Presumptive Antibiotics in Tube Thoracostomy for Traumatic Hemopneumothorax: A Prospective, Multicenter American Association for the Surgery of Trauma
Forrest O. Moore, MD, FACS Trauma, Critical Care & Acute Care Surgery Banner Healthcare System Phoenix, AZ
Address correspondence to: Forrest O. Moore, MD, FACS Trauma, Critical Care & Acute Care Surgery Banner Healthcare System Phoenix, AZ Moore677@aol.com Phone: (480) 284-1703
This statement was based on English studies published between 1977 and 2011 and vary in quality and in outcome. Because the practice of administering presumptive antibiotics to decrease the incidence of infectious complications in tube thoracostomy is controversial. Gonzalez et al. They concluded that patients who received antibiotics had significant reductions in infectious complications and suggested that patients who undergo TT for chest trauma would benefit from prophylactic antibiotics. and presumptive antibiotics have been advocated by some to decrease the incidence of these infections. published the results of their randomized. prospective study of the role of prophylactic antibiotics for TT in patients with isolated chest trauma. the Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Work Group published guidelines in 1998 and updated those guidelines in 2012 (publication pending). The 2012 work group made the following recommendations:
There is insufficient published evidence to support any recommendation either for or against the use of presumptive antibiotics to reduce the incidence of empyema and pneumonia in tube thoracostomy for traumatic hemopneumothorax. The two most recent. The complications of empyema and pneumonia were not evaluated separately in their
. controlled studies showed no reduction in either empyema or pneumonia.INTRODUCTION Post-traumatic empyema and pneumonia are potential complications of tube thoracostomy (TT).
prospective study published by Maxwell et al. In surgical cases. The practice of antibiotic prophylaxis in TT after chest trauma remains controversial for numerous reasons. The study was divided into three groups. A randomized. and prior to TT in traumatic hemopneumothorax. then placebo until TT was removed. Two of these studies also reported presumptive antibiotics in TT for
. Group B had an incidence of empyema in 2. Group A (77 patients) received cefazolin until TT was removed. should be considered presumptive therapy when antibiotics are given post-injury. as contamination of the pleural space has already occurred at the time of injury.9% (6/76). Group A did not develop any empyemas. In addition. The timing of administration of antibiotics may explain why antibiotics given post-injury. adequate antibiotic tissue levels are reached when administered prior to incision. prior to antibiotic administration. group B (76 patients) received cefazolin for 24 hours. and group C (71 patients) received placebo for the entire duration of TT. this 3-year study was terminated because of poor patient accrual that resulted in less than 20% of the predicted number of patients needed (approximately 1200 needed).6% (2/76) and pneumonia in 7. may not be as effective as those given truly prophylactically. and therefore.5% (5/77) was noted for pneumonia.6% (4/71) and pneumonia 4. Drug concentrations in the tissues are not achieved before contamination. Group C had an incidence of empyema in 5. several studies did not control for mechanism of injury (penetrating versus blunt) or did not specify the mechanism of injury. However.article. however an incidence of 6. in 2004 concluded that presumptive antibiotics did not reduce the incidence of either empyema or pneumonia. The term “prophylactic” may not be accurate after trauma. thereby reducing the incidence of surgical site infection.2% (3/71).
compared to the group of 68 patients who received placebo (albumin). averaging 4. published the results of their randomized. prospective trial using cefazolin as the presumptive antibiotic in the group of 71 patients who received antibiotics. Only three studies from the 1998 guidelines used a first-generation cephalosporin. however. including MRSA and Pseudomonas aeruginosa. The study concluded that presumptive antibiotics
. The remaining studies used suboptimal Staphylococcus aureus coverage or used suboptimal dosing. antibiotics were given during the entire length of TT placement. controlled study compared two antibiotic regimens and one placebo regimen. However.spontaneous pneumothoraces. they concluded that infectious complications were significantly reduced. antibiotic prophylaxis is typically limited to 24 hours duration and is usually a first-generation cephalosporin for the penicillin-allergic patient. In the era of emerging resistant organisms.9 days. As previously noted. few studies adhered to these definitions. when empyema and pneumonia were analyzed separately. the reduction was not significantly different. First-generation cephalosporins provide adequate coverage for Staphylococcus aureus. This heterogeneity confounds which patient population may actually benefit from presumptive antibiotics. a non-traumatic patient population. the most common infectious organism in post-traumatic empyema. Of concern was the increased incidence of resistant organisms in patients receiving antibiotics. Only one study limited antibiotic prophylaxis to 24 hours. Several studies used non-standard or no standard definition for both empyema and pneumonia. while the Centers for Disease Control and Prevention have definitions for the diagnosis of empyema and pneumonia. Gonzalez et al. Furthermore. Maxwell’s randomized.
