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Three Part Question

In [patients suffering isolated penetrating chest injuries which require tube thoracostomy] does [the administration of prophylactic antibiotics] reduce [the incidence of intrathoracic infection]?

Clinical Scenario

A 25 year old man is stabbed in the chest during a pub brawl. He sustains an isolated chest injury that requires a tube thoracostomy. You wonder whether the administration of prophylactic antibiotics will reduce the incidence of intrathoracic infection in this patient.

Search Strategy

Medline 1966-08/02 using the OVID interface.
[exp thoracic injuries OR chest injury.mp OR exp chest tubes OR exp thoracostomy OR chest drain.mp OR chest tube$.mp OR thoracostomy.mp] AND [exp antibiotic prophylaxis OR antibiotic prophylaxis.mp OR exp antibiotics OR antibiotics.mp OR prophylactic antibiotics.mp] LIMIT to human AND English.

Search Outcome

321 papers were found, of which 308 were irrelevant. One paper was a systematic review of 11 other relevant papers up to 1997 that were also found on our search. Only one other relevant paper was found after this date. Therefore the systematic review and the remaining paper are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gonzalez RP and Holevar MR, 1998, USA	139 patients with isolated chest injuries either blunt (34) or penetrating (105) with ISS scores of 9 or 10 requiring tube thoracostomy	Double blind PRCT	Empyema/Pneumonia	Antibiotic group - No infection v placebo group - 2 empyemas, 2 pneumonias. Fischer's exact test p=0.05	Sample size not justified Small number of positive cases in the placebo group
Luchette FA et al for EAST practise management guidelines work group, 2000, USA	4 double-blinded PRCTs, 5 PRCTs and 2 meta-analyses Search methodology: Medline search 1977-1997) using chest tubes, human, drainage, tube thoracostomy, infection, empyema, bacterial infection-prevention and control. (this identified 44 references of relevance) bibliographies were searched.Articles reviewed by 5 trauma surgeons, 2 pharmacists and a health care economist.	Meta-analysis	Pneumonia	Antibiotic group 4.1% (14/338) Placebo group 14% (49/332) p=0.001	This well conducted systematic review pointed out that of the 9 primary studies found, Demitriates et al gave a single dose of antibiotics to all pts. before randomisation thus they excluded it from further pooled results. Of the 8 other studies, only 4 were double blinded and only 3 had applied Center for Disease Control criteria for pneumonia and Empyema. Despite the weaknesses in the evidence the EAST group recommends that there is sufficient class 1 and 2 evidence to recommend 24 hours of a first generation cephalosporin
			Empyema	Antibiotic group 0.6% (2/338) Placebo group 8.7% (29/332) P<0.0001
			Total thoracic infection rate	Antibiotic group 5.0% (17/338) Placebo group 23.2% (77/332) P<0.0001 (note ?small adding up error in total figures published by journal)

Comment(s)

The EAST practise management group have recently performed an excellent quality systematic review on this subject that included all other studies except Gonzalez et al. They give figures that show that the number needed to treat with antibiotics to prevent an intrathoracic infection is 6. They caution that the available studies are small and these studies look at chest drains inserted under differing clinical situations and by differing grades of clinicians.

Clinical Bottom Line

Administration of prophylactic antibiotics to patients requiring chest tube thoracostomy for isolated chest injuries reduces the incidence of intrathoracic infection especially empyema with an NNT of 6. The ideal regime is 24 hours of a first generation cephalosporin.

References

1. Gonzalez RP, Holevar MR. Role of prophylactic antibiotics for tube thoracostomy in chest trauma. Am Surg 1998;64(7):617-20.
2. Luchette FA, Barrie PS, Oswanski MF, et al. Practice Management Guidelines for Prophylactic Antibiotic Use in Tube Thoracostomy for Traumatic Hemopneumothorax: the EAST Practice Management Guidelines Work Group. Eastern Association for Trauma. J Trauma 2000;48(4):753-757.