Practice management guidelines for prophylactic antibiotic use in penetrating abdominal trauma: the EAST Practice Management Guidelines Work Group.

Abstract

Fullen et al. first described the role for antibiotics in patients sustaining penetrating abdominal injuries. They retrospectively reviewed 295 patients who underwent celiotomy after sustaining penetrating abdominal wounds and categorized patients according to the timing of their first antibiotic dose: preoperative, n 5 16; intraoperative, n 5 98; and postoperative, n 5 81. The reported rate of trauma-related infections (incisional and intra-abdominal abscess) were 7%, 33%, and 30%, respectively. Individuals with colon injuries had postoperative infection rates of 11%, 57%, and 70% for each group, respectively. These rates remained constant even when the data were analyzed for additional risk factors, including the number of associated intra-abdominal organs injured, frequency of shock, and need for transfusion of blood products. The average time from hospital admission to laparotomy was the same for all three groups. Regardless of whether the observed difference was caused by the intraoperative or postoperative groups having a longer interval between injury and antibiotic administration or that the preoperative group had antibiotics circulating at the time of incision, this was the first study to suggest that the timing of antibiotic administration can impact the development of injury-related infections in patients with penetrating abdominal injuries. The importance of broad-spectrum antibiotic coverage for these patients was demonstrated by Thadepalli et al. in 1973. This study was a prospective, randomly assigned comparison of kanamycin and cephalothin to kanamycin and clindamycin. Both antibiotic combinations were administered preoperatively. The clindamycin group had a significantly lower rate of infection in the postoperative period compared with the cephalothin group (10% vs. 27%). They further demonstrated that the difference was caused by significantly more anaerobic infections in the cephalothin group (21%) compared with the clindamycin group (2%). These two studies demonstrated a significantly lower rate of infection when antibiotics providing aerobic and anaerobic coverage are administered before operative treatment. Prophylactic antibiotics for patients sustaining penetrating abdominal injuries with intestinal contamination have a role for reducing the rate of incisional wound infection subjected to gastrointestinal soiling. A single dose providing sufficient concentration within the wound during the vulnerable period is optimal. The other aspect of prophylactic antibiotic administration in trauma is the potential therapeutic role. The problem is to define the time period when contamination of the abdominal cavity becomes an established infection. At celiotomy, the intestinal wound is closed, eliminating further contamination and soiling of the peritoneal cavity. Thus, no further antibiotic should be necessary. Surgeons have concluded that “prophylactic antibiotics” in penetrating abdominal trauma can reduce the incidence of postoperative infectious complications. Since the mid-1970s, no study has included a placebo control group because of the high incidence of infectious complications after intestinal injury. However, many studies in the past 2 decades have compared various antibiotic regimens to evaluate single agents versus combination regimens, duration of administration, and, more recently, the pharmacokinetics and cost implications of single versus combination therapy.