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 χ2 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.
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.
Submitted: December 1, 2018, Revised: March 1, 2019, Accepted: March 28, 2019, Published online: April 25, 2019.
Address for reprints: Laura A Harmon, MD, University of Colorado, Anschutz Medical Campus, Rm 6203, 12631 E 17th Ave, Aurora, CO 80045; email: firstname.lastname@example.org.
Online date: April 26, 2019