A review of antibiotic prophylaxis in facial and cranial trauma at a level 1 pediatric trauma center
Authors: Fly James H , Shapiro Kate , Arnold Sandra , Bagga Bindya , Herrara Oscar , Lee Kelley 
Published: January 2025

Corresponding author:

Dr. James H. Fly, Department of Clinical Pharmacy and Translational Science, Le Bonheur Children’s Hospital, 848 Adams Street, Memphis, TN 38103, Email: jfly1@uthsc.edu, Phone: 901 448 1689

No conflicts of interest.

Background

There is no consensus guideline for antibiotic prophylaxis in open head trauma. Patients often receive broad-spectrum antibiotic prophylaxis after craniofacial and craniocerebral injury. We have observed a rise in open head fractures including penetrating head trauma, especially craniofacial and craniocerebral gunshot wounds at our pediatric institution. This prompted our antimicrobial stewardship team to review infectious outcomes for open craniofacial and cerebral trauma patients who received various prophylactic antibiotic regimens.

Methods

This was a single center, retrospective chart review of patients admitted to our institution for open head trauma including penetrating injuries from 2014 to 2022. Patients were excluded from analysis if they were transferred to an outside facility after stabilization, declared dead on arrival, expired within 48 hours of arrival, or were not admitted. Patients were stratified by injured structures: cranium (including craniocerebral), facial bones with sinus or mandibular involvement, or ocular lens or globe disruption. Data regarding prophylactic antibiotic choice, length of prophylaxis, suspected infection, time to infection, culture data, and infectious disease consultation were collected for all cases. Antibiotics used for treatment of infection were not included in this analysis.

Results

124 patients met inclusion criteria. Facial fractures with sinus or mandibular involvement (n=73) were the most common, followed by open cranium with or without cerebral involvement (n=45) and fractures with lens or globe involvement (n=6). Four patients received no prophylaxis, none of whom developed an injury related infection. Sixteen different antibiotics were utilized for prophylaxis. Cefazolin, the most administered antibiotic alone or in combination, was prescribed in 50% of patients. Duration of antibiotic prophylaxis ranged from 1-21 days. Infectious disease consultation was obtained for 7 patients for prophylaxis management. Prophylactic antibiotic regimen and duration categorized by location of injury are shown in Table 1. Cultures were collected from 17 patients with suspected infection, with 5 demonstrating bacterial growth detailed in Table 2.

Conclusions

Use of antibiotics, specific antibiotic selection, and duration were inconsistent for prophylaxis among craniofacial or craniocerebral trauma cases at our institution. Overall, the rate of infection in these patients was very low. The data will be used to standardize appropriate antibiotic prophylaxis of open head fractures including penetrating craniofacial and craniocerebral injuries at our institution.

Table 1: Prophylactic antibiotic regimen, duration, and culture data categorized by location of injury

Table 2: Culture data for 5 cases of suspected infection