Antimicrobial prophylaxis guidance for bomb blast victims

Public Health England


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Principles of treatment

  • This advice is suitable for ALL age groups of our patients
  • This guidance is based on the best available evidence but its application must be modified by professional judgement and any knowledge of previous culture results. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  • This guidance has been prepared mindful of best practice in the management of antimicrobial resistance issues
  • In the event of any uncertainty clinicians are advised to contact their local microbiology department for advice
    • Where multiple injuries have been sustained (eg bone fractures and eye injuries) it may be possible to rationalise antibiotic regimes following discussions with local microbiology departments
    • Blast injured patients will mount a brisk inflammatory response and so inevitably have pyrexia and a high C-reactive protein. If white cell count is rising assess carefully for infection. Consider monitoring Procalcitonin (PCT) every other day to differentiate infection from an inflammatory response linked to Systemic Inflammatory Response Syndrome (SIRS) or trauma*
    • Local microbiology advice should be sought to consider possibility of nosocomial infection and take into account any prevalent organisms that have posed infection control risks
    • Consider linking patients in the laboratory using IT systems (such as LIMS)
    • To ensure continuity of prescribing it is advised that treating hospitals dispense sufficient medication to allow patients to complete antibiotic courses at home
    • MRI will show high marrow signal after blast injury which mimics osteomyelitis–these changes last for around six months, so bear in mind if investigating possible bone infection
    • Where receiving hospitals have had problems with resistant gram negative rods (especially carbapenemase producing enterobacteriaceae – CPE); affected patients will require isolation and screening as per Public Health England (PHE) guidance
    • Zygomycete infection has presented around 10 days post injury in military casualties where there was implantation of organic matter. This scenario is less likely following bomb injuries acquired in a civilian setting, but the microbiology of wounds should be monitored for invasive fungal infection

Tetanus prophylaxis

  • ALL bomb victims with injuries must have their tetanus immunisation status checked and treated according to the extant advice on management of patients with tetanus prone wounds in the ‘Green Book’
*PCT may be expected to be elevated in the first 24-48 hours post trauma but fall quickly (Castillo GP et al, critical care medicine 2009, 37 (6):1845-9 Procalcitonin as a prognostic and diagnostic tool for septic complications after major trauma)

Blood-borne virus prophylaxis

  • Guidance on the appropriate post-exposure prophylaxis of blood-borne viruses is contained in a separate guidance document. In summary the current recommendations from PHE are:
    • All patients who sustained injuries that breached the skin as a result of a bomb injury must receive an accelerated course of hepatitis B vaccination (0, 1, and 2 months, or, day 0, day 7, day 21 and at 12 months)
    • Patients who are discharged from inpatient care before completion of an accelerated hepatitis B vaccination course should receive their remaining doses of vaccine either at out-patient follow up, or by arrangement with their GP
    • All patients should be tested at 3 months to determine their hepatitis B vaccine response and at 3 months and 6 months to determine their hepatitis C and HIV status. These samples should be referred for testing to their local PHE public health laboratory, quoting the relevant ILog reference number to ensure that the results of these tests can be linked to their patient record
    • Post exposure prophylaxis for HIV should not normally be given
  • PHE will liaise with primary care to ensure that vaccination schedules and screening tests have been properly scheduled and completed

Antibiotic prophylaxis

  • These regimens are appropriate for adult and paediatric patients. For dosing recommendations refer to the British National Formulary (BNF), local hospital formulary, or contact local microbiology department
Soft tissue injury
(No foreign body in situ)
i.v co-amoxiclav OR cefuroxime/metronidazole until first surgical debridement/washout
Then to complete 1 week course with oral Co-amoxiclav
Soft tissue injury
(Foreign body in situ)
i.v. co-amoxiclav OR cefuroxime/metronidazole until first surgical debridement/washout and removal of projectile foreign body
Then to complete 2 week course with oral co-amoxiclav
If foreign body remains in situ liaise with local microbiology department regarding duration of antibiotics
Open fractures
OR
"Through and through fractures"
OR
Intra-articular injuries
i.v. co-amoxiclav OR cefuroxime/metronidazole
Stat dose of Gentamicin during initial operation (repeated if septic during subsequent operations)
Continue i.v. antibiotics until wound closure OR until no planned return to theatre
Complete a six week course of oral co-amoxiclav§ after conversion from i.v. antibiotics
Penetrating CNS injury
(Foreign body in situ)
i.v. ceftriaxone (high dose)/metronidazole
Continue for 6 weeks
Penetrating CNS injury
(Foreign body removed/not in situ)
i.v. ceftriaxone (high dose)/metronidazole
Continue for 2 weeks
Open skull fracture from penetrating trauma i.v. ceftriaxone until closure, then, if no brain injury, continue with oral Augmentin for 6 weeks
CSF leak post-skull fracture No antibiotics indicated
Give Pneumovax
Penetrating eye injuries i.v./p.o. ciprofloxacin AND i.v./p.o. clindamycin AND topical chloramphenicol
Continue for 2 weeks after removal of any foreign body
If foreign body remains in situ liaise with local microbiology department regarding duration of treatment
Penetrating abdominal injuries i.v. co-amoxiclav OR cefuroxime/metronidazole)
Add fluconazole if perforation and spillage of gastrointestinal contents
Continue intravenous antibiotics for a minimum duration of 7 days following surgery
If foreign body remains in situ liaise with local microbiology department regarding duration of treatment
Penetrating chest trauma i.v co-amoxiclav OR cefuroxime/metronidazole
If oesophageal perforation consider adding fluconazole
Continue intravenous antibiotics for a minimum duration of 7 days following surgery
If foreign body remains in situ liaise with local microbiology department regarding duration of treatment
An injury involving a penetrating object which has passed through a victim
For example a decision made to allow a wound to heal by secondary intention.
§ Extended duration recommended due to the high risk of a contaminated foreign body and the logistical challenges of ensuring appropriate follow-up for all victims due to their geographical dispersion.

References

full guideline available from...
www.gov.uk/government/publications/antimicrobial-prophylaxis-administering-to-bomb-blast-victims

Public Health England. Antimicrobial prophylaxis guidance for bomb blast victims. London: Public Health England. June 2017.


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