARTICIPANTS

Comatose mechanically-ventilated patients with traumatic, surgical or medical brain injury.

INTERVENTIONS

Patients were randomized to either ampicillin-sulbactam prophylaxis (3 g every 6 h for 3 days) plus standard treatment or standard treatment alone.

MEASUREMENTS AND RESULTS

Main outcome was the occurrence of EOP. Secondary outcome measures were occurrence of late-onset pneumonia, percentage of non-pulmonary infections and of emerging multiresistant bacteria, duration of mechanical ventilation and of ICU stay and ICU mortality. Interim analysis at 1 year demonstrated a statistically significant reduction of EOP in the ampicillin-sulbactam group, and the study was interrupted. Overall, 39.5% of the patients developed EOP, 57.9% in the standard treatment group and 21.0% in the ampicillin-sulbactam group (chi-square 5.3971; P =0.022). Relative risk reduction of EOP in patients receiving ampicillin-sulbactam prophylaxis was 64%; the number of patients to be treated to avoid one episode of EOP was three. No differences in other outcome parameters were found; however, the small sample size precluded a definite analysis.

CONCLUSIONS

Antibiotic prophylaxis with ampicillin-sulbactam significantly reduced the occurrence of EOP in critically ill comatose mechanically ventilated patients. This result should encourage a large multicenter trial to demonstrate whether ampicillin-sulbactam prophylaxis reduces patient mortality, and whether antibiotic resistance is increased in patients receiving prophylaxis.

Prevention of infection in the intensive care unit

PURPOSE OF REVIEW

Infections remain an important threat for critically ill patients, and the emergence of antibiotic resistance is increasingly hampering successful treatment. In this review, new aspects of the diagnosis and prevention of ventilator-associated pneumonia and of strategies of antibiotic use to limit the development and spread of resistance are described.

RECENT FINDINGS

Prevention of ventilator-associated pneumonia is cost effective, but the most optimal preventive measure (or set of measures) remains controversial. There is growing evidence that antibiotic prophylaxis reduces the occurrence of ventilator-associated pneumonia and improves patient outcome. Moreover, antibiotic use can be reduced by increasing the specificity of diagnosing ventilator-associated pneumonia and by limiting the duration of antibiotic treatment.

SUMMARY

Recent developments in diagnosis, treatment, and prevention of ventilator-associated pneumonia and strategies to reduce emergence of antibiotic resistance have been reviewed. Whether changes in antibiotic policy will reduce the emergence of antibiotic resistance remains to be determined. In this area, methodologic problems that have been overlooked in many studies have been addressed recently. These issues must be clarified to provide reliable data on the effects of interventions in hospital settings.

Prevention of hospital-associated pneumonia and ventilator-associated pneumonia

OBJECTIVE

To synthesize the available clinical data for the prevention of hospital-associated pneumonia (HAP) and ventilator-associated pneumonia (VAP) into a practical guideline for clinicians.

DATA SOURCE

A Medline database and references from identified articles were used to perform a literature search relating to the prevention of HAP/VAP.

CONCLUSIONS

There is convincing evidence to suggest that specific interventions can be employed to prevent HAP/VAP. The evidence-based interventions focus on the prevention of aerodigestive tract colonization (avoidance of unnecessary antibiotics and stress ulcer prophylaxis, use of sucralfate for stress ulcer prophylaxis, chlorhexidine oral rinse, selective digestive decontamination, short-course parenteral prophylactic antibiotics in high-risk patients) and the prevention of aspiration of contaminated secretions (preferred oral intubation, appropriate intensive care unit staffing, avoidance of tracheal intubation with the use of mask ventilation, application of weaning protocols and optimal use of sedation to shorten the duration of mechanical ventilation, semirecumbent positioning, minimization of gastric distension, subglottic suctioning, avoidance of ventilator circuit changes/manipulation, routine drainage of ventilator circuit condensate). Clinicians caring for patients at risk for HAP/VAP should promote the development and application of local programs encompassing these interventions based on local resource availability, occurrence rates of HAP/VAP, and the prevalence of infection due to antibiotic-resistant bacteria (Pseudomonas aeruginosa, Acinetobacter species, and methicillin-resistant Staphylococcus aureus).

Current concepts in the diagnosis and management of trauma-related sepsis

Traumatic injury is common, and accounts for a large health care burden. Trauma and in particular haemorrhagic shock are closely related to the onset of multiple organ failure, the systemic inflammatory response and sepsis. Despite overall improvements in the care of septic critically ill patients there has been little impact on morbidity and mortality. In recent years our understanding of sepsis both as an illness and at a molecular level has led to the development of a number of therapeutic interventions. This article outlines the current evidence for such interventions and points to possible future research that is required in the diagnosis and management of trauma-related sepsis.