Antibiotic prophylaxis in injury: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document

• Published in: Trauma surgery & acute care open Vol. 9; no. 1; p. e001304
• Main Authors: Appelbaum, Rachel D, Farrell, Michael S, Gelbard, Rondi B, Hoth, J Jason, Jawa, Randeep S, Kirsch, Jordan M, Mandell, Samuel, Nohra, Eden A, Rinderknecht, Tanya, Rowell, Susan, Cuschieri, Joseph, Stein, Deborah M
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd 03.06.2024; BMJ Publishing Group LTD; BMJ Publishing Group
• Subjects: antibiotic prophylaxis; Antibiotics; Bacteria; Committees; Critical care; Debridement; Disease prevention; Dogs; Fractures; Guidelines/Algorithms; Infections; Injuries; Multiple Trauma; Nervous system; Patients; Penicillin; Saline water; Sinuses; Surgery; Trauma; Working groups; antibiotic prophylaxis; Multiple Trauma
• ISSN: 2397-5776
• DOI: 10.1136/tsaco-2023-001304

Table 1 Contamination considerations Type of contamination Antibiotic recommendations Additional considerations Water contamination Short course, 3–5 days Salt water Doxycycline and ceftazidime Fluoroquinolone Freshwater Ciprofloxacin Levofloxacin Third or fourth-generation cephalosporin Vibrio Aeromonas Pseudomonas Soil contamination Short course, 3–5 days High-dose penicillin Clostridium sp Farm-related injuries Mammalian bites (human, dog, or cat) Short course, 3–5 days Amoxicillin-clavulanate Clindamycin plus trimethoprim-sulfamethoxazole for penicillin-allergic patients Table 2 Summary of antibiotic recommendations Injury Antibiotic recommendations Additional considerations Face and scalp Open or contaminated facial fractures Prophylactic antibiotics 24 h or less Cefazolin—coverage against GP bacteria Ceftriaxone—broader GN coverage and CNS penetration Ampicillin/sulbactam—broader GN and anaerobic coverage Clindamycin—for penicillin-allergic patients Frontal sinus fracture that involves the posterior table Contaminated fractures Open mandible fractures Closed or non-contaminated operative facial fractures Preoperative antibiotics Cefazolin—coverage against GP bacteria Ceftriaxone—broader GN coverage and CNS penetration Ampicillin/sulbactam—broader GN and anaerobic coverage Clindamycin—for penicillin-allergic patients No postoperative antibiotics Fractures of the upper one-third of the face Frontal sinus fractures that do not involve the posterior table Fractures of the middle one-third of the face (LeFort, zygomaticomaxillary complex, orbital, maxillary sinus, nasal bone) Fractures of the lower one-third of the face (non-dentate segments of mandible) Non-operative facial fractures No prophylactic antibiotics Orbital fractures Upper face fractures Mid-face fractures Mandibular fractures Facial and scalp lacerations Prophylactic antibiotics 24 h or less if complex or high-risk patient Amoxicillin-clavulanate Clindamycin—for penicillin-allergic patients Communication to oral cavity High infection risk: significant tissue destruction, large dead space, extensive contamination, underlying medical problems that place a patient at high risk (diabetes, immunosuppression, steroids, extremes of age, obesity, etc) Nasal packing No prophylactic antibiotics Central nervous system Pneumocephalus No prophylactic antibiotics Associated with open skull fracture and communication to the sinuses CSF leaks No prophylactic antibiotics Associated with basilar skull fractures Penetrating brain injury Short course of prophylactic antibiotics, <3 days Cefazolin Clindamycin - for penicillin-allergic patients Visible contamination—add metronidazole Penetrating spine injury Short course of prophylactic antibiotics, no more than 48 h First and second-generation cephalosporins Ampicillin-sulbactam Piperacillin-tazobactam Clindamycin with second-generation cephalosporin Gastrointestinal involvement, specifically transcolonic Extremity Closed extremity fractures No prophylactic antibiotics if non-operative management Preoperative antibiotics within 1 h of incision First-generation cephalosporin Clindamycin—for penicillin-allergic patients Open extremity fractures Prophylactic antibiotics 24 h or less Types I and II should be treated with GP coverage First-generation cephalosporin Clindamycin - for penicillin allergic patients Type III should be treated with GP and GN coverage First-generation cephalosporin and aminoglycoside Piperacillin/tazobactam Ceftriaxone Antibiotics should be initiated within 1 h of injury and continued for 24 h Washout and debridement should take place within 24 h of injury Soft tissue injury Soft tissue Lacerations/stab wounds Prophylactic antibiotics 24 h or less if complex or high-risk patient First-generation cephalosporin Clindamycin—for penicillin-allergic patients High-risk infection Specific wound-related concerns (presence of significant contamination, crush injury, or specific at-risk anatomic sites) Underlying patient factors that would increase the risk or worsen the outcome of infection GSW Prophylactic antibiotics 24 h or less if complex or high-risk patient First-generation cephalosporin Clindamycin—for penicillin-allergic patients Surgical debridement of devitalized tissue if needed Consideration of low-energy vs. high-energy mechanism Burn injury No prophylactic antibiotics Providers should take into account their institutional antibiogram when choosing antibiotics for prophylaxis and/or treatment. Iterative selection of studies was not performed as in a systematic review, and the methodology of the literature search was at the discretion of the authors. Freshwater wounds should be managed with ciprofloxacin, levofloxacin, or a third-generation or fourth-generation cephalosporin.1 Potential clostridial contamination, such as farm-related injuries, requires high-dose penicillin irrespective of the fracture type.2 A full review of the treatment of bite injuries is beyond the scope of this document, but wounds caused by human, cat, and dog bites (the most common bite wounds encountered) are often treated with antibiotics due to the high load of more variable pathogens found in the oral cavity and the wound mechanism, with punctures that make both natural movement of the bacteria and adequate irrigation difficult.3 A course of 3–5 days of amoxicillin-clavulanate is a suggested regimen, with clindamycin plus trimethoprim-sulfamethoxazole two times per day as an alternative for patients with a penicillin allergy.4 5 While there is increasing question in the literature about the benefit of treating bite injuries with empiric antibiotics, there seems to be general consensus that injuries in high-risk locations (specifically hands, and over cartilage) and in high-risk patients should be treated.4–6 Rabies treatment should also be considered and addressed with any mammalian bite wounds (table 1). [...]there is tremendous variability in practice patterns among treating surgeons, and many providers continue antibiotic prophylaxis longer than proposed, which leads to overuse of antibiotics in this patient population.7 8 The Surgical Infection Society (SIS) recently published a guideline for prophylactic antibiotic use in patients with traumatic facial fractures.9 The authors of the SIS guidelines defined prophylactic antibiotics as antibiotics administered for more than 24 hours.