Hong Kong Journal of Emergency Medicine

The use of prophylactic antibiotics in trauma

ECP Yuen

Infection is an important cause of morbidity and mortality in trauma. In this literature review, the
microbiological profiles and the use of prophylactic antibiotics in various traumatic situations are discussed.
This review includes abdominal and chest trauma, craniocerebral trauma, long bone fractures, open globe
injuries and animal bite injuries. (Hong Kong j.emerg.med. 2004;11:161-168)

Keywords: Antibiotic prophylaxis, drug therapy, wound infection, wounds and injuries

Introduction in the use of prophylactic antibiotics in trauma

Trauma mortality follows a trimodal pattern.1 The first
peak of death occurs within minutes of the event.
These are due to injuries that are non-salvageable even
with the most advanced medical resources immediately
available. Injury prevention is the main strategy in
combating this phase of mortality. The second peak,
which may account for about 30% of deaths, usually
occurs in the first few hours after injury. Death is due
to hypoxia or hypovolaemic shock. The majority of
this group is readily salvageable from prompt and
proper trauma care. The third peak, which accounts
for up to 20% of trauma deaths, occurs late after the
injury. It is usually the result of sepsis, multi-system
organ failure, or other complications. The purpose of
this literature review is to revisit the current strategy
Correspondence to:
Yuen Cheuk Pun, Eddie, FRCSEd, FHKAM(Emergency Medicine), MSc(Birm)
Queen Elizabeth Hospital, Accident and Emergency Department,
30 Gascoigne Road, Kowloon, Hong Kong
Email: fhkcem@yahoo.com.hk
patients. The review is divided into four parts:
(1) abdominal trauma; (2) thoracic trauma; (3) head
trauma; and (4) miscellaneous injuries, including long
bone fractures, open globe injuries and animal bites.
Abdominal trauma
The use of prophylactic antibiotics in abdominal
trauma varies among institutions. The outcome
depends not only on the choice of antibiotics, but also
the timing of administration and the duration of
usage. Other important factors include the age of the
patient, site of injury and choice of treatment, i.e.
conservative versus operative.
Site of trauma
The presence of hollow organ injury is one of the most
important factors in the development of infection.
Most penetrating abdominal trauma with hollow
organ injury involves infection from contamination
162
by gastrointestinal flora. It has been shown that even
without hollow viscus injury, up to half of penetrating
abdominal trauma may develop infection.2,3
Colonic injury has the highest incidence of intra-
abdominal infection. High concentrations of colonic
bacteria like Enterobacteriaceae and anaerobic Gram-
negative rods are released into the abdominal cavity.
It was estimated that colonic injury carried an
infection rate of up to 39%.2,4,5 Multivariate analyses
by various authors showed that colonic injury was an
independent predictor of infection.3,5,6
Trauma to the stomach in theory carries a lesser risk
of infection, due to the acidity of the gastric secretions.
But the gastric pH is frequently raised after ingestion
of food and drink and oral bacteria can survive in such
environment. Croce et al found that the infection rate
between patients with gastric and colonic injuries were
not significantly different in 812 cases.7 The situation
was similar for patients with hepatic injury and
intestinal injury, when 39% of them developed intra-
abdominal infection. 2
Antibiotic usage
Research on prophylactic antibiotic use in abdominal
injury dated back to 1972, when Fullen et al studied
the infection rate in abdominal trauma with different
timing of antibiotic administration. 8 Penicillin and
doxycycline were administrated preoperatively,
intraoperatively, or postoperatively. Infection rate was
lowest in the preoperative group, 7% compared with
33% in the intraoperative group and 30% in the
postoperative group. It was concluded that antibiotic
should be given as soon as possible after abdominal
injury occurred.
The choice of antibiotics depends on the group of
bacteria involved. In a study by Nichols et al,5 35%
of the isolates were aerobic Gram-negative bacteria,
with Enterobacter species being the most dominant,
followed by Pseudomonas and Escherichia coli. Gram-
positive aerobes accounted for 39% of isolates, with
Enterococcus species as the dominant group, while
17% of the isolates were Gram-negative anaerobes and
only 5% were Gram-positive anaerobes.
