Duration of antibiotic prophylaxis in high-risk patients with penetrating abdominal trauma: a prospective randomized trial.

To evaluate the effect of varying durations of antibiotic prophylaxis in trauma patients with multiple risk factors for postoperative septic complications, a prospective randomized trial was undertaken at an urban level I trauma center. The inclusion criteria were full-thickness colon injury and one of the following: (1) Penetrating Abdominal Trauma Index > 25, (2) transfusion of 6 units or more of packed red blood cells, or (3) more than 4 hours from injury to operation. Patients were randomly assigned to a short course (24 hours) or a long course (5 days) of antibiotic therapy. All patients received 2 g cefoxitin en route to the operating room and 2 g intravenously piggyback every 6 hours for a total of 1 day vs. 5 days. Sixty-three patients were equally divided into short-course (n = 31) and long-course (n = 32) therapy. This was a high-risk patient population, as assessed by the mean Penetrating Abdominal Trauma Index (33), number of patients with multiple blood transfusions (51 of 63; 81%), number of patients with an Injury Severity Score greater than 15 (37 of 63; 59%), number of patients with destructive colon wounds requiring resection (27 of 63; 43%), and number of patients requiring postoperative critical care (37 of 63; 59%). Differences in intra-abdominal (1-day, 19%; 5-days, 38%) and extra-abdominal (1-day, 45%; 5-days, 25%) infection rates did not achieve statistical significance. There continues to be no evidence that extending antibiotic prophylaxis beyond 24 hours is of benefit, even among the highest risk patients with penetrating abdominal trauma. A large, multi-institutional trial will be necessary to condemn this common practice with statistical validity.

Characteristics of Xanthomonas infections in critically ill surgical patients.

The aim of our study was to describe the characteristics of Xanthomonas infections in a population of critically ill surgical patients. The clinical records and microbiological data on 93 patients in a surgical intensive care unit (SICU) developing Xanthomonas infections were reviewed. Xanthomonas was isolated in 125 sites in the 93 patients. Their average age was 48 years (range, 14-94). Mortality occurred in 25 patients (26.9%) versus 10.3 per cent of SICU patients in general (P < 0.05). Patients were in the SICU for an average of 11.9 days before developing a positive Xanthomonas culture, and 87 per cent (81/93) of patients developed an infection at some other site before isolation of Xanthomonas. Trimethoprim sulfamethoxazole was the only drug to which the isolates were commonly sensitive (123/125 = 98.4%). We conclude that Xanthomonas 1) is associated with increased mortality; 2) is resistant to many of the drugs that usually cover Gram-negative infections; and 3) commonly complicates a prolonged intensive care stay, thus serving as a marker for severity of illness.

The pattern of fungal infections in critically ill surgical patients.

There continues to be difficulty making the clinical distinction between fungal colonization and systemic infection in critically ill surgical patients. This distinction is important, given the potential risks of aggressive antifungal therapy. In order to evaluate the significance of fungal infections by various sites, we retrospectively reviewed the clinical courses of patients with cultures positive for fungi (Candida species or Torulopsis glabrata) in the SICU of LAC + USC Medical Center from January 1992-December 1993. There were 129 patients who were culture positive for Candida (110 patients) or Torulopsis glabrata (19 patients). There were 187 positive cultures. Fifty-five patients (43%) had systemic fungal infections (two or more sites, or fungemia). The proportion of patients with positive cultures from any given site going on to develop systemic infections was similar (wound, 49 per cent; urine, 54 per cent; sputum, 57 per cent; drain, 68 per cent; P = 0.61, NS). The mortality for SICU patients with systemic fungal infection was significantly increased (36.3% versus 10.5%, P < 0.05) when compared with SICU patients in general. No significant increase in mortality was seen in patients with single site isolation (13.5% versus 10.5%, P = 0.52). This study suggests that although systemic fungal infection is associated with increased mortality in SICU patients, no single site of isolation is superior to others in predicting which patients are likely to develop systemic infection. Prospective studies with antifungal agents with reduced toxicity are justified in patients with single site isolation.