Strategy of antimicrobal therapy in patients with severe trauma: importance of initial severity state evaluation

Introduction

A high rate of nosocomial infections among patients with severe multiple trauma including severe traumatic brain injury and initial APACHE II score of 15 or more leads to increased length of stay (LOS), costs and high mortality. That makes the prevention of severe nosocomial infections one of the major therapeutic interventions in these patients. Because of a high rate of mixed nosocomial infections with high resistance to antibiotics it is necessary to start antimicrobal therapy with extended-spectrum antibiotics. Taking into account pharmacodynamics, pharmacokinetics and microbiological features of carbapenems, they make the best choice for these patients. In the case of MRSA infection it is necessary to use the combination of carbapenem and vancomycin.

Objective

The goal of the study was to assess the influence of maximal initial antimicrobal therapy with meropenem on mortality, rate of nosocomial infections and LOS in the ICU in patients with severe trauma including severe traumatic brain injury and initial APACHE II score of 15 or more.

Results

The study was performed in a general ICU from April 2003 to September 2004. All patients with severe trauma with predominant severe traumatic brain injury and initial APACHE II score of 15 or more were included in the study. We studied two groups of patients. In the case of known or suspected nosocomial infection, patients in the maximal antimicrobal therapy (MAT) group (n = 16, APACHE II 19.88 ± 3.6) received meropenem 3–6 g/day depending on body weight for 14 days. In the case of proven MRSA infection, vancomycin 2 g/day was added. Patients in the control group (n = 22, APACHE II 19.90 ± 3.7) with known or suspected infection received initial antimicrobal therapy with cefalosporines 3 or fluoroquinolones with change of antimicrobal therapy according to microbiological data. The observed data did not follow the normal distribution. Comparisons between groups were performed using the chi-square test. Mortality in the MAT group was 6.25% (1/16), and in the control group was 50% (11/22), P = 0.002. Nosocomial infection rate (ventilator-associated pneumonia, meningitis) was observed in 31.25% of patients (5/16) in the MAT group and in 91% of patients (20/22) in the control group, P < 0.001. LOS in the ICU did not differ between groups (19.44 ± 3.1 in the MAT group and 18.09 ± 10.3 in the control group). But comparision between LOS among survivors in the two groups revealed significant reduction in LOS in the ICU in the MAT group (19.42 ± 3.2 in the MAT group and 25.54 ± 11.1 in the control group, P < 0.05).

Conclusions

Initial antibiotic therapy with meropenem in patients with severe trauma including severe traumatic brain injury and initial APACHE-II score of 15 or more leads to a reduction in mortality, nosocomial infection rate and LOS in the ICU.