Hong Kong j. emerg. med. „ Vol. 11(3) „ Jul 2004
It is therefore logical to provide antibiotic coverage
for both aerobic and anaerobic bacteria. A review by
Dellinger et al 9 showed that anaerobic coverage
resulted in lower infection rates. A meta-analysis of
17 trials investigated on the use of β-lactam therapy
against combination aminoglycoside/anaerobe-specific
therapy, and no statistically significant difference was
found.10
The optimal duration and dosage for prophylactic
antibiotics have also been investigated. Dellinger et
al9 found no advantage in administrating antibiotics
for more than 24 hours, after reviewing 18 trials.
The pharmacokinetics of drugs differs in trauma
patients due to the presence of hypovolaemic shock,
metabolic acidosis, cellular hypoxia or anaemia. Most
of the available data on pharmacokinetics of antibiotics
are derived from healthy individuals and therefore
cannot be applied in trauma patients. The volumes of
distribution and rates of excretion are higher for
aminoglycosides in trauma patients.11 The dosing and
timing of administration have to be adjusted in order
to prevent under-dosing.
Recent evidences
The Eastern Association for the Surgery of Trauma
has published a new guideline on prophylactic
antibiotics in penetrating abdominal trauma.12 They
evaluated 39 clinical studies between 1976 and 1996.
These studies were classified according to the
methodology established by the Agency for Health
Care Policy and Research (AHCPR) of the United
States Department of Health and Human Services.
Class I studies include prospective, randomised and
double-blinded trials. Class II studies refer to
prospective, randomised, and non-blinded trials. Class
III studies refer to retrospective series or meta-analysis.
They concluded that there were sufficient Class I and
II data to support the use of single preoperative dose
of prophylactic antibiotic with broad-spectrum
aerobic and anaerobic coverage in patients with
penetrating abdominal trauma (Level 1 evidence).
Sufficient Class I and II data were available to
recommend the continuous usage of antibiotic for
24 hours only (Level 2 evidence). Owing to the
Yuen/Prophylactic antibiotics in trauma
presence of shock and vasoconstriction, tissue
penetration of antibiotics is reduced. The dose of
antibiotics may be increased and repeated after every
ten units of blood-product transfusion until
haemodynamic stability is achieved. Aminoglycosides,
with optimal activity in alkaline environment, should
not be the first choice due to the presence of acidosis
in the trauma patient. It was also concluded that
single-agent therapy with aerobic and anaerobic
coverage may be a more cost-effective choice as
compared with traditional combination therapy
regimen. The Interhospital Multidisciplinar y
Programme on Antimicrobial Chemotherapy
(IMPACT) of Hong Kong suggested the use of
cefoxitin 2 g q6h i.v. or cefuroxime 1.5 g q8h i.v. and
metronidazole (Flagyl) 0.5 g q8h i.v.13 for prophylaxis
in ruptured viscus.
Thoracic trauma
American data suggested that up to 25% of trauma
death were due to thoracic injury, and 85% of thoracic
trauma cases eventually required tube thoracostomy.
After the initial phase of stabilisation, empyema
remains the major cause of morbidity. 14 The
presumptive role of prophylactic antibiotics in this
situation is to reduce the risk of empyema and bacterial
pneumonia.
Ventilation mismatch, haemothoraces and hypoxaemia
are the main problems immediately after blunt and
penetrating thoracic injuries. After initial stabilisation
and treatment, empyema becomes the main cause of
morbidity, especially after the placement of chest
drain. Empyema may be due to direct contamination
from the injury site, or secondary infection from intra-
abdominal injuries associated with diaphragmatic
disruption. It can also be iatrogenic relating to the
placement of chest drain. Secondary infection from
undrained haemothoraces has also been recognised.
