Antibiotic prophylaxis in penetrating traumatic brain injury: analysis of a single-center series and systematic review of the literature

Abstract

Purpose Penetrating traumatic brain injury (pTBI) is an acute medical emergency with a high rate of mortality. Patients with survivable injuries face a risk of infection stemming from foreign body transgression into the central nervous system (CNS). There is controversy regarding the utility of antimicrobial prophylaxis in managing such patients, and if so, which antimicrobial agent(s) to use. Methods We reviewed patients with pTBI at our institution and performed a PRISMA systematic review to assess the impact of prophylactic antibiotics on reducing risk of CNS infection. Results We identified 21 local patients and 327 cases in the literature. In our local series, 17 local patients received prophylactic antibiotics; four did not. Overall, five of these patients (24%) developed a CNS infection (four and one case of intraparenchymal brain abscess and meningitis, respectively). All four patients who did not receive prophylactic antibiotics developed an infection (three with CNS infections; one superficial wound infection) compared to two of 17 (12%) patients who did receive prophylactic antibiotics. Of the 327 pTBI cases reported in the literature, 216 (66%) received prophylactic antibiotics. Thirty-eight (17%) patients who received antibiotics developed a CNS infection compared to 21 (19%) who did not receive antibiotics (p = 0.76). Conclusions Although our review of the literature did not reveal any benefit, our institutional series suggested that patients with pTBI may benefit from prophylactic antibiotics. We propose a short antibiotic course with a regimen specific to cases with and without the presence of organic debris.

Antibiotic prophylaxis in trauma: Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and World Society of Emergency Surgery guidelines

“…However, based on the published studies, some indications are clear. No significant differences in infection rates exist between patients who received AP and those who did not 11–21 . No differences were observed between basilar or skull close and open fractures 22 .…”

“…No significant differences in infection rates exist between patients who received AP and those who did not. [11][12][13][14][15][16][17][18][19][20][21] No differences were observed between basilar or skull close and open fractures. 22 Data showed heterogeneity in terms of inclusion criteria, duration of antibiotic therapy, and dosages.…”

Emergent Management of Severe Hypothermia, Acidemia, and Coagulopathy in Operative Penetrating Ballistic Cranial Trauma

“…For example, the minimization of lines could be achieved through a consolidation of prophylactic antibiotics. The triple-antibiotic regimen was initiated on arrival, but a single coverage with cefazolin may be appropriately used for aerobic and anaerobic agents in the setting of penetrating ballistic injury [12,34]. In severe TBIs, mild induced hypothermia (35-36°C) has been considered to offer benefits in reducing the cerebral metabolic rate of oxygen while patients are prevented from shivering (via sedation/paralytic medications) [35].…”

“…He was intubated, sedated, and taken urgently for right-sided decompressive craniectomy followed by external ventricular drain (EVD) placement for intracranial pressure monitoring. En route to the operating room, he received mannitol (1 g/kg); tranexamic acid 1 gm; triple antibiotic coverage including vancomycin, metronidazole, and cefepime [12]; levetiracetam for seizure prophylaxis; and propofol for sedation. The triple antibiotics were administered in accordance with the department protocol.…”

Transmastoid pediatric penetrating brain injury, interdisciplinary, and tailored patient’s treatment

“…[ 10 ] The decision to administer prophylactic antibiotics to TBI patients is largely based on previous guidelines and the preferences of neurosurgeons. [ 3 ] In a study conducted by Marut et al .,[ 6 ] it was found that 24 out of 33 patients received prophylactic antibiotics, and none of these 33 patients experienced central nervous system infections.…”