Surgical infection society guidelines for vaccination after traumatic injury.
BACKGROUND
Recommendations for vaccination of injured patients against infection are evolving. Newly-recognized infections, safety considerations, changing epidemiology, and redefinition of patient groups at risk are factors that may influence vaccine development priorities and recommendations for immunization. However, recommendations must often be formulated based on incomplete data, forcing reliance on expert opinion to address some crucial questions. These guidelines provide evidence-based recommendations for the prevention or treatment of infectious morbidity and mortality after traumatic injury, such as soft tissue wounds, human or animal bites, or after splenectomy.


METHODS
A panel of experts conducted a thorough review of published literature, as well as information posted on the internet at the websites of the U.S. Centers for Disease Control and Prevention, among others. MEDLINE was searched for the period 1966-2004 using relevant terms including "anthrax," "rabies," "tetanus," "tetanus toxoid," and " splenectomy," in combination with "vaccine" and "immunization." The Cochrane database was searched also. Reference lists were cross-referenced for additional relevant citations. All published reports were analyzed for quality and graded, with the strength of the recommendation proportionate to the quality of the supporting evidence.


RESULTS
Recommendations are provided for pre- and post-exposure prophylaxis of rabies and anthrax. For tetanus prophylaxis, recommendations are provided for prophylaxis of acute wounds stratified y age and prior immunization status, and for immunization of persons at high risk. After splenectomy, it is recommended that all persons ages 2-64 years receive 23- valent pneumococcal vaccine and meningococcal vaccine, with Haemophilus influenzae type B vaccine administered to high-risk patients as well (all are Grade D recommendations). Vaccination should be given two weeks before elective splenectomy (Grade C), or two weeks after emergency splenectomy (Grade D). A booster dose of pneumococcal vaccine is recommended after five years (Grade D); no re- vaccination recommendation is made for meningococcal or Haemophilus influenzae type B vaccine. Recommendations for prophylaxis of splenectomized children under the age of five years are also provided.


CONCLUSIONS
There are limited data on the use of vaccines after injury. This document brings together a disparate literature of variable quality into a discussion of the infectious risks after injury relevant to vaccine administration, a summary of safety and adverse effects of vaccines, and evidence-based recommendations for vaccination.
Howdieshell
Thomas R
TR
Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico 87131, USA. thowdieshell@salud.unm.edu
Heffernan
Daithi
D
Dipiro
Joseph T
JT
D000367:Age Factors; D000881:Anthrax / Q000276:immunology / Q000517:prevention & control*; D022122:Anthrax Vaccines / Q000008:administration & dosage / Q000009:adverse effects; D023482:Bioterrorism; D019317:Evidence-Based Medicine; D006801:Humans; D011818:Rabies / Q000276:immunology / Q000517:prevention & control* / Q000635:transmission; D011819:Rabies Vaccines / Q000008:administration & dosage / Q000009:adverse effects; D013156:Splenectomy; D013742:Tetanus / Q000276:immunology / Q000517:prevention & control*; D013745:Tetanus Toxoid / Q000276:immunology; D014611:Vaccination / Q000009:adverse effects; D014612:Vaccines / Q000008:administration & dosage / Q000009:adverse effects; D014947:Wounds and Injuries / Q000276:immunology* / Q000601:surgery
D022122:Anthrax Vaccines; D011819:Rabies Vaccines; D013745:Tetanus Toxoid; D014612:Vaccines