nor the combination of several studies. the routine practice of presumptive antibiotics in TT for chest trauma will remain controversial.were of minimal benefit considering the need to treat large numbers of patients to prevent a single empyema. has been powered to adequately address the practice of administering presumptive antibiotics in TT for traumatic hemopneumothorax to decrease the incidence of empyema or pneumonia. This conclusion combined with the emergence of resistant organisms found the use of presumptive antibiotics for TT in chest trauma to be unwise. Until a large and likely multicenter trial can be performed.
SUMMARY No single published study.
. Patients are excluded if they are receiving antibiotics at the time of presentation (pre-injury prescription).
TYPE AND DURATION OF STUDY Two year.e.
HYPOTHESIS Presumptive antibiotics in TT for traumatic hemopneumothorax do not reduce the incidence of empyema or pneumonia. multicenter study. these patients may ultimately be included.STUDY OBJECTIVES To perform an adequately powered multicenter study to determine if presumptive antibiotics in TT for traumatic hemopneumothorax reduce the incidence of empyema or pneumonia. however. Patients who develop empyema or pneumonia (and require antibiotics) are clearly included. with blunt or penetrating trauma. Initially will exclude patients if they receive antibiotics for other reasons (i. including pediatric and pregnant patients. observational. dependent upon patient accrual.
INCLUSION/EXCLUSION CRITERIA All patients. open fractures and procedures/surgeries such as exploratory laparotomy or rib plating). who undergo TT for traumatic hemopneumothorax. prospective.
incidence of Clostridium difficile colitis. These variables will be used to create a propensity score of receiving a single dose of antibiotics compared to no antibiotics. injury characteristics. Pneumonia is defined as a new or evolving infiltrate on chest radiograph with any of the following: 1) purulent sputum 2) positive blood culture or 3) positive sputum culture or protected brush specimen >103 or bronchoalveolar lavage >104 or 105 (institutionspecific) CFUs. ISS. GCS.
ANALYSIS Univariate analysis of patient demographics. Infectious complications (empyema and pneumonia) associated with TT will be evaluated separately and compared among each group.DATA COLLECTION/OUTCOMES Groups will be divided into three: 1) no antibiotics 2) one dose of antibiotics pre-/periprocedural (within one hour of placement) 3) antibiotics for 24 hours. Empyema is defined as having a positive pleural culture or pus within the pleural space. and trauma center characteristics with respect to the antibiotic regimen employed will be performed to identify potential confounders. Secondary
. mechanism of injury. AIS. including the method of diagnosis. days on mechanical ventilation. ICU length of stay. and type and duration of antibiotic use. and demographics and outcomes compared including: age. A 1:1 matching method will be employed based upon patient’s propensity score and those treated with antibiotics will be compared to those without to determine if the relative risk of the outcomes (empyema and pneumonia) are affected by the antibiotic treatment. hospital length of stay.
binary outcomes will be assessed in a similar manner while continuous outcomes will be assessed by t-test.
Alexander RH. Laneve L. Tischler CD.
5. Vinsant GO. Griffin CC. Hooper CA. Prophylactic antibiotics and closed tube thoracostomy. J Trauma.
LoCurto JJ Jr. Fewel JG. A prospective double-blind study.REFERENCES 1. Cefamandole for prophylaxis against infection in closed tube thoracostomy. Reiner DS.
