ADULT
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TRAUMA-RELATED INFECTIONS
1. ORAL & DENTAL
1. ORAL & DENTAL
1.1 Spreading infections and infections of fascial spaces (with/without systemic signs)
Traumatic wound infection is usually caused by endogenous organisms rather than exogenous.
Common organisms:
Viridans Streptococci
Staphylococci
Prevotella intermedia
Peptostreptococcus
Eubacterium
Fusobacterium nucleatum
Preferred
Benzylpenicillin 2-4MU IV q4-6h
PLUS
Metronidazole 500mg IV q8h
OR
Amoxicillin/Clavulanate 1.2gm IV q8h
OR
Cefuroxime 1.5g IV q8h
PLUS
Metronidazole 500mg IV q8h
Alternative
If not responding to first-line antibiotics:
Ceftriaxone 1-2g IV q24h
PLUS
Metronidazole 500mg IV q8h
Antibiotic allergy:
Clindamycin 300-450mg PO q6h or 600-900mg IV q8h
Comments
Empirical antibiotics are started.
Incision and drainage are advised and the antibiotic is changed in accordance with the result of culture and sensitivity.
Continue intravenous therapy for 1 to 2 days following successful abscess drainage, then switch to oral therapy.
Refer to Appendix 6 for IV to PO switch.
References:
Antibiotics and The Treatment of Endodontic Infections, Endodontics colleagues for Excellence 2006; American Association of Endodontics
Med Oral Patol Oral Cir Bucal2005; 10:77-85
CPG 2016 Management of periodontal abscess
J Clin Microbiol.2003;41(12):5794-7
Journal of the Irish Dental Association 2009; 55 (4): 190 – 192
Clinical Periodontology-12thed.2014
Clinical Periodontology-9thed.2002
Periodontology 2000, Vol. 62, 2013, 218-231
CPG Management of chronic periodontitis Nov 2012 MOH,Malaysia
JClin Periodontol.2012;39:284-294
JClin Periodontol.2011;38:43-49
J ClinPeriodontol 2008; 35: 696–704
J Periodont Res 2012; 47: 137–148
Periodontology 2000. Jun2014, Vol. 65 Issue 1, p149-177. 29p.
Malaysian Dental Journal (2008) 29(2) 154-157
CPG Management of periodontal abscess-MOH,Malaysia 2003
Eur J Oral Implantol 2012; 5 (Suppl): S21-S41
Clin Oral Impl Res 2012 (23): 205-210
Int.J Oral Maxillofac Implants 2014 (29): 325-345
Clin Oral Impl Res 2000:11(suppl): 146-155
Aust Dent J 2005;50 Suppl 2: S31-S35
2. ORTHOPAEDIC
2. ORTHOPAEDIC
2.1 Simple Soft Tissue Injuries
2.1.1 Minor Wounds with Simple Repair
Gunshot wound and superficial stab wound of extremities.
Antibiotic not required.
Good wound care is required:
Debridement of devitalized tissue
Irrigation and remove all foreign material
Hemostasis
Closure of the wound when safe and appropriate
2.2 Complex Soft Tissue Injuries
Muscular, skeletal and soft tissue trauma, gunshot or crush & degloving injuries or stab wounds
2.2.1 Penetrating and puncture-type wounds / Complex soft tissue wounds without open fractures
Common organisms:
Staphylococcus aureus
Beta-haemolytic streptococci
Polymicrobial infection
Preferred
Cloxacillin 2g IV q6h
MAY ADD
*Metronidazole 500mg IV q8h
MAY ADD
**Gentamicin 5mg/kg IV q24h
Alternative
Cefazolin 2g IV q6-8h
OR
Cefuroxime 1.5g IV q8h
PLUS
*Metronidazole 500mg IV q8h
OR
Amoxicillin/Clavulanate 1.2g IV q8h
Comments
*Metronidazole: In soil/rust contamination or heavy machinery.
**Gentamicin: If there’s extensive skin and soft tissue involvement (for gram negative coverage).
Tetanus immunization should be given in addition to appropriate antibiotics.
