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Three Part Question

[In patients who have nearly drowned] are [prophylactic antibiotics better than expectant therapy] at [reducing pulmonary infections and improving survival]?

Clinical Scenario

A 17 year old man presents to the emergency department having been pulled from a local river. He fell whilst intoxicated and was submerged for a short period of time. He has clearly aspirated some water as evidenced by his cough and sputum production.

You wonder if prophylactic antibiotics are indicated to prevent lower respiratory tract infection.

Search Strategy

Medline 1966-March week 5 2005 and EMBASE 1980-Week 15 2005 using the OVID interface.
Medline: [Antibiotic$.mp. OR exp Anti-Bacterial Agents OR Antibiotic Prophylaxis.mp. OR exp Antibiotic Prophylaxis OR Prophylactic Antibiotic$.mp. OR Anti-biotic$.mp.] AND [exp Near Drowning/ OR exp Drowning/ OR Drowning.mp. OR Drown$.mp. OR Submers$.mp. OR exp Immersion/ OR Immersion$.mp.] LIMIT to human AND English language.

Embase: [Antibiotic$.ti.ab. OR exp Antibiotic Agent/ OR Antibiotic Prophylaxis. ti.ab OR exp Antibiotic Prophylaxis/ OR exp Prophylaxis/ OR Prophylactic Antibiotic$. ti.ab. OR Anti-biotic$. ti.ab] AND [exp Near Drowning/ OR exp Drowning/ OR Drowning. ti.ab. OR Drown$. ti.ab. OR Submer$. ti.ab. OR exp Water Immersion/ OR exp Immersion/ OR Immersion$. ti.ab.) LIMIT to human AND English language.

Cochrane Library January 2010: (drowning):ti,ab,kw OR MeSH descriptor Drowning explode all trees.

Search Outcome

Altogether 122 papers were identified by the MEDLINE search strategy and 289 by the EMBASE search strategy. Of these four papers were identified as being relevant. No relevant reviews were found in the Cochrane database.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
van Berkel M et al, 1996, Netherlands	125 submersion victims	Retrospective analysis of charts	Pneumonia	Pneumonia not related to prophylactic administration of antibiotics	Retrospective series Not a controlled trial
Oakes DD et al, 1982, USA	40 victims of near drowning at one centre over 10 years. 39 in fresh water of which 30 were bath tub. 31 received prophylactic antibiotics	Retrospective analysis of charts	Resistance	In 16 cases where pneumonia did develop organisms were ‘frequently resistant to the previously administered antibiotics’	Retrospective series Not a controlled trial Results for antibiotics not fully reported.
Model JH et al, 1976, USA	91 near-drownings: 61 in fresh water, 27 sea water, 3 brackish water. 54 received prophylactic antibiotics and 36 did not (1 unaccounted for)	Retrospective analysis of charts	Survival with or without antibiotics	With: 47 lived, seven died; without: 34 lived, two died	Retrospective series not a controlled trial. One patient not accounted for in analysis of prophylactic antibiotics.
Corbin DO & Fraser HS, 1981, Barbados	98 near drownings; 66 received antibiotics	Retrospective analysis of charts	Survival	All survived	Retrospective series Not a controlled trial

Comment(s)

All the reports suggest that prophylactic antibiotics are of no benefit in near drowning and that a proper randomised controlled trial would be beneficial, though perhaps impractical. It is particularly interesting to note that organisms causing pneumonia are often atypical and are frequently resistant to the antibiotics prescribed empirically.

Clinical Bottom Line

There is currently no evidence for giving prophylactic antibiotics to victims of near-drowning.

References

1. van Berkel M, Bierens JJ, Lie RL, et al. Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients. Int Care Med 1996;22(2):101-7.
2. Oakes DD, Sherck JP, Maloney JR, et al. Prognosis and management of victims of near-drowning. J Trauma 1982;22(7):544-9.
3. Modell JH, Graves SA, Ketover A. Clinical course of 91 consecutive near-drowning victims. Chest 1976;70(2):231-8.
4. Corbin DO, Fraser HS. A review of 98 cases of near-drowning at the Queen Elizabeth Hospital, Barbados. West Indian Medical Journal 1981;30(1):22-9.