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Three Part Question

In [patients with chest trauma requiring tube thoracostomy], do [prophylactic antibiotics] reduce [the incidence of thoracic infection]?

Clinical Scenario

A 45 year old male is involved in a head on RTC whilst driving his car. He suffers blunt trauma to his left thorax from the steering wheel and develops a haemopneumothorax. You place a tube thoracostomy and ask if prophylactic antibiotics should be given to reduce the incidence of infection in the thoracic cavity.

Search Strategy

PubMed search from 1950 to 31st March 2019
(thoracostomy[Test Word] OR chest tube[Test Word] OR chest drain[Test Word]) AND (antibiotic[Test Word] OR infection[Test Word] OR empyema[Test Word] OR prophylaxis[Test Word])

Search Outcome

3398 papers were identified in the initial search of PubMed. A screen of titles/abstracts left 32 papers for full text review. 6 more papers were identified from the full texts by reviewing citations/references. Retrospective, observational and non-randomised trials were excluded. A total of 6 meta-analyses were identified, 2 were included whilst 3 were excluded due to age and more recent analyses being available and one excluded due to poor quality. 12 RCTs were identified, 11 of which were excluded as they were used in both meta-analyses. The remaining RCT was only in the later meta-analysis and is included. One further relevant systematic literature review was identified for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bosman et al. 2012 Netherlands	RCTs comparing antibiotic prophylaxis and placebo/no treatment in patients with isolated thoracic injuries undergoing tube thoracotomy. 11 RCTs identified. 1234 patients.	Meta-analysis	All infections (10 RCTs)	OR 0.24 (95% confidence interval 0.12 to 0.49) favouring antibiotics	Different antimicrobial classes used in different studies. Variation in definition of empyema/ pneumonia between studies. 3 articles identified for full review excluded as not available. Blunt subgroup relatively small.
			Empyema (11 RCTs)	OR 0.32 (95% confidence interval 0.17 to 0.61) favouring antibiotics
			Pneumonia (8 RCTs)	OR 0.51 (95% confidence interval 0.24 to 1.07)
			Penetrating Trauma Subgroup - All Infections (6 RCTs)	OR 0.28 (95% confidence interval 0.14 to 0.57) favouring antibiotics
			Blunt Trauma Subgroup - All Infections (3 RCTs)	OR 1.30 (95% confidence interval 0.46 to 3.67)
Moore et al. 2012 USA	Update to EAST management guidelines on the use of prophylactic antibiotics. Literature review of all relevant studies since previous guideline published in 1997. 7 papers included.	Systematic Literature Review	Effects of prophylactic antibiotics on incidence of Empyema and Pneumonia	Concluded insufficient evidence to either support or refute the use of prophylactic antibiotics. No recommendation made.	Did not consider subgroups of blunt and penetrating trauma.
Heydari et al. 2014 Iran	Patients with haemopneumothorax following blunt trauma requiring chest tube. Intervention, 2g Cefazolin (Group A) vs Placebo (Group B)	RCT	Empyema	Group A 0/54, Group B 1/50 (p=0.48)	Poorly designed study with few details in article. No power calculation. No mention of blinding. Small study.
			Pneumonia	Group A 2/54, Group B 4/50 (p=0.3)
Ayoub et al. 2019 UK	RCTs comparing prophylactic antibiotic vs placebo in patients with isolated chest trauma requiring chest drain. 12 RCTs identified. 1263 patients.	Meta-analysis	Empyema (12 RCTs)	RR 0.25 (95% CI 0.13 to 0.49) favouring antibiotics	Different antimicrobial classes used in different studies. Variation in definition of empyema/ pneumonia between studies. No differentiation between penetrating and blunt groups.
			Pneumonia (11 RCTs)	RR 0.41 (95% CI 0.24 to 0.71) favouring antibiotics

Comment(s)

Despite multiple positive meta-analyses showing a benefit with the use of prophylactic antibiotics, their use remains controversial. In the most recent guidelines from EAST in 2012, they felt the quality of studies was insufficient to make a recommendation either for or against the use of antibiotics. Importantly, neither EAST or many of the other trials have differentiated the penetrating or blunt subgroups when making recommendations. Both the meta-analyses included above demonstrated antibiotics reduce the incidence of all infections and empyema in a mixed group of blunt and penetrating trauma. However, the study by Boseman et al. also performed subgroup analysis of penetrating and blunt trauma. The benefit of antibiotics was maintained in the penetrating subgroup but not in the blunt. Despite the weaknesses of the studies, the consistent signal in the penetrating group provides Level 2 evidence of benefit, based upon the The Oxford Levels of Evidence 2. The lack of observed benefit in the blunt subgroup could be due to the small sample size or lack of effect. It is also possible that the benefit observed in the mixed patient groups is entirely due to the penetrating subgroup. More research is required in order to make a recommendation in patients with blunt thoracic trauma.

Editor Comment

Trauma

Clinical Bottom Line

In patients with chest trauma requiring tube thoracostomy, prophylactic antibiotics should be given to all patients with penetrating chest trauma to reduce the incidence of thoracic infections. In patients with blunt trauma, antibiotics should be considered on a case by case basis.

References

1. Bosman A, de Jong MB, Debeij J, van den Broeck PJ, Schipper IB. Systematic review and meta-analysis of antibiotic prophylaxis to prevent infections from chest drains in blunt and penetrating thoracic injuries. Br J Surg. 2012;99:p506-513.
2. Moore FO, Duane TM, Hu CK, Fox AD, McQuay Jr N, Lieber ML et al. Eastern Association for the Surgery of Trauma. Presumptive antibiotic use in tube thoracostomy for traumatic hemopneumothorax. J Trauma Acute Care Surg 2012;73:S341-4
3. Heydari MB, Hessami MA, Setayeshi K, Sajadifar F. Use of prophylactic antibiotics following tube thoracostomy for blunt chest trauma in the prevention of empyema and pneumonia. J Inj Violence Res 2014;6:p91-2
4. Ayoub F, Quirke M, Frith D. Use of prophylactic antibiotic in preventing complications for blunt and penetrating chest trauma requiring chest drain insertion: a systematic review and meta-analysis. Trauma Sure Acute Care Open 2014;4:e000246