13 Prophylactic antibiotics for penetrating injury: a review of practice at a major trauma centre, literature review and recommendations.

BACKGROUND: There is a lack of clarity regarding the use of prophylactic antibiotics for patients presenting with penetrating injuries. A structured literature review and review of penetrating injury records in an MTC was undertaken with a view to help guide clinical practice.

METHOD: Searches were conducted on Medline (1946-2017), Embase (1974-2017), and Cochrane (up to 2017) using key words pertaining to penetrating trauma, prophylactic antibiotics and infection. Cases of penetrating injury presenting to one MTC during 2015-2016 were extracted from the TARN database. Patient information (age, sex), injury details (ISS score, anatomical site, nature), antibiotic use in ED, and infectious outcomes were analysed.

RESULTS: A 2012 systematic review by Bosman et al . included 11 RCTs, totalling 1234 patients with blunt and penetrating chest injuries requiring tube thoracostomy. Those that were given prophylactic antibiotics were less likely to develop empyema (OR:0.32), pneumonia (OR:0.51) and wound infections (OR:0.41) compared to placebo.A 2013 Cochrane meta-analysis on penetrating abdominal trauma found no RCTs comparing infection outcomes for prophylactic antibiotics vs placebo. No further trials have since been done. EAST guidelines (2012) recommend a single dose of prophylactic antibiotics for penetrating abdominal trauma. No relevant trials were found for penetrating soft tissue injuries.70 penetrating injuries for 2015-2016 were recorded on TARN, 40 of which were transfers from other hospitals. Half of the total injuries were stabbings, with the rest being shootings, falls and crush injuries. 62.5% of patients were given prophylactic antibiotics in ED. 83% of the remaining patients received antibiotics for another indication.

CONCLUSIONS: Strong evidence exists for the use of prophylactic antibiotics for chest wounds requiring tube thoracostomy. The Cochrane review concluded that there is no evidence base for prophylactic antibiotic use for penetrating abdominal trauma, with EAST recommendations based on weaker evidence.Drawing conclusions about infectious outcomes from TARN data is difficult due to low total numbers, differences in record-keeping for secondary transfers and a high proportion of patients with another requirement for antibiotics.For penetrating thoracic injury requiring chest drain there is evidence of benefit for prophylactic antibiotics, in other patients with penetrating injury due to the current lack of evidence, clinical judgement based on the circumstances of penetrating injury is recommended.