cefoxitin and Wounds--Gunshot

Twenty-nine patients who incurred a transperitoneal low-velocity gunshot wound to their spine were evaluated for the occurrence of spinal infectious complications. All patients underwent an exploratory laparotomy to determine the extent of viscera involvement. No attempt was made to debride the involved spinal area, and the bullet was not removed unless it was easily accessible. Of the 21 patients with a parenchymal and/or noncolonic viscous injury, 17 (77%) were treated with intravenous (i.v.) antibiotics for a minimum of 5 days the remainder received treatment for a maximum of 48 h. All 8 patients with colonic injuries received a minimum of > or = 5 days of antibiotic treatment. Follow-up averaged 44.9 months (range 3-144 months). Only 1 (4.7%) patient with either a noncolonic or parenchymal perforation developed an infectious complication (subdiaphragmatic abscess); two patients (25%) with colonic perforations developed a psoas abscess. No patient developed a spinal infection. This study suggests that patients who sustain a transperitoneal low-velocity gunshot wound to their spine do not need to undergo spinal debridement and may be treated with parenteral antibiotics. Any course of broad-spectrum antibiotics for 5 days appears to minimize infectious complications. Bullet removal and missile tract debridement of the spine is not routinely necessary.

Topics: Adolescent; Adult; Antifungal Agents; Cefoxitin; Child; Colon; Discitis; Drug Therapy, Combination; Female; Gentamicins; Humans; Liver Abscess; Male; Meningitis; Middle Aged; Multiple Trauma; Osteomyelitis; Paralysis; Peritoneum; Psoas Abscess; Retrospective Studies; Spinal Cord Injuries; Spinal Injuries; Subphrenic Abscess; Treatment Outcome; Vancomycin; Viscera; Wounds, Gunshot

Postoperative infection accounts for significant morbidity and mortality following penetrating abdominal trauma. During a 2 1/2-year period, December 1980 through June 1983, 257 patients sustaining penetrating abdominal injury were initially treated at Parkland Memorial Hospital in Dallas. Following the patient's written consent, they were prospectively randomized to receive, prior to surgery, intravenous clindamycin 600 mg every 6 hours and tobramycin 1.2 mg/kg every 6 hours (CT), or cefamandole 1 gm every 4 hours (M), or cefoxitin 1 gm every 4 hours (C). The antibiotics were continued for 48 hours. Major organ injuries in the three groups were comparable. The overall infection rate was significantly less in the cefoxitin group (13%), compared to cefamandole at 29%, and was comparable to the combination of clindamycin/tobramycin at 20%. The most significant difference followed colon injury. There were 96 patients who sustained colon injuries and the infection rate was CT 33%, M 62%, and C 19% (p = 0.002). If nonoperative wound infections were excluded from the colon group and only severe infections were evaluated, the infection rate was CT 18%, M 38%, and C 13% (p = 0.021). The infection rate was higher in the shock patients and tended to increase as age increased. Enterococcus, Escherichia coli, and Klebsiella pneumoniae were the most frequent aerobes isolated along with anaerobes. Five of six Bacteroides isolates from major infections occurred in the cefamandole group; two of which were in bacteremic patients. The hospital stay corresponded with infection rates, being 11.4 days (CT), 13.1 days (M), and 9.4 days (C). The results of this study indicate that cefoxitin is comparable to the combination of clindamycin/tobramycin and superior to cefamandole when used before surgery in patients sustaining penetrating abdominal trauma. The study suggests that antibiotic coverage should be against aerobes and anaerobes. Routine administration of an aminoglycoside is unnecessary.

Topics: Abdominal Injuries; Abscess; Adolescent; Adult; Aged; Aminoglycosides; Anti-Bacterial Agents; Cefamandole; Cefoxitin; Clindamycin; Colostomy; Drug Therapy, Combination; Humans; Ileostomy; Middle Aged; Premedication; Prospective Studies; Random Allocation; Tobramycin; Wound Infection; Wounds, Gunshot; Wounds, Stab

Two prospective, randomized trials of the efficacy of antibiotic regimens after penetrating abdominal trauma demonstrated that a combination of clindamycin and tobramycin was superior to cefamandole or cefoxitin in preventing postinjury wound infection but that no difference could be demonstrated between combination therapy (clindamycin plus tobramycin) and moxalactam. Infection was more likely to occur after a gunshot wound or with a high injury severity score and occurred after the 10th postinjury day only in those patients who received cefamandole or cefoxitin. There was a higher incidence of culture of B. fragilis in the latter groups as well as infections due to resistant organisms. Short-term antibiotic therapy for 72 hours with either tobramycin plus clindamycin or moxalactam appears adequate for the majority of patients after gunshot or knife wounds. The costs of these regimens to the patient were similar in our hospital. The most important single factor, however, in maintaining low infection rates after penetrating injury to the abdominal cavity is appropriate and timely surgical management.

Topics: Abdominal Injuries; Adolescent; Cefoxitin; Cephalosporins; Clindamycin; Clinical Trials as Topic; Drug Therapy, Combination; Humans; Moxalactam; Premedication; Prospective Studies; Random Allocation; Time Factors; Tobramycin; Wound Infection; Wounds, Gunshot; Wounds, Stab

Recent studies showed high populations of both aerobes and anaerobes in penetrating abdominal trauma infections. Combined aminoglycoside-clindamycin therapy has resulted in infection rates of 7 to 10 per cent. However, high side-effect incidences of nephrotoxicity and ototoxicity have been attributed to the aminoglycosides. Cefoxitin is reportedly free of these side effects. In our study, 62 penetrating abdominal trauma patients requiring laparotomy were treated with cefoxitin pre- and postoperatively. The majority of the injuries, 75.8 per cent, involved small bowel and large bowel. Infections occurred in four patients of the total 62 (6.5%). Two side effects, a fever and a rash, subsided immediately after discontinuing cefoxitin; no ototoxicity or nephrotoxicity occurred. The safety and efficacy of cefoxitin alone versus aminoglycoside-clindamycin combination therapy was statistically compared in intestinal injuries only among two historical controls and our subgroup. Our infectious rate, 8.5 per cent, was comparable to 7.4 per cent and 10.4 per cent of the historical controls. We concluded that pre- and postoperative use of cefoxitin alone is as effective in the prevention of penetrating abdominal trauma infections as combined aminoglycoside-clindamycin therapy. Experience to date suggests that the use of a beta-lactam antibiotic such as cefoxitin may allow the physician to avoid the more serious side effects associated with the use of aminoglycosides in these patients.

Topics: Abdominal Injuries; Adolescent; Adult; Aminoglycosides; Anti-Bacterial Agents; Cefoxitin; Clindamycin; Drug Therapy, Combination; Female; Humans; Male; Middle Aged; Surgical Wound Infection; Wound Infection; Wounds, Gunshot; Wounds, Stab