title: Systematic review of the literature and evidence-based recommendations for antibiotic prophylaxis in trauma: results from an Italian consensus of experts.
abstract: BACKGROUND
  Antibiotic prophylaxis is frequently administered in severe trauma. However, the risk of selecting resistant bacteria, a major issue especially in critical care environments, has not been sufficiently investigated. The aim of the present study was to provide guidelines for antibiotic prophylaxis for four different trauma-related clinical conditions, taking into account the risks of antibiotic-resistant bacteria selection, thus innovating previous guidelines in the field.
  
  
  METHODS
  The MEDLINE database was searched for studies comparing antibiotic prophylaxis to controls (placebo or no antibiotic administration) in four clinical traumatic conditions that were selected on the basis of the traumatic event frequency and/or infection severity. The selected studies focused on the prevention of early ventilator associated pneumonia (VAP) in comatose patients with traumatic brain injury, of meningitis in severe basilar skull fractures, of wound infections in long-bone open fractures. Since no placebo-controlled study was available for deep surgical site-infections prevention in abdominal trauma with enteric contamination, we compared 24-hour and 5-day antibiotic prophylaxis policies. A separate specific research focused on the question of antibiotic-resistant bacteria selection caused by antibiotic prophylaxis, an issue not adequately investigated by the selected studies. Randomised trials, reviews, meta-analyses, observational studies were included. Data extraction was carried out by one author according to a predefined protocol, using an electronic form. The strength of evidence was stratified and recommendations were given according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.
  
  
  RESULTS
  Uncertain evidence deserving further studies was found for two-dose antibiotic prophylaxis for early VAP prevention in comatose patients. In the other cases the risk of resistant-bacteria selection caused by antibiotic administration for 48 hours or more, outweighed potential benefits.
  
  
  CONCLUSIONS
  When accounting for antibiotic-resistant bacteria selection we found no evidence in favour of antibiotic prophylaxis lasting two or more days in the studied clinical conditions.
authors.affiliation: U.O. Anestesia e Rianimazione, Ospedale S. Martino, Belluno, Italy.
authors.forename: Daniele
authors.initials: D
authors.lastname: Poole
authors.affiliation: SOD Anestesia e Area Intensiva CTO, AOU Careggi, Firenze, Italy.
authors.forename: Arturo
authors.initials: A
authors.lastname: Chieregato
authors.affiliation: Dipartimento di Anestesia e Rianimazione, Fondazione IRCCS Istituto Nazionale dei Tumori e Università degli Studi di Milano, Milano, Italy.
authors.forename: Martin
authors.initials: M
authors.lastname: Langer
authors.affiliation: SOD Anestesia e Area Intensiva CTO, AOU Careggi, Firenze, Italy.
authors.forename: Bruno
authors.initials: B
authors.lastname: Viaggi
authors.affiliation: UOC Shock e Trauma, AO San Camillo-Forlanini, Roma, Italy.
authors.forename: Emiliano
authors.initials: E
authors.lastname: Cingolani
authors.affiliation: U.O. Anestesia e Rianimazione - P.S., Azienda Ospedaliera Universitaria Pisana, Pisa, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Malacarne
authors.affiliation: U.O. Rianimazione 118, Ospedale Maggiore, Bologna, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Mengoli
authors.affiliation: UOC Shock e Trauma, AO San Camillo-Forlanini, Roma, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Nardi
authors.affiliation: Neurorianimazione Ospedale S. Maria di Ca' Foncello, Treviso, Italy.
authors.forename: Ennio
authors.initials: E
authors.lastname: Nascimben
authors.affiliation: UOC Shock e Trauma, AO San Camillo-Forlanini, Roma, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Riccioni
authors.affiliation: U.O. Rianimazione 118, Ospedale Maggiore, Bologna, Italy.
authors.forename: Ilaria
authors.initials: I
authors.lastname: Turriziani
authors.affiliation: Anestesia e Rianimazione 1, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.
authors.forename: Annalisa
authors.initials: A
authors.lastname: Volpi
authors.affiliation: U.O. Rianimazione 118, Ospedale Maggiore, Bologna, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Coniglio
authors.affiliation: U.O. Rianimazione 118, Ospedale Maggiore, Bologna, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Gordini
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use; D019072:Antibiotic Prophylaxis; D003128:Coma / Q000473:pathology; D016208:Databases, Factual; D024881:Drug Resistance, Bacterial / Q000187:drug effects; D019317:Evidence-Based Medicine; D006801:Humans; D007558:Italy; D053717:Pneumonia, Ventilator-Associated / Q000150:complications / Q000188:drug therapy; D013530:Surgical Wound Infection / Q000517:prevention & control; D014947:Wounds and Injuries / Q000150:complications / Q000473:pathology
chemical_list: D000900:Anti-Bacterial Agents