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219126_NCS_Currents_March_2_eMag

NEUROCRITICAL CARE PHARMACY Argument for Conservative Use of Prophylactic Antibiotics in Penetrating Brain Injury By Andrea Sikora Newsome, PharmD and Emily Durr, PharmD Recent literature challenges the prolonged use of antimicrobial therapy in penetrating brain injury (PBI). Prophylactic antibi- otic therapy has been a generally accepted practice in the management of PBI to reduce the morbidity and mortality associated with infectious complications that can result from the cranial vault being entered by a foreign, non-sterile object. Andrea Sikora Here, we make an argument for the more Newsome, conservative use of prophylactic antimicro- PharmD bial regimens that will account for both the most likely pathogens and specifi c risk factors known to increase the risk of infection in PBI. PBI is often highly idiosyncratic, resulting in a lack of well-designed literature to guide duration and selection of antimicrobial therapy . In the pre-antibiotic era, when the use of perisurgical antimicrobial prophylaxis and topical antiseptics was rare, infectious complications of PBI in military personnel Emily Durr, were reported to be greater than 50%. PharmD Not surprisingly, when antimicrobial therapy was introduced, a substantial benefi t was observed. A more recent review reports the civilian PBI infection (4.03-fold increased risk, 95% CI, 1.30-12.43; p < 0.05), external rate around 1-5% and for injuries sustained in combat to have cerebrospinal fl uid drainage catheter use (4.09-fold increased slightly higher risk at approximately 4-11%. risk, 95% CI 1.57-10.67; p < 0.005), and local skin and soft tis- sue infection (5.10-fold increased risk, CI, 1.34-19.36; p < 0.05). Microbiologic studies of bone, metal, and wood fragments from However, antibiotic use beyond the 48-hour postoperative period penetrating injuries have found gram positive organisms to be the was not associated with fewer infections (p = 0.220). most likely cause of contamination. Clostridia species were more rarely encountered and were often associated with wood fragments. Based on available literature, we propose the following prophy- Identifi ed risk factors for infection include PBI associated with lactic antibiotic regimens. For high velocity PBI (i.e., gunshot cerebrospinal fl uid leak, air sinus wounds, and transventricular wound) – wherein the projectile has most likely been sterilized injuries. In addition, high and low velocity PBI should be differ- – coverage of common skin fl ora with fi rst-generation cephalo- entiated when selecting antimicrobial coverage as well as duration. sporins in the perioperative period (<48 hours) is most likely suffi cient. In the setting of low velocity PBI – where the penetrat- Expert opinion has recommended antimicrobial strategies ranging ing object is not sterile – broader coverage with a third generation from reducing complications from the most frequently observed cephalosporin and anaerobic coverage is reasonable. organisms in the acute setting to attempting complete sterilization In the setting of posterior wall injuries with frontal sinus fractures, of the wound area. While the former requires the use of a short gram positive, gram negative, and anaerobic coverage is warranted. course of targeted therapy, the latter necessitates up to a six-week Addition of vancomycin to an antibiotic regimen should be consid- course of broad spectrum antibiotics. ered in a patient-specifi c manner for resistant staphylococcus species PBI that involves facial fractures and/or frontal sinus injury poses but is not routinely necessary. Antibiotic use beyond the 48-hour an additional risk of infection. In 2010, Lauder and colleagues postoperative period may be reasonable in severe facial trauma with conducted an observational study of 233 patients with traumatic multiple fractures due to the increased infection rate observed. facial fractures to determine the effect of antibiotic prophylaxis on infection rate. They observed an overall infection rate of 9% and Length of this prolonged prophylactic regimen has not been well that increased infection was positively correlated with number of studied, but some recommendations exist to support fi ve to seven fractures (p < 0.0001) and open fracture wounds (p = 0.034). days postoperatively. Patient-specifi c consideration evaluating the risk factors for increased infection as well as the type of organisms Four different antibiotic prophylaxis regimens were evaluated: is essential for designing the most appropriate regimen. Group A received pre- (>2 hours before surgery) and perioperative Andrea Sikora Newsome, PharmD and Emily Durr, PharmD are members (≤2 hours before surgery), Group B received only perioperative, of the NCS Pharmacy Committee and invited guest writers for Currents. Group C received peri- and postoperative, and Group D received pre-, peri-, and postoperative antibiotic treatment. They found that use of antibiotics beyond the perioperative timeframe did not reduce postoperative infections (p = 0.248). In 2014, Bellamy and colleagues retrospectively evaluated 242 patients with surgically-managed frontal sinus fractures. Seri- ous infections were observed in 14 cases (5.8%). They observed increased risk of infection with operative delay beyond 48 hours 14


219126_NCS_Currents_March_2_eMag
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