Staphylococcus aureus and Streptococcus species are
the main culprits in empyema formation, especially
with chest drain insertion, whereas Gram-negative or
mixed bacterial pathogens are responsible for the
163
pneumonia process.15,16 Prophylactic antibiotics could
reduce the need for thoracotomy in those with
penetrating thoracic injuries requiring chest drain
placement.17 The same double-blind study also found
that antibiotics could reduce the incidence of
empyema. 17 Cant et al concluded there were less
positive sputum culture and shorter length of hospital
stay in patients receiving antibiotics.16 However, two
other randomised, open-label studies did not show any
decrease in infection rate with the use of antibiotics.18,19
Various antibiotics have been tried and there was no
solid data to select any particular group. The duration
of antibiotic use for prophylaxis varies from once only
to after the removal of chest drain. Demetriades et al
could not demonstrate any difference in the infection
rate between the group that received single dose of
intravenous ampicillin and the group that continued
with oral treatment.19 However, with 24-hour duration
of cefazolin, Cant et al reported no empyema in the
treatment group, against 5% infection rate in the
placebo group. 16 The role, choice and duration of
prophylactic antibiotic in thoracic injury are therefore
subject to much debate.
Recently, The Eastern Association for the Surgery of
Trauma has published a new guideline on prophylactic
antibiotics in penetrating thoracic injury. They could
find level III evidence only. Prophylactic antibiotics
c a n b e re c o m m e n d e d i n p a t i e n t s a f t e r t u b e
thoracostomy and first generation cephalosporins
should be used, with duration not longer than 24
hours. The rate of pneumonia may be reduced, but
not the rate of empyema. 20 The IMPACT suggested
the use of intravenous co-amoxiclav (Augmentin) or
sultamicillin (Unasyn) for prophylaxis in closed tube
thoracostomy for chest trauma.13
Head trauma
The topic comprises of two entities, penetrating
craniocerebral injuries and traumatic cerebrospinal
fluid (CSF) leakage. Penetrating craniocerebral injury
results from penetrating injury through the skull. It
can be caused by bullets or other sharp objects. It can
also be classified as military or civilian injuries. Bullet
164
injuries can be further subdivided into high velocity
and low velocity. High velocity bullet used to be
confined to the military setting, but the difference is
less clear-cut nowadays. Injuries by high velocity bullet
are mainly caused by secondary shock wave and
cavitation as the bullet travels through the brain tissue,
causing devastating tissue destruction even at sites
distant from the bullet path. The injuries are far greater
than those caused by low velocity bullet. Low velocity
bullet mainly causes local crushing effect along its path
and may bring along debris, skin, hair, bone fragments
and bacteria into the path, but to a lesser extent than
high velocity bullet.
Microbiological data are mainly derived from the
battlefield. Aarabi studied 125 patients wounded in
the Iran-Iraq war in 1983-84, and found that wound
cultures yielded mainly coagulase negative
Staphylococci (CoNS), brain tracks grew
Staphylococcus aureus, CoNS, and Acinetobacter
species and the bone fragments grew Staphylococcus
aureus and CoNS. 21 Data from the Vietnam War
suggested that Staphylococcus epidermidis was the
main isolate from bone fragments. 22 Rish et al found
that infection could occur in up to 17% of survivors
in modern warfare after penetrating craniocerebral
injury and carried a mortality rate of up to 50%.
Infection was associated with scalp dehiscence and was
more likely in the presence of retained fragments.
Gr a m - p o s i t i ve b a c t e r i a , u s u a l l y C o N S , wer e
commonly found in scalp wounds and removed bone
fragments, whereas most deep infections were due to
either Staphylococcus aureus or Gram-negative
facultative aerobic bacteria. 23
Currently, there is no double-blind randomised
clinical trial on the use of antibiotics in penetrating
craniocerebral injury. Most recommendations are
based on expert opinions or routine practice only.
