Presumptive antibiotics in tube thoracostomy for traumatic hemopneumothorax: a prospective, Multicenter American Association for the Surgery of Trauma Study

Alan Cook; Chengcheng Hu; Jeanette Ward; Susan Schultz; Forrest O'Dell Moore Iii; Geoffrey Funk; Jeremy Juern; David Turay; Salman Ahmad; Paola Pieri; Steven Allen; John Berne; AAST Antibiotics in Tube Thoracostomy Study Group

doi:10.1136/tsaco-2019-000356

Presumptive antibiotics in tube thoracostomy for traumatic hemopneumothorax: a prospective, Multicenter American Association for the Surgery of Trauma Study

Trauma Surg Acute Care Open. 2019 Nov 4;4(1):e000356. doi: 10.1136/tsaco-2019-000356. eCollection 2019.

Authors

Collaborators

AAST Antibiotics in Tube Thoracostomy Study Group:
Geoffrey Funk, Nathan Kugler, David Turay, Xian Luo-Owen, Salman Ahmad, Stephen Barnes, Paola Pieri, Steven Allen, John Berne, Jurek Kocik, LaDonna Allen, Alan Cook, Rachel Nygaard, Kenji Inaba, Konstantinos Chouliaras, Alexander Colonna, Toby Enniss, Christopher Michetti, Margaret Griffen, Paula Ferrada, Jinfeng Han, Joshua Hazelton, Anna Goldenberg, James Haan, Kelly Lightwine, George Velmahos, Ahmed Eid, Susan Schultz, Remigio Flor, Jeanette Ward, Chengcheng Hu, Forrest O Moore, Annette Ruiz Taylor, Jeff Wellard, Lauren Graham, Charles Hu, Fred Rogers, Tawnya Vernon, Craig Egan, Matthew Carrick, Isaac Howley, Ronald Gross, Andrew Doben, Douglas Paul, Melody Campbell, Jeffrey Upperman, Andrew Kerwin

Affiliations

¹ Department of Surgery, University of Texas Health Science Center at Tyler, Tyler, Texas, USA.
² Department of Epidemiology and Biostatistics, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona, USA.
³ Department of Trauma, HonorHealth, Scottsdale, Arizona, USA.
⁴ Department of Surgery, William Beaumont Army Medical Center, El Paso, Texas, USA.
⁵ Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas, USA.
⁶ Department of Surgery, Baylor Scott and White Health, Dallas, Texas, USA.
⁷ Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
⁸ Department of Surgery, Loma Linda University, Loma Linda, California, USA.
⁹ Department of Surgery, University of Missouri Hospital & Clinics, Columbia, Missouri, USA.
¹⁰ Department of Surgery, Maricopa Medical Center, Phoenix, Arizona, USA.
¹¹ Department of Surgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA.
¹² Department of Surgery, Broward Health, Fort Lauderdale, Florida, USA.

Abstract

Background: 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.

Methods: 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.

Results: 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: 0.86~3.03; p=0.14) or empyema (OR 1.51; 95% CI: 0.42~5.42; p=0.53).

Conclusion: 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.

Level of evidence: II Prospective comparative study.