2.160:259-263. 1985. Trinkle JK.25:639-643.
Brunner RG.21:975-977.26:1067-1072. Symbas PN. Montano J.
. Prophylactic antibiotics and no antibiotics compared in penetrating chest trauma.74:528-536.
Mandal AK. 1985. J Thorac Cardiovasc Surg. Rocko JM. Tube thoracostomy and trauma--antibiotics or not? J Trauma. Lazaro EJ.30:1148-1154. 1977. Thadepalli H. Arom KV.
Stone HH. Blackwood JM. Fallon WF Jr. Webb GE. Tucker WY. Swan KG. 1986. 1990. Richardson JD. The role of antibiotic therapy in the prevention of empyema in patients with an isolated chest injury (ISS 9-10): a prospective study.
4. 1981. Surg Gynecol Obstet. J Trauma. J Trauma.
3. Grover FL. Prophylactic antibiotics in the treatment of penetrating chest wounds.
1997. Love EJ.73:348-351.132:647-650. Owings JT. Flint LM. Risk factor analysis.33:110-117.
11. Carlin PE. Battistella FD. Chest. Muzik AC. Breckon V. Br J Surg.
. Kakoyiannis S. Antibiotic prophylaxis in penetrating injuries of the chest.7.
Fallon WF Jr.
9. Green JD. Timberlake G.
10. McSwain NE. Posttraumatic empyema.
Cant PJ. 1991. Ann R Coll Surg Engl. 1994. Meta-analysis of antibiotics in tube thoracostomy. Barrett LO. Preventive antibiotic usage in traumatic thoracic injuries requiring closed tube thoracostomy.
Demetriades D. Charalambides D.80:464-466. Smith JW. Prophylactic antibiotics for the prevention of infectious complications including empyema following tube thoracostomy for trauma: Results of metaanalysis. Su T.
Evans JT. Lakhoo M.106:1493-1498.
Aguilar MM. Wears RL. 1993.61:215-219. Breckon C.
Nichols RL. Smyth S. Am Surg. Antibiotic prophylaxis is indicated for chest stab wounds requiring closed tube thoracostomy. Psaras G. 1992. Smart DO.
8. 1995. J Trauma. Arch Surg.
Sanabria A. Chettipalli U. Pasquale MD.
16. Prophylactic antibiotics in chest trauma: a meta-analysis of high-quality studies. Echeverry G.
. 2006. Mandal AK. Barie PS. Gomez G. Nagy K. Mullins CD. Campbell DJ. J Trauma.57-742-748. Use of presumptive antibiotics following tube thoracostomy for traumatic hemopneumothorax in the prevention of empyema and pneumonia – a multi-center trial. Practice management guidelines for prophylactic antibiotic use in tube thoracostomy for traumatic hemopneumothorax: The EAST Practice Management Guidelines Work Group.43:764771. Fabian TC.
Luchette FA. Am Surg. Oswanski MF. J Trauma. 2000. 1997.
Gonzalez RP. Spain DA. Kerwin AJ. Luchette FA.
15. Tisherman S. 2004. Posttraumatic empyema thoracis: a 24-year experience at a major trauma center. Palumbo F. Role of prophylactic antibiotics for tube thoracostomy in chest trauma. 1998.13. discussion 620-621. Davis KA.
17. Croce MA.64:617-620. Thadepalli H.
Mandal AK.48:753-757. J Trauma. Valdivieso E. Holevar MR. World J Surg.
Debeij J. The risk factors and management of posttraumatic empyema in trauma patients.39:44-49. van den Broeck PJ.
20.7744. Br J Surg. Durkan A. doi10. Esme H. de Jong MB.18.
Bosman A. [Epub ahead of print]
. Schipper IB.
Eren S. 2008. 2011 Dec 2. Systematic review and meta-analysis of antibiotic prophylaxis to prevent infections from chest drains in blunt and penetrating thoracic injuries. Injury.1002/bjs. Sehitogullari A.