Antibiotic therapy should be tailored to the susceptibility of deep wound cultures isolates once available.
Duration: depends on the extent of infection.
For combat-related isolated soft tissue injury, antibiotic duration of 1 - 3 days may be adequate.
For severe penetrating injuries, especially those involving joints and/or tendons, antibiotics must be given for at least 5 days.
2.2.2 Plantar Wounds
E.g.: penetrating injury through the plantar foot
Common organisms:
Pseudomonas aeruginosa
Staphylococcus aureus
Preferred
*Piperacillin/tazobactam 4.5g IV q6-8h
OR
Cefepime 2g IV q8h
Alternative
Ciprofloxacin 750mg PO q12h
Comments
Tetanus immunization should be given in addition to appropriate antibiotics.
Antibiotic therapy should be tailored to the susceptibility of deep wound cultures isolates once available.
Duration: total 7-14 days following adequate surgical debridement if no evidence of established osteomyelitis upon presentation.
If there is osteomyelitis, refer to the Orthopaedic Infection section – Bone and Joint Infections: Osteomyelitis.
*Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 -4 hours).
2.2.3 Burn & Electrocution
Antibitics not required
2.3 Compound fractures / Open fractures
Compound fractures: Antibiotics are administered as prophylaxis within 3 hours of injury.
2.3.1 Gustilo Type I & II Fractures
Common organisms: Gram positive organisms
Preferred
Cefazolin 2g IV q8h
OR
Cefuroxime 1.5g IV q8h
MAY ADD
*Metronidazole 500mg IV q8h
Alternative
--
Comments
Pre-debridement and post-debridement cultures are not representative of actual infection.
Duration:
Gustilo Type I: stop after 24 hours
Gustilo Type II: discontinue after 24 hours to 48 hours
*Metronidazole: In soil/rust contamination or heavy machinery.
2.3.2 Gustilo Type III Fractures
Common organisms:
Gram positive organisms
Gram negative organisms
Preferred
As per Gustilo Type I & II fractures
PLUS
Gentamicin 5mg/kg IV q24h
MAY ADD
*Metronidazole 500mg IV q8h
Alternative
Ceftriaxone 2g IV q24h
MAY ADD
*Metronidazole 500mg IV q8h
Presence of water contamination
Fresh water contamination:
**Piperacillin/tazobactam 4.5g IV q6-8h
Sea water contamination:
**Piperacillin/tazobactam 4.5g IV q6-8h
PLUS
Doxycycline 100mg PO q12h
Comments
Pre-debridement and post-debridement cultures are not representative of actual infection.
Duration:
Gustilo Type III: 24 hours after wound closure or up to a maximum of 72 hours (whichever is earlier)
*Metronidazole: In soil/rust contamination or heavy machinery.
**Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3-4 hours).
References:
Charles D. Mabry: Arkansas Trauma System Evidence-Based Guidelines for Proper Use of Antibiotics in Trauma. Arkansas Trauma Society and Arkansas Chapter of the American College of Surgeons 2020
Uptodate. Infectious Complications of Puncture Wounds, 2022
Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society.J Trauma. 2011;71(2 Suppl 2):S210.
Prevaldi et al. Management of traumatic wounds in the Emergency Department: position paper from the Academy of Emergency Medicine and Care (AcEMC) and the World Society of Emergency Surgery (WSES). World Journal of Emergency Surgery (2016) 11:30
Alex K & Brit L. The Emergency Medicine Trauma Handbook. Downloaded from https://www.cambridge.org/core. University of Edinburgh
Uptodate. Preventive antibiotic regimens for patients with open fractures, 2022
3. CENTRAL NERVOUS SYSTEM
3. CENTRAL NERVOUS SYSTEM
Antibiotic prophylaxis NOT RECOMMENDED for:
Basal skull fractures
Traumatic CSF fistula
Post-surgical CSF leak
3.1 Cranial Trauma
3.1.1 Open Fracture / Penetrating Injuries without Dura Breach
Preferred
Cefazolin 2g IV q8h
OR
Cefuroxime 1.5g IV q8h
MAY ADD
Metronidazole 500mg IV q8h
Alternative
Amoxicillin clavulanate 1.2g IV q8h
Comments
Duration:
Until 24 hours after wound closure or 72 hours total (whichever occurs first).
