Rapidly fatal pneumococcal meningitis following non-penetrating traumatic brain injury.

A previously healthy young man presented to hospital with severe traumatic brain injury following a motor vehicle collision. Within 24 hours of admission, and despite antibiotic coverage, he developed a fever. On the second day, the source of infection was discovered to be purulent pneumococcal meningitis. At 48 hours post-accident, he developed brain-stem death without evidence of raised intracranial pressure or trans-tentorial herniation. Initial CT scans of the head were essentially normal, but early repeat scans revealed evidence of pneumocephalus and possible frontal bone fracture. Current recommendations do not make room for targeted antibiotic prophylaxis in traumatic brain injury patients with traumatic skull fracture. We argue that our case demonstrates the need for aggressive targeted antibiotic prophylaxis in the presence of certain features such as frontal or sphenoid bone fracture and pneumocephalus.

Lateral nasal wall abscess following manipulation of fractured nasal bones.

Nasal fracture accounts for over 50% of facial fractures and is a frequent presentation to ear, nose and throat emergency clinics. Optimal management of nasal injuries with deformity is by manipulation under anaesthetic and should be offered when appropriate. A healthy 27-year-old woman presented with a lateral nasal wall mass with purulent discharge 1 month following manipulation. CT imaging revealed a mass arising from fragments of the nasal bone, consistent with an abscess. Bone fragments and purulent material were initially debrided, with a subsequent formal excision of a persistent granuloma performed with an excellent cosmetic outcome. This appears to be the first description of a granuloma resulting from a closed reduction-manipulation of a nasal fracture.

Facing the facts on prophylactic antibiotics for facial fractures: 1 day or less.

BACKGROUND: To evaluate the role of initial prophylactic antibiotics on facial fractures, outcomes were compared between a short course (≤24 hours) of antibiotics to those who received an extended course (>24 hours). METHODS: Adults admitted (2010-2015) to a Level I trauma center intensive care unit with at least one facial bone fracture and major injuries isolated to the head and neck were included. Our primary analysis compared infectious complications of the head or neck (H/N infection) between patients given short or extended courses of antibiotic prophylaxis. Multivariate logistic regression and analysis of propensity score matched pairs were performed. RESULTS: A total of 403 patients were included, 85.6% had blunt injuries and 72.7% had their facial fracture managed nonoperatively. The H/N infection rate was 11.2%. Two hundred eighty patients received a short course of antibiotics and 123 patients received an extended course. Median Injury Severity Score was 14 in both groups (p = 0.78). Patients receiving an extended course of antibiotics had higher rates of H/N infection (20.3% vs. 7.1%, p < 0.001). Factors associated with development of H/N infection included younger age, penetrating injury, open fracture, upper face or mandible fracture, fractures in multiple facial thirds, vascular injury, hypertension, and extended antibiotic course. Multivariate logistic regression identified younger age (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96-1.00; p = 0.02), multiple facial third fractures (OR, 4.9; 95% CI, 2.4-10.2; p < 0.001), and penetrating mechanism (OR, 3.1; 95% CI, 1.5-6.4; p = 0.003) as independent predictors of H/N infection, but not antibiotic duration. Propensity score-matched analysis found no differences in H/N infection between short and extended antibiotic courses (11.4% vs. 12.5%; p = 1.0). Subgroup analyses demonstrated no differences in H/N infection between short or extended antibiotic courses by injury pattern, mechanism, or treatment (operative or nonoperative). CONCLUSION: These results lead us to believe that we should limit antibiotics to 24 hours or less upon admission for facial fractures. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

[Invasive mycoses and trauma]. / Invasive Mykosen und Trauma.

Perforating injury allows the dispersion of environmental fungi and fungal spores together with miniscule foreign bodies into traumatized tissue where they can multiply and cause invasive infection. Acute invasive fungal infection after open fractures is uncommon. The severity of the fungal infections depends on the type of injury (perforating, presence of foreign material), the body area and the general condition of the patient. Fungal infections of the immuncompetent host are generally localized within the dermis, invasion of the fascia, muscles and the bone is rare. Injury-related fungal infections of the immuncompromised host may lead to rapid invasion and generalization of the fungal infection. The following review will focus on the fungal infections after perforating injuries and open fractures including the invasive mycoses as a direct consequence of the trauma, post-traumatic fungal infections, tropical fungal infections (mycetoma), invasive fungal infections after near-drowning and nosocomial invasive fungal infections of the critically ill post-traumatic patient admitted to the intensive care unit.

Acinetobacter meningitis: four nosocomial cases.

We report the clinical features and therapeutic outcomes of four patients with multiantibiotic-resistant Acinetobacter meningitis. There were three males and one female, aged from 17 to 49 years. Three of them had suffered from head injuries with skull fractures, and the other suffered from an intracerebral hemorrhage and underwent a craniotomy. All four patients acquired nosocomial Acinetobacter meningitis, and multiantibiotic resistance developed. After treatment with imipenem/cilastatin, three of the four patients survived; one died of multiorgan failure. Because the clinical manifestations of Acinetobacter meningitis are similar to those of other gram-negative bacillary meningitis, the diagnosis can only be confirmed by bacterial culture. Resistance to multiple antibiotics, including third-generation cephalosporins, is frequently seen in patients with nosocomial Acinetobacter meningitis, and imipenem/cilastatin seems to be the antibiotic of choice for this potentially fatal central nervous system infection.

