Conundrums in the surgical intensive care unit: fevers and antibiotic prophylaxis

The Critical Care Committee of the American Association for the Surgery of Trauma has produced a series of Clinical Consensus Guidelines, the latest three of which focus on surgical infections and their treatment. The committee authors thoughtfully provide guiding commentary, especially in areas where strong evidence in the literature is lacking; that is, the unique space that these consensus guidelines fill. These latest guidelines cover the evaluation of fever and antibiotic prophylaxis after injury and peri-procedurally.1–3

The authors eloquently provided a broad sweeping discussion on fever evaluation, including both infectious and non-infectious pathogenesis, which interestingly are a 50/50 split in occurrence in the surgical intensive care unit. The tension in the article—similar to that of caring for critically ill patients—lies in appropriately recognizing and treating sepsis, where we know that early antibiotics are essential in improving outcomes,4 and avoiding unnecessary antibiotic use, in a world of growing antibiotic resistance primarily driven by overuse.5 6 Table 3 of the Norha et al article provides an excellent overview and quick reference that every surgical intensivist should have committed to memory or readily available for reference.

The consensus on post-injury antibiotic prophylaxis is underscored by the importance of targeted prophylaxis in trauma patients and balancing infection prevention with judicious antibiotic use. This practical guide categorizes recommendations by injury type and severity, further stratified by level of evidence. This consensus document is invaluable for trauma providers, streamlining antibiotic choices and ultimately optimizing patient care and minimizing the emergence of antibiotic resistance and should be incorporated into the practice management guidelines of each institution.

Lastly, the consensus on peri-procedural antibiotic prophylaxis in the surgical intensive care unit is most notable for recommending a single pre-procedural dose of antibiotics for most procedures. For promptly treated traumatic bowel injuries, antibiotics should not be continued beyond 24 hours. Cefazolin is appropriate in most cases, but consideration should be given to methicillin-resistant Staphylococcus aureus or gram-negative/anaerobic coverage based on the surgical indication. As above, antibiotic stewardship is paramount to limiting unnecessary exposure and resistance in our highly susceptible surgical and trauma intensive care unit population.