Guidelines for Trauma-Related Antibiotic Prophylaxis

The Global Alliance for Infection in Surgery (GAIS), in collaboration with the Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and World Society of Emergency Surgery (WSES), has outlined key recommendations regarding antibiotic prophylaxis (AP) in traumatic lesions to the head, brain, torso, maxillofacial region, extremities, skin, and soft tissues.

The guidelines were published online December 18, 2023, in the Journal of Trauma and Acute Care Surgery by Wolters Kluwer.

The World Health Organization (WHO) strongly emphasizes the importance of administering AP in patients before surgical incision based on the type, time, and duration of operation. However, the misuse of antibiotics is a global concern, posing risks to patient safety and spurring antimicrobial resistance. This issue is a result of errors occurred in the selection, dosage, duration, timing, and means of administration of drugs.

The challenges are particularly pronounced in patients with multiple associated injuries, resulting in a lack of clear and defined rationale for antibiotic use. Heterogeneous practices prevail due to difficulties in standardizing definitions and approaches in clinical research.

The guidelines offer specific recommendations for different types of traumatic injuries:

Head and brain trauma:

• AP is contradicted in nonoperatively treated patients with blunt head and brain trauma.
• Prolonged AP (24 hours) is recommended for patients with penetrating head and brain traumas.

Maxillofacial trauma:

• AP is recommended for patients with blunt maxillofacial trauma undergoing open reduction of fractures.
• AP is recommended for patients with penetrating maxillofacial trauma.
• Prolonged AP (24 hours) may be considered for patients undergoing open reduction of contaminated wounds.

Thoracic trauma:

• AP is not required for healthy patients with blunt thoracic trauma.
• AP is not indicated for patients with blunt thoracic trauma undergoing chest tube placement.
• AP is recommended for patients with penetrating thoracic trauma undergoing chest tube placement.
• AP is recommended for all patients presenting with delayed drainage of retained hemothorax.
• AP is indicated for patients with blunt and penetrating thoracic trauma who are undergoing surgical exploration (thoracotomy or thoracoscopy).

Abdominal trauma:

• AP is not recommended in nonoperatively treated patients with blunt abdominal trauma.
• AP is recommended for patients with penetrating abdominal trauma, especially in those undergoing surgical exploration (laparotomy or laparoscopy).
• Prolonged AP (24 hours) and/or antibiotic therapy should be considered in patients with hollow viscus injury.

Open fractures:

• AP should be promptly administered to effectively reduce wound infections.
• Long-term antibiotic treatment (7-10 days) is not recommended.
• AP longer than 24 hours is not indicated in patients with gunshot-related fractures.

Burns:

• Routine AP is not indicated.
• Source control with extensive irrigation is crucial for infection prevention.
• No significant differences exist between systemic and topical AP when it comes to infection prevention in patients with burns.
• AP is recommended in patients with severe burns who are undergoing endotracheal intubation and mechanical ventilation, ideally administered before intubation.
• AP may be indicated in patients with severe burns to prevent split-thickness skin graft infection.
• Routine AP is not indicated following the debridement of devitalized tissues.

Skin wounds and bites:

• Routine AP is not strictly indicated and should be considered on a case-by-case basis.
• Routine AP in case of mammalian bites is not strictly indicated and should be considered on a case-by-case basis.
• Accurate prevention of viral infectious diseases in case of animal bites, such as dogs infected with rabies virus, is crucial.
• Tetanus vaccination is recommended.

Source control, including cleaning, irrigating, and disinfecting wounds, is emphasized for all skin and soft tissue injuries, including mammalian bites.