2. Antibiotics in Trauma??? Tim Hardcastle Trauma Service Tygerberg Hospital / Stellenbosch University

3. Introduction Evidence based review Rational antibiotic use in trauma Differentiate between: –Prophylaxis (most commonly required) –Therapy Propose local guideline

4. Statement of the problem Multitude of studies relating to antibiotic use Use different drugs and doses Seldom use placebo as control Most are studies in “delayed” presentation

5. What does the evidence reveal? Grading according to the “Sacket criteria” Level one evidence should be standard of care Level two evidence strongly advised as a guideline Level three optional clinician choice

6. Chest drains No level 1 evidence to support / deny No level 2 evidence Level 3 evidence suggests single dose of 1 st Generation Cephalosporin (Kefzol 1g IVI push) may decrease the incidence of nosocomial pneumonia, but not empyema 16/05/2005 www.surgicalcritcalcare.netwww.surgicalcritcalcare.net

7. Fractures Two types of fracture: open vs. closed Two types of management –Closed reduction and POP –ORIF Which antibiotics and how long therapy? Is there a difference in fracture severity

8. Fractures Open fractures –Any patient with metalwork –Grade 1 & 2 maximum 24 hours (Level 1) First generation cephalosporin As soon as possible –Grade 3 (Level 1 & 2) Cephazolin 1 or 2g alone X 72 hours or wound cover Add gram negative and anaerobe cover if severe contamination www.east.orgwww.east.org Practice management guidelines

9. Base of skull fractures No evidence to support routine antibiotic prophylaxis or empiric therapy in cases without meningitis Irrespective of CSF leak Other open skull fractures treat as open fracture Cochrane database systemic review 25 January 2006

10. Penetrating Abdominal Trauma All penetrating abdominal trauma: single dose prophylaxis (“contaminated”): Level 1 –Must cover G+ and G- –2 nd Generation Cephalosporin (Cephuroxime) or Augmentin® –Avoid 3 rd Generation cephalosporin Maximum 24hr course except established infection (Level 2) www.east.orgwww.east.org practice management guidelines De Lalla: Journal of hospital infection 2002 (50) suppl A S9-S12

11. Penetrating Abdominal Trauma Repeat dose every 10 PC with major trauma (Level 3) No need for routine Metronidazole Avoid aminoglycosides (Level 3) www.east.orgwww.east.org Practice guidelines 2002 Sganga, Journal of Hospital Infection 2001

12. Vascular injuries Level 2 evidence Single dose of 1 st generation cephalosporin. 24 hours if synthetic graft used Single dose in endovascular procedures DSTC Manual: Ed. K D Boffard

13. The Trauma Patient in ICU No empiric therapy without “Septic Screen” Broad spectrum cover empirically only in unstable patients (Level 3) Source-directed therapy in stable patients (Level 3) De-escalate to culture-directed therapy (Level 3) Avoid the 3 rd Generation Cephalosporins www.surgicalcriticalcare.net