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Three Part Question

In [an adult with compound depressed skull fracture] does [the administration of antibiotics] reduce [the incidence of meningitis]?

Clinical Scenario

A 23 year old man attends the emergency department having been assaulted outside a nightclub with a hammer. He has sustained an isolated head injury with no loss of consciousness and is fully alert and oriented. He has a compound depressed left parietal skull fracture (confirm and defined by CT scan). No surgical intervention is considered. You wounder whether the adminstration of antibiotics will reduce the chance of meningitis developing.

Search Strategy

Medline 1966-11/02 using the Ovid interface.
[{exp skull fractures OR skull fracture$.mp} OR {(exp fractures, open OR compound fracture$.mp OR depressed fracture$.mp) AND (exp skull OR skull$.mp OR cranium$.mp OR calvarium$.mp)} AND {exp antibiotics OR antibiotic$.mp OR exp penicillin OR penicillin$.mp OR benzylpenicillin.mp OR exp metronidazole OR metronidazole.mp OR flagyl.mp}] LIMIT to human AND English language.

Search Outcome

Altogether 198 papers were found, of which 197 were irrelevant or of insufficient quality. The remaining paper is shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Mendelow AD et al, 1983, Edinburgh	223 patients were admitted to the Edinburgh Royal Infirmary (head and spinal injury unit) with depressed fracture of the skull over the 8-year period 1971-1978. 176 patients with compound depressed skull fracture.	Retospective Study	107 patient had ampicillin and sulphonamide, one patient developed meningitis and ventriculitis. 45 patients had other prophylactic antibiotics. four developed meningitis and brain abscess. 19 patient had no antibiotics, one developed meningitis	Early treatment with ampicillin and sulphonamide, in addition to adequate surgical debridement, is recomended in patient with compound depressed skull fractures	The group designated (other combinations) was made up of patients on a variety of antibiotics, the number on each antibiotic being too small for individual analysis. They accepted that, there are other factors related to the occurence of the infection.

Comment(s)

The incidence of infectious complicatons other than meningitis in the non antibiotic group was higher than in the group given antibiotics.

Clinical Bottom Line

The results of the present study do not provide a definitive answer regarding the role of antibiotics in preventing meningitis. There is very little evidence in value of giving antibiotic in depressed compound skull fracture. Local advice should be followed.

References

1. Mendelow AD, Campbell D, Tsementzis SA, et al. Prophylactic antimicrobial management of compound depressed skull fracture. J R Coll Surg Edinb 1983;28(2):80-3.