The use on antibiotic here is pre-emptive antibiotics and should not be continued beyond a short course.
3.1.2 Penetrating Injuries with Dura Breach
Preferred
Ceftriaxone 2g IV q12h
PLUS
Metronidazole 500mg IV q8h
Alternative
--
Comments
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References:
Pasquale Pagliano et al. Listeria monocytogenes meningitis in the elderly: epidemiological, clinical and therapeutic findings. Le Infezioni in Medicina, n. 2, 105-111, 2016
Van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clinical Microbiology and Infection. 2016;22:S37-S62. doi:10.1016/j.cmi.2016.01.007
McGill, F. et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults.Journal of Infection, Volume 7, Issue 4 , 405 – 438.
Solomon, T. et al. Management of suspected viral encephalitis in adults – Association of British Neurologist and British Infection Association National Guidelines. Journal of Infection, Volume 64, Issue 4 , 347 – 373.
Allan R. Tunkel et al. 2017 Infectious Diseases Society of America’s Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis, Clinical Infectious Diseases, Volume 64, Issue 6, 15 March 2017,
Peter R. Williamson et al. Cryptococcal meningitis: epidemiology, immunology, diagnosis and therapy. Nature Reviews Neurology Volume 13, pages 13–24 (2017)
The Sanford Guide to Antimicrobial Therapy 2023.
Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Melbourne: Therapeutic Guidelines Limited; May 2023.
Chaudhuri A. et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. European Journal of Neurology 2008, 15: 649–659
Allan R. Tunkel et al. Practice Guidelines for the Management of Bacterial Meningitis Clinical Infectious Diseases 2004; 39:1267–84
Beardsley J, Sorrell TC, Chen SC. Central nervous system cryptococcal infections in non-HIV infected patients. Journal of Fungi. 2019 Aug 2;5(3):71.
Ganga A, Leary OP, Sastry RA et al Antibiotic prophylaxis in penetrating traumatic brain injury: analysis of a single-center series and systematic review of the literature. Acta Neurochirurgica. 2023 Feb;165(2):303-13.
CLSI. Performance Standards for Antimicrobial Susceptibility testing. 33rd ed. CLSI supplement M100. Clinical and Laboratory Standards Institute; 2023.
Drevets DA, Canono BP, Leenen PJ et al . Gentamicin kills intracellular Listeria monocytogenes. Infect Immun 1994; 62:2222.
Sallevelt BT, Smeijsters EH, Egberts TC et al. Acute renal and neurotoxicity due to weight-based dosing of intravenous acyclovir: How to dose in obese patients?. Clinical Infection in Practice. 2020 Oct
Guidelines for Diagnosing, Preventing and Managing Cryptococcal Disease among Adults, Adolescents and Children Living with HIV. World Health Organization; 2022.
Walter A. Hall, Brain Abscess. BMJ Best Practice. May 2023. https://bestpractice.bmj.com/topics/en-gb/925. Last accessed 20 July 2023.
Gelfand MS et al., Treatment and prevention of Listeria monocytogenes infection. UpToDate Retrieved July 20, 2023, from https://www.uptodate.com/contents/treatment-and-prevention-of-listeria-monocytogenes-infection
Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2015;(4):CD004
Salford Royal, NHS. Antibiotic Prophylaxis in Cranial Neurosurgery Antibiotic Guidelines, Unique ID: 144TD(C)25(F4) Issue number: 6, 2018
4. RESPIRATORY
4. RESPIRATORY
4.1 Chest Trauma
4.1.1 Penetrating Chest Trauma Requiring Chest Tube Insertion
Preferred
Cefazolin IV 2g q8h for 1 day (prophylaxis)
Alternative
--
Comments
Prophylactic antibiotic use is not indicated in patients with blunt chest trauma (non-penetrating trauma).
References:
Yuan, KC., Huang, HC. Antimicrobial Prophylaxis in Patients with Major Trauma. Curr Trauma Rep (2017) 3, 292–299.
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