Posttraumatic meningitis: bacteriology, hydrocephalus, and outcome.

To investigate the conditions that have developed in the treatment of posttraumatic meningitis with the use of new antibiotics, the authors studied cases with this infection retrospectively for a period of 68 months. Among 860 patients with moderate to severe head injuries, 12 (1.39%) sustained this complication. Of these, nine patients (75%) had a demonstrable basilar skull fracture and seven (58.3%) presented obvious rhinorrhea. Of these seven, four (57.1%) were treated conservatively and three (42.8%) finally underwent surgery for dural repair. The infecting agents were Gram-positive cocci (Staphylococcus haemolyticus, Staphylococcus warneri, Staphylococcus cohnii, Staphylococcus epidermidis, and Streptococcus pneumoniae) in five patients and Gram-negative bacilli in six patients (Escherichia coli in two, Klebsiella pneumoniae in two, and Acinetobacter anitratus in two). In one patient, the culture results were negative. All Gram-negative strains appeared resistant to ampicillin and third-generation cephalosporins, but sensitive to imipenem and to the quinolone ciprofloxacin. Gram-positive strains were sensitive to vancomycin. Hydrocephalus finally developed in the two patients who had received intrathecal infusions of amikacin. No other report of the relation of intrathecal infusion of antibiotics and the development of hydrocephalus was found. All patients survived, indicating that, for the present, posttraumatic meningitis is a nonfatal complication of head injury.

Infection following cranial bone grafting--a need for caution?

A case of delayed infection following the use of split-cranial bone graft is presented. Trauma and bacterial contamination of the donor area six months before harvest were the likely causes. We advise caution and the use of alternate donor sites in cases where a history of previous contaminating trauma exists, even if the cranial bone is clinically completely healthy.

Shedding of herpes simplex virus type 1 into saliva in patients with orofacial fracture.

Shedding of herpes simplex virus type 1 (HSV-1) into saliva was studied in 83 patients with orofacial fractures. Infectious virus was isolated from 14 of 83 patients (16.8%) with no detectable herpetic lesion during hospitalization. Of the 83 patients, 44 (53%) had HSV-1 specific antibody. Virus shedding into saliva was observed only in the patients with antibody to HSV-1; thus, the frequency of virus shedding patients among those with antibody was 31% (14 of 44 patients). The frequency was obviously higher than that of a healthy population. The period of HSV-1 shedding had a mean of 3.7 days with range of 1 to 8 days, which is also significantly longer than that of a healthy population. These results strongly suggest that both treatment and operation lead effectively to reactivation of latently infected HSV-1.

Comparative study of bacteriological contamination between primary and secondary exploration of missile head wounds.

Aerobic and anaerobic bacterial contamination of scalp wounds, indriven bone fragments, and brain tracks were studied in two groups (A and B) of nonrandomized patients with missile head wounds in a 20-month study of patients from the front lines of the Iran-Iraq war. In the 53 Group B patients, the primary debridements, most of which had been performed within 24 hours after injury, were deemed insufficient and a secondary definitive exploration was performed. Group A patients (62) had primary definitive explorations at Nemazee Hospital after a mean of 66.5 hours since injury. All of the patients had been started on dexamethasone and a combination of either ampicillin and chloramphenicol or crystalline penicillin G and chloramphenicol after field evacuation. The contamination rate of scalp wounds, bone fragments and brain tracks was slightly higher in Group A (38.4%, 22.2%, and 29.6% respectively, for Group A and 31.9%, 19.5%, and 27% for Group B, respectively). Staphylococcus albus among the gram-positive and Acinetobacter among gram-negative bacteria were the most common infecting organisms. Fifty per cent of the bacteria cultured from the brain tracks of Group A and 30.8% of those cultured from Group B patients were gram-negative. A total of 125 patients in four groups was included in our overall study of victims of missile wounds that violated the dura mater. Four patients developed meningitis at Nemazee Hospital (3 postoperatively and 1 after facial penetration). Two patients in Group B were admitted with meningitis (1 with an accompanying abscess), 1 of them 20 days and the other 60 days after exploration at two different centers.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prevention of wound infection in open skull and brain injuries]. / O profilaktike infitsirovaniia ran pri otkrytykh povrezhdeniiakh cherepa i golovnogo mozga.

Measures aimed at the prevention of complications gain foremost importance when timely surgical treatment of a penetrating craniocerebral wound cannot be conducted. Experimental research and clinical experience have shown that the administration of 50 000--100 000 U of an antibiotic (kanamycin, monomycin, hectamycin, chloramphenicol) into the wound soon after an open penetrating injury had been inflicted to the skull and brain protects the wound from microbial contamination. This provides the possibility for postponing the plastic operation of the defect in the dura mater.