Introduction: Civilian gunshot wounds to the head (GSWH) are a significant cause of traumatic brain injury-related mortality in the US. Intracranial infections are feared delayed complications in civilian GSWH and the benefit of prophylactic antibiotics has not been thoroughly studied.
Methods: We conducted a meta-analysis of retrospective studies. A database search was conducted in PubMed, EMBASE, Scopus, Web of Science and Cochrane Library for articles after 2000 for intracranial infections (meningitis, cerebritis, ventriculitis and cerebral abscess) after civilian GSWH. We compared the intracranial infection rate in patients who received antibiotic prophylaxis with those who did not. We also compared the mortality of postoperative patients developing intracranial infections with the rest, and their morbidity, as evidenced by their Glasgow Outcome Scale (GOS), and grouped as favorable (GOS 4-5) or unfavorable (GOS 2-3).
Results: We identified 64 relevant articles, 7 of which had extractable information. Two articles compared intracranial infection rates with and without antibiotic prophylaxis in 219 GSWH patients. Prophylactic antibiotics did not decrease the risk of developing intracranial infections (OR 1.84; 95% CI 0.93 - 3.62; P = 0.08). Five articles reported 509 patients admitted with GSWH, 91.9% male, mean age 26.6 years old. 224 patients survived resuscitation and surgery. Postoperative intracranial infections did not significantly increase mortality (OR 0.67; CI 0.19 - 2.43; P = 0.55), but led to more unfavorable outcomes (OR 4.86; CI 1.19 - 19.79; P = 0.03). Of note, 160 out of the 224 initial survivors (71.4%) were reported to have received prophylactic antibiotics.
Conclusions: Prophylactic antibiotics are routinely given to GSWH patients to prevent infections. This meta-analysis of retrospective studies suggests that 1. prophylactic antibiotics did not decrease the risk of intracranial infections; 2. the presence of intracranial infections in a GSWH setting did not affect mortality and 3. patients developing intracranial infections had worse neurological outcomes.
Patient Care: The fear of infectious complications can lead to extended use of prophylactic antibiotics. In the past, it led to extended cerebral debridement plans, sacrificing normal brain tissue to reach retained bone and metallic fragments. Knowledge of the morbidity and mortality burden of infections in GSWH and the effects of prophylactic antibiotics on them, could lead to more effective plans to prevent and manage them.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of intracranial infections after craniocerebral gunshot wounds in civilians; 2) Discuss, in small groups the possible effects of antibiotic prophylaxis in these cases; 3) Identify an effective management plan for GSWH, to decrease infection-related mortality.