Cook Alan, Hu Chengcheng, Ward Jeanette, Schultz Susan, Moore Iii Forrest O'Dell, Funk Geoffrey, Juern Jeremy, Turay David, Ahmad Salman, Pieri Paola, Allen Steven, Berne John
Department of Surgery, University of Texas Health Science Center at Tyler, Tyler, Texas, USA.
Department of Epidemiology and Biostatistics, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona, USA.
Trauma Surg Acute Care Open. 2019 Nov 4;4(1):e000356. doi: 10.1136/tsaco-2019-000356. eCollection 2019.
Thoracic injuries are common in trauma. Approximately one-third will develop a pneumothorax, hemothorax, or hemopneumothorax (HPTX), usually with concomitant rib fractures. Tube thoracostomy (TT) is the standard of care for these conditions, though TTs expose the patient to the risk of infectious complications. The controversy regarding antibiotic prophylaxis at the time of TT placement remains unresolved. This multicenter study sought to reconcile divergent evidence regarding the effectiveness of antibiotics given as prophylaxis with TT placement.
The primary outcome measures of in-hospital empyema and pneumonia were evaluated in this prospective, observational, and American Association for the Surgery of Trauma multicenter study. Patients were grouped according to treatment status (ABX and NoABX). A 1:1 nearest neighbor method matched the ABX patients with NoABX controls. Multilevel models with random effects for matched pairs and trauma centers were fit for binary and count outcomes using logistic and negative binomial regression models, respectively.
TTs for HPTX were placed in 1887 patients among 23 trauma centers. The ABX and NoABX groups accounted for 14% and 86% of the patients, respectively. Cefazolin was the most frequent of 14 antibiotics prescribed. No difference in the incidence of pneumonia and empyema was observed between groups (2.2% vs 1.5%, p=0.75). Antibiotic treatment demonstrated a positive but non-significant association with risk of pneumonia (OR 1.61; 95% CI: 0.863.03; p=0.14) or empyema (OR 1.51; 95% CI: 0.425.42; p=0.53).
There is no evidence to support the routine use of presumptive antibiotics for post-traumatic TT to decrease the incidence of pneumonia or empyema. More investigation is necessary to balance optimal patient outcomes and antibiotic stewardship.
II Prospective comparative study.
胸部损伤在创伤中很常见。大约三分之一的患者会发生气胸、血胸或血气胸（HPTX），通常伴有肋骨骨折。胸腔闭式引流术（TT）是治疗这些病症的标准方法，不过胸腔闭式引流术会使患者面临感染并发症的风险。关于在放置胸腔闭式引流管时预防性使用抗生素的争议仍未解决。这项多中心研究旨在调和关于预防性使用抗生素与放置胸腔闭式引流管有效性的不同证据。
在这项前瞻性、观察性且由美国创伤外科协会开展的多中心研究中，对院内脓胸和肺炎的主要结局指标进行了评估。患者根据治疗状态（使用抗生素组和未使用抗生素组）进行分组。采用1:1最近邻法将使用抗生素组患者与未使用抗生素组对照进行匹配。对于匹配对和创伤中心具有随机效应的多水平模型，分别使用逻辑回归和负二项回归模型对二元和计数结局进行拟合。
23个创伤中心的1887例患者接受了用于治疗血气胸的胸腔闭式引流术。使用抗生素组和未使用抗生素组分别占患者的14%和86%。头孢唑林是所开具的14种抗生素中最常用的。两组之间肺炎和脓胸的发生率没有差异（2.2%对1.5%，p = 0.75）。抗生素治疗与肺炎风险（比值比1.61；95%置信区间：0.86至3.03；p = 0.14）或脓胸风险（比值比1.51；95%置信区间：0.42至5.42；p = 0.53）呈正相关但不显著。
没有证据支持创伤后胸腔闭式引流术常规预防性使用抗生素以降低肺炎或脓胸的发生率。需要更多研究来平衡最佳患者结局和抗生素管理。
II级前瞻性比较研究。
