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Three Part Question

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

Clinical Scenario

A 22 year old man is brought into A&E having been stabbed. He has an isolated chest injury which requires a tube thoracostomy. There is a discussion as to whether administration of presumptive antibiotics will reduce the risk of intrathoracic infection in this patient.

Search Strategy

Medline 1966 – 03/2019 using PubMED interface.
Search (((((thoracic injuries) OR chest injury) AND Humans[Mesh])) AND ((((prophylaxis) OR antibiotics) OR prophylactic antibiotics) AND Humans[Mesh])) AND ((((chest tube) OR chest drain) OR tube thoracostomy) AND Humans[Mesh]) Filters: Humans Sort by: [pubsolr12]

Search Outcome

The above search produced 181 results. Of these 2 retrospective studies were found to be relevant, the rest of the papers were included in the EAST practice guidelines or the 2019 meta-analysis and systematic review and therefore were not duplicated.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
M del Pilar Quiroga et al January, 2015 Colombia	240 patients included with thoracic trauma requiring closed thoracostomy. Included blunt and penetrating trauma	Prospective observational cohort study	Empyema	25 developed empyema (10.4%)	Risk factors for development of empyema included retained HTX, and the non-use of antibiotics. They did not assess antibiotic used or at what dose. The majority of their patients sustained blunt trauma (67.5%), whereas our investigation Is looking at mainly penetrating trauma.
FO Moore et al 2012 USA	Update of 1998 guidelines (based on 4 double-blinded PRCTs, 5PRCTs and 2 meta-analyses), included 7 studies up to 2008 including 3 retrospective studies, 2 double-blinded PRCTs and 2 meta-analyses	Meta-analysis	Empyema and pneumonia	1998 guidelines recommend 24h of first generation cephalosporin. Overall the majority of the papers showed a reduction infection rates, the majority of these came from meta-analyses. However, following further evaluation of more recent literature they conclude that no paper up to 2008 had sufficient power to confidently recommend presumptive antibiotics in TT, this seems to be secondary to a concern regarding increasing antibiotic resistance.
F Ayoub Feb, 2019 UK	12 randomised studies including 1263 patients with isolated penetrating or blunt chest trauma	Systematic review and meta-analysis	Empyema and pneumonia	Incidence of pneumonia was 1% in Abx group and 10.7% in placebo group Use of prophylactic abx was associated with reduced risk of empyema (RR 0.25; 95% CI 0.13-0.49) and pneumonia (RR 0.41 95% CI 0.24-0.71) after chest drain insertion.	Combined results from blunt and penetrating trauma. Included only RCTs, but not all were double-blinded. There is some evidence to show prolonged use of Abx increased antibiotic resistance however insufficient studies have researched whether 24h of antibiotics is enough.

Comment(s)

The most recent study by Ayoub et al concluded that antibiotics should be used for chest trauma requiring tube thoracostomy insertion. They caution against prolonged courses of antibiotics given the increased risk of antibiotic resistance. This also corresponds with the updated EAST practice guidelines which cautions against antibiotic use due to increasing resistance. Ayoub et al figures show a significant reduction in risk of pneumonia and empyema with the use of antibiotics compared to placebo. In our question, looking at penetrative chest injury, the term used should be presumptive not prophylactic antibiotic use given that chest drain insertion should be an aseptic procedure however the potential inoculation has occurred at time of injury.

Clinical Bottom Line

Use of 24h of cefuroxime is recommended for penetrative chest injury leading to pneumothorax or haemothorax requiring the insertion of tube thoracostomy.

References

1. VY Kong et al Prophylactic antibiotics for tube thoracostomy may not be appropriate in the developing world setting Injury 46(5):814-6
2. M del Pilar Quiroga et al Developing risk factors for post traumatic empyema in patients with chest trauma Journal of Acute Disease January 2015; pages 48-50
3. FO Moore et al Presumptive antibiotic use in tube thoracostomy for traumatic hemopneumothorax: An Eastern Association for the Surgery of Trauma practice management guideline
4. F Ayoub Use of prophylactic antibiotic in preventing complications for blunt and penetrating chest trauma requiring chest drain insertion: a systematic review and meta-analysis Trauma Surg Acute Care Open