Authors: Rob Hirst, Liz Farah, Andy Neill, Dave McCreary, Becky Maxwell, Chris Connolly/ Codes: GP9, IP1, NeuP2, PC4, ResC7, SLO10, SLO2, SLO8, SuP7, TP1 / Published: 04/04/2024

onlinelibrary.wiley.com
doi.org
www.acutemedicine.org.uk

Clinical question

Does giving antibitoics to those ventilated with a brain injury improve outcomes.

Title Ceftriaxone to prevent early ventilator-associated pneumonia in patients with acute brain injury: a multicentre, randomised, double-blind, placebo-controlled, assessor-masked superiority trial https://doi.org/10.1016/S2213-2600(23)00471-X Authors
  • Claire Dahyot-Fizelier et al lancet resp med
Background
  • Those with signifcant brain injury of any kind tend to lose their airway reflexes, they often vomit and aspirated either before, during or after their attendance at the ED. Many end up intubated and later go on to be given a label of ventialtor associated pneumonia. The pneumonia leads to fevers which is bad for the brain, it delays them coming of the vent, all kinds of bad things that lead to bad outcomes
  • If we give them up front antibiotics does it improve outcomes
Methods
  • The trial is called PROPHY-VAP, multicentre RCT double blinded, all good words. 9 ICUs in France
  • Included stroke, SAH, head trauma patrients likely to be intubated for at leatd 48 hrs.
  • Randomised within 12 hrs of intubation
  • Single dose of 2g ceftriaxone vs placebo. The syringes were opaque as we all know that cef has that yellow green colour
  • Primary outcome was VAP (defined by well recognised definitions)
Results
  • 330 pts
  • Fairly even split of stroke, SAH and trauma
  • 14% vs 32% incidence of early VAP
  • In their secondary outcomes it even reduced mortlaity (15% vs 25%) which makes me think it might be too good to be true!!
  • It did not seem to result in a world ending resistant super bug but with these numbers you couldn't tell.
Thoughts
  • I love these slightly tangential trials. Where you make an intervention that seems to hvae no outcome on the big issue but still improves outcomes. THe best example that springs to mind is the fact that one of the most effective interventions we have for variceal bleeding is antibitoics. That makes no sense but it does work.
  • We have seen a few similar trials of prophylactic antibiotics in post cardiac arrest patients (who also have brain injury) with some postivie outcomes so i do think there's something here even if not ready for prime time as the cool kids say
Departmental Handover - RCEMLearning Recognising Paediatric Sepsis - RCEMLearning Congenital Heart Disease - RCEMLearning