Various antibiotics have been suggested, like
ceftriaxone, gentamicin 21 and metronidazole. 24 In a
survey by Kaufman et al on the choice of antibiotics
by neurosurgeons in the United States, 59% of
the surgeons used cephalosporin, 24% used
chloramphenicol, 16% used penicillin, 12% used
aminoglycoside and 6% used vancomycin. There was
Hong Kong j. emerg. med. „ Vol. 11(3) „ Jul 2004
no consensus on the duration of prophylaxis, which
ranged from 4 to 10 days in 64% of cases. 25
Basing on the limited research data, expert opinions
and routine practice, the Working Party of the British
Society for Antimicrobial Chemotherapy has suggested
a five day course of broad spectrum antibiotics. 26
Intravenous co-amoxiclav 1.2 g 8-hourly, or
intravenous cefuroxime 1.5 g stat, then 750 mg 8-
hourly, with intravenous metronidazole 500 mg 8-
hourly (or 1 g 12-hourly per rectum or 400 mg 8-
hourly by mouth) should be given promptly for five
days. In children, intravenous co-amoxiclav 20 mg/
kg 6-hourly, or intravenous cefuroxime 20 mg/kg
6-hourly with metronidazole 7.5 mg/kg 8-hourly
orally, intravenously, or per rectum, should be given for
five days and as soon as possible after injury occurs.26
Human antitetanus immunoglobulin (250-500 IU)
intramuscularly should also be given to all patients
regardless of their immune status.27
Traumatic cerebrospinal fluid leakage after head injury
carries a risk of meningitis. The condition can be
difficult to diagnose as the symptoms and signs may
be subtle. Choi et al studied 293 patients with head
injury and found that the risk of traumatic
cerebrospinal fluid leakage increased significantly with
CSF rhinorrhoea, frontal and ethmoid fractures.
Ethmoid fracture is however difficult to pick up on
plain X-ray. 28 Friedman et al conducted a review of
51 head injury patients from 1984 to 1988 and
showed that only 10% of patients developed
meningitis with antibiotic prophylaxis, as compared
to 21% in the group without antibiotics.29 The study
was only retrospective and the level of evidence was
not strong. However, with respect to the severity of
the complications, antibiotics are usually given.
Miscellaneous injuries
Long bone fractures
Gillespie et al analysed 22 previous studies on the
effect of antibiotic prophylaxis in reducing the rate of
wound infection and other hospital acquired infection
in patients with surgical fixation of long bone
Yuen/Prophylactic antibiotics in trauma
fractures. They found that single dose antibiotic
prophylaxis could reduce the rate of deep wound
infection with a relative risk of 0.40 (95% CI 0.24-
0.67). Superficial wound infection, urinary tract
infection and respiratory tract infection were also
reduced. Multiple dose antibiotics also reduced the
rate of deep wound infection, but not urinary or
respiratory infection. They concluded that antibiotic
prophylaxis should be given to patients undergoing
surgical fixation of long bone fractures.30
Open globe injuries
Infection after open globe injury can be devastating and
may result in irreversible visual loss. Antibiotic is therefore
given to prevent the development of endophthalmitis.31
Narang et al studied the efficacy of prophylactic
intravitreal antibiotics in reducing the rate of
endophthalmitis after open globe injuries.32 This was a
prospective, randomised control trial involving 70
consecutive patients with open globe injuries. Group A
patients were given intravitreal injection of vancomycin
(1 mg) and ceftazidime (2.25 mg), with intravenous
ciprofloxacin at the end of primary repair. Group B
patients were given intravenous ciprofloxacin only. The
infection rate was 6.25% in group A, as compared with
18.42% in group B. They therefore recommended the
use of intravitreal broad-spectrum antibiotic injection,
together with intravenous antibiotic, to reduce the rate
of endophthalmitis.
Animal bites
Dog bites account for up to 90% of animal bites in
the United States, with boys being the predominant
victims. 33 Dog bites usually involve the extremities,
but head and neck injuries are more common in small
children, probably due to their small size and height.
Infections from dog bites wounds are usually
polymicrobial and originated from the dog's oral flora.
It has been estimated that aerobic bacteria are present
in almost all wounds, whereas anaerobic bacteria are
present in only 40% of cases. 34 Commonly isolated
aerobic bacteria include Staphylococcus aureus,
Streptococcus species, Capnocytophaga canimorsus
(DF-2), Pseudomonas, Klebsiella and Enterobacteriaceae.
