Bomb Blast Injuries Antibiotic Management for Adults (551)

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Introduction

This guidance is adapted from Public Health England guidance (issued May 2017) and is intended for ED use. Further advice on ongoing antibiotic management may be provided by microbiology if required. In addition to antibiotics, tetanus and BBV exposure should be considered:

Tetanus immunisation

ALL bomb blast 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’3.

Hepatitis B vaccination

ALL patients who sustained injuries that breached skin 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 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.

Post exposure prophylaxis for HIV

HIV PEP is not usually required. Discuss with ID on call if uncertain.

Soft Tissue Injury +/- Foreign body (FB) in situ

IV therapy Oral switch Duration/comments

Co-amoxiclav 1.2g 8 hourly

OR if Penicillin allergy

Clindamycin 600mg 6 hourly

And

Gentamicin (dose as per gentamicin treatment guidelines, max 4 days)

Co-amoxiclav 625mg

8 hourly

OR if Penicillin allergy

Clindamycin 600mg 8 hourly

And

Ciprofloxacin 500mg 12 hourly

IV antibiotics until first surgical debridement/ washout and removal of projectile FB

Oral therapy for 3 days post-debridement/removal of FB

Or

7 days if FB retained

Open fractures OR “Through and through fractures” OR Intra-articular injuries

IV Therapy Duration//comments

IV Co-amoxiclav 1.2g 8 hourly

OR if Penicillin allergy

Clindamycin 600mg 6 hourly

And

Gentamicin (dose as per gentamicin treatment guidelines, max 4 days)

Continue IV antibiotics until soft tissue closure or for a maximum of 72 hours whichever is sooner.

Prolonged antibiotic therapy post op may be required – discuss with microbiology

Penetrating CNS injury (or multiple penetrating injuries including CNS)

IV therapy Oral switch Duration/comments

Ceftriaxone 2g

12 hourly

AND

Metronidazole 400mg 8 hourly
Switch to oral metronidazole when able to swallow, but continue IV ceftriaxone

2 weeks if FB removed/ not in situ

6 weeks if FB retained

Open skull fracture from penetrating trauma

IV therapy Oral switch Duration/comments
Ceftriaxone 2g 12 hourly

Co-amoxiclav 625mg 8 hourly

OR if Penicillin allergy

Ciprofloxacin 500mg 12 hourly

And Clindamycin 600mg 8 hourly

IV therapy until closure

IV/Oral therapy for 2 weeks

CSF leak post-skull fracture

IV Therapy Duration/Comments
No antibiotics indicated Give Pneumovax

Internal Ear Injury

Keep clean and dry. Urgent referral to ENT for examination and removal of debris +/- instillation of antibiotic ear drops

Penetrating eye injuries

IV Therapy Oral Switch Duration / Comments
IV route only if unable to swallow

Ciprofloxacin 500mg 12 hourly And

Clindamycin 600mg 8 hourly And

Topical Chloramphenicol 0.5% drops 2 hourly and 1% eye ointment nocte

2 weeks post removal of FB
If FB remains in situ liaise with micro

Penetrating abdominal/ thoracic wound

IV Therapy Oral Switch Duration / Comments

Co-amoxiclav 1.2 g 8 hourly

OR if Penicillin allergy

Clindamycin 600mg 6 hourly

And

IV Gentamicin (dose as per gentamicin treatment guideline, max 4 days)

If perforation and spillage of gastrointestinal contents

Add Fluconazole 400mg IV

Co-amoxiclav 625mg 8 hourly

OR if Penicillin allergy

Clindamycin 600mg 8 hourly

And

Ciprofloxaicn 500mg 12 hourly

IV therapy for 24 hours and IVOST when able to swallow

Duration 7 days IV/ oral

If FB remains in situ liaise with microbiology regarding duration

Review ongoing antifungal cover with microbiology

Last reviewed: 10 May 2022

Next review: 31 May 2025

Author(s): Ysobel Gourlay

Version: 3

Author Email(s): [email protected]

Approved By: Antimicrobial Utilisation Committee

Document Id: 551