From the Department of Surgery, University of Colorado Anschutz Medical Center (L.A.H.), Aurora, Colorado; Department of Surgery, Trauma, R Adams Cowley Shock Trauma Center (D.J.H., J.A.K., D.M.S.), University of Maryland (S.A.), School of Medicine, Baltimore MD; St Mary's Medical Center, Florida Atlantic University, Charles E. Schmidt School of Medicine (D.C., L.L.), Boca Raton, Florida; Department of Surgery, Carolinas Medical Center (K.W.C.), Charlotte, North Carolina; Department of Surgery, Division of Trauma, Rutgers, The State University of New Jersey (S.B.), Newark New Jersey; Department of Surgery, Division of Trauma, Eastern Virginia Medical School (J.B., J.E., J.L.R.), Norforlk, Virginia; Department of Surgery, Wright State Boonshoft School of Medicine, (G.S.), Beavercreek, Ohio; Department of Surgery, Division of Trauma, Allegheny General Hospital (M.R.N., B.N.C.), Pittsburgh, Pennsylvania; Department of Surgery, Division of Trauma, Methodist Hospital (V.A., M.T.), Dallas, Texas; Department of Surgery, Division of Trauma, Cooper Health (J.M., A.G.), Camden, New Jersey; Banner Health System (M.B., N.K.), Phoenix, Arizona; Department of Surgery, Division of Trauma, Indiana University School of Medicine (P.M.H.), Indianapolis, Indiana; Department of Surgery, Division of Trauma, University of California Irvine (J.N., A.G.), Orange County; Department of Surgery, Division of Trauma, Loma Linda Medical Center (D.T., V.C.), Loma Linda; Department of Surgery, Division of Trauma, LA County Harbor-UCLA Medical Center (P.L., D.K.), Los Angeles, California; Department of Surgery, Division of Trauma, UC Health Northern Colorado (T.C., J.D.), Loveland, Colorado; Medical City Plano Hospital (V.P.), Plano, Texas; and Department of Surgery, Division of Trauma, University of Colorado Health (T.S.), Colorado Springs, Colorado.
J Trauma Acute Care Surg. 2019 Jul;87(1):61-67. doi: 10.1097/TA.0000000000002327.
Fatality rates following penetrating traumatic brain injury (pTBI) are extremely high and survivors are often left with significant disability. Infection following pTBI is associated with worse morbidity. The modern rates of central nervous system infections (INF) in civilian survivors are unknown. This study sought to determine the rate of and risk factors for INF following pTBI and to determine the impact of antibiotic prophylaxis.
Seventeen institutions submitted adult patients with pTBI and survival of more than 72 hours from 2006 to 2016. Patients were stratified by the presence or absence of infection and the use or omission of prophylactic antibiotics. Study was powered at 85% to detect a difference in infection rate of 5%. Primary endpoint was the impact of prophylactic antibiotics on INF. Mantel-Haenszel χ and Wilcoxon's rank-sum tests were used to compare categorical and nonparametric variables. Significance greater than p = 0.2 was included in a logistic regression adjusted for center.
Seven hundred sixty-three patients with pTBI were identified over 11 years. 7% (n = 51) of patients developed an INF. Sixty-six percent of INF patients received prophylactic antibiotics. Sixty-two percent of all patients received one dose or greater of prophylactic antibiotics and 50% of patients received extended antibiotics. Degree of dural penetration did not appear to impact the incidence of INF (p = 0.8) nor did trajectory through the oropharynx (p = 0.18). Controlling for other variables, there was no statistically significant difference in INF with the use of prophylactic antibiotics (p = 0.5). Infection was higher in patients with intracerebral pressure monitors (4% vs. 12%; p = <0.001) and in patients with surgical intervention (10% vs. 3%; p < 0.001).
There is no reduction in INF with prophylactic antibiotics in pTBI. Surgical intervention and invasive intracerebral pressure monitoring appear to be risk factors for INF regardless of prophylactic use.
Therapeutic, level IV.
穿透性创伤性脑损伤（pTBI）后的死亡率极高，幸存者往往留下严重的残疾。pTBI 后的感染与更差的发病率有关。目前尚不清楚平民幸存者中枢神经系统感染（INF）的现代发生率。本研究旨在确定 pTBI 后 INF 的发生率和危险因素，并确定抗生素预防的影响。
17 家机构提交了 2006 年至 2016 年期间存活超过 72 小时的成人 pTBI 患者。根据是否存在感染以及是否使用或省略预防性抗生素对患者进行分层。该研究的功率为 85%，以检测感染率差异 5%。主要终点是预防性抗生素对 INF 的影响。采用 Mantel-Haenszel χ 和 Wilcoxon 秩和检验比较分类和非参数变量。p>0.2 的显著性差异被纳入调整后的中心的逻辑回归。
在 11 年期间确定了 763 例 pTBI 患者。7%（n=51）的患者发生了 INF。66%的 INF 患者接受了预防性抗生素治疗。62%的患者接受了一剂或多剂预防性抗生素治疗，50%的患者接受了延长抗生素治疗。穿透性颅骨的程度似乎不会影响 INF 的发生率（p=0.8），也不会影响经口咽的轨迹（p=0.18）。控制其他变量后，预防性使用抗生素与 INF 发生率无统计学显著差异（p=0.5）。有颅内压监测器的患者（4%比 12%；p<0.001）和接受手术干预的患者（10%比 3%；p<0.001）感染率更高。
在 pTBI 中，预防性使用抗生素并不能降低 INF 的发生率。手术干预和侵入性颅内压监测似乎是无论预防性使用与否发生 INF 的危险因素。
治疗，IV 级。