Anaerobic bacteria include Actinomyces species,
Bacteroides and Fusobacterium. 35,36 DF-2 is a
165
fastidious Gram-negative rod and is the normal oral
flora in dogs and cats. Infection with DF-2 is
characterised by hypotension, disseminated
intravascular coagulation and renal failure. Purpura
and petechiae are frequently seen. Cutaneous gangrene
at the bite wound is a hallmark of the disease. Another
severe complication is Waterhouse-Friderichsen
syndrome. The mortality is about 30% and up to 70%
in the immunocompromised.37
Cat bites account for up to 18% of animal bites in
the United States. The majority of the cases involve
the upper limbs, especially the hands. The wounds
are typically punctured in nature due to the sharp and
slender teeth of the cat. Up to 80% of the wounds are
infected as a result of this puncture characteristic.38
Pasteurella multocida is found in 53-80% of infected
cat bite wounds.38 Infection is rapid in onset, within
a few hours after the bite. It causes an intense
inflammatory response, with pain and swelling as
prominent features. Besides local cellulitis and
lymphangitis, it can also cause septic arthritis,
endocarditis and osteomyelitis at sites distant from
the bite. 39,40 The presence of prosthetic joints,
immunosuppression and alcoholism are risk factors
for severe diseases. 41
Cummings et al did a meta-analysis on randomised
trials involving prophylactic antibiotics for dog and
cat bites. Co-amoxiclav as prophylactic antibiotic was
shown to result in statistically significant reduction
in the rate of infection (relative risk 0.56, 95% CI 0.38
-0.82). 42 The Emergency Medicine Animal Bite
Infection Study Group also supported the use of
antibiotics, such as co-amoxiclav as the drug of choice
for prophylaxis or for treatment of established infection.35
Trunk, head and neck lacerations from dog bite should
be sutured.43 Lacerations of hands and feet should not
be sutured immediately. Lacerations over proximal
extremities should be cleaned, irrigated and sutured.
Large and extensive lacerations should be explored and
sutured in the operating room.44 Bites to hands and
high-risk individuals should be covered with co-
amoxiclav for 3-5 days.43
166
Wounds that are infected at presentation warrant
antibiotics. The choice of antibiotics depends on the
speed of infection. Infection within 24 hours of dog
and cat bites is usually due to Pasteurella multocida
and should be treated with ciprofloxacin or septrin.
Pencillin can be used in children. Infection beyond
24 hours of the bite suggests Staphylococcus or
Streptococcus species and penicillinase-resistant
penicillin or cephalosporin should be used.45
In suspected DF-2 infection, penicillin G is the drug
of choice. First generation cephalosporin, tetracycline
and er ythromycin can also be used. DF-2
demonstrates variable susceptibility to septrin and is
resistant to aminoglycosides. Established DF-2 infection
should be treated with intravenous co-amoxiclav, or
second/third generation cephalosporins.46,47
In cat bite, puncture wounds and wounds less than
2 cm in length should not be closed primarily as the
wounds could not be cleaned adequately. Larger
lacerations can be sutured. 43 The patient should be
covered with antibiotics. Co-amoxiclav, cefuroxime
or doxcycline should be given for 3 to 5 days.45
Conclusion
In this revie w, current recommendations for
prophylactic antibiotic use in various trauma settings
are discussed. Antibiotics should be used for up to
24 hours in abdominal trauma to reduce infection
(Level 2). Single preoperative dose of prophylactic
antibiotic with broad-spectrum aerobic and anaerobic
coverage should be administrated to patients with
penetrating abdominal trauma (Level 1).
No level 1 or 2 evidence is currently available for the
use of antibiotics in penetrating thoracic injuries.
Prophylactic antibiotics for less than 24 hours can be
used in patients after tube thoracostomy for thoracic
trauma and first generation cephalosporins may be the
drug of choice (Level 3).
In penetrating craniocerebral injuries, there is no
evidence to support the use of prophylactic antibiotics
Hong Kong j. emerg. med. „ Vol. 11(3) „ Jul 2004
but it is routinely given due to the severity of the
possible complications. Expert opinions suggest the
use of broad-spectrum antibiotics for prophylaxis.
Retrospective revie ws of head injur y patients
recommended the use of antibiotics in patients with
traumatic cerebrospinal fluid leakage to reduce the risk
of meningitis.
Current data also support the use of antibiotics in
long bone fracture fixation to reduce the rate of
deep wound infection and other hospital related
infections. The use of intravitreal and intravenous
antibiotics to reduce the rate of endophthalmitis after
open globe injuries is accepted. Various aspects of dog
and cat bite wound management have also been
discussed. Antibiotics should be given to all established
wound infections, all cat bite and dog bite wounds to
hands and high risk patients. The choice of antibiotics
after dog bite depends on the onset of established